Tibério M. Siqueira

Laparoscopic treatment for ureteropelvic junction obstruction

OBJECTIVES To assess retrospectively the subjective and objective outcomes achieved after laparoscopic treatment for ureteropelvic junction obstruction at our institutions. METHODS Between August 1999 and July 2001, 19 patients (11 women and 8 men), with a mean age of 31.2 years (range 17 to 67), underwent laparoscopic treatment for ureteropelvic junction obstruction. Of these, 17 patients were eligible for postoperative analysis. Nine of these patients had a history of prior surgical intervention on the affected side. The patients were subjectively assessed by an analog pain scale performed before and at least 6 months after surgery. Preoperatively, patients had a diuretic renal scan to confirm the presence of obstruction. Helical computed tomography was also performed preoperatively to assess for the presence of crossing vessels. The renal scan was repeated at least 12 weeks after surgery to document the relief of obstruction objectively. RESULTS Helical computed tomography correctly predicted the presence of crossing vessels in 12 patients (63%). The Anderson-Hynes and Fenger pyeloplasty techniques were performed in 16 and 2 patients, respectively. In 1 patient, a small crossing vein over the ureteropelvic junction was identified and divided without complications. The average operative time was 240 minutes (range 128 to 470). The blood loss was minimal, and no open conversions were required. The mean hospital stay was 2.9 days (range 2 to 7). Two postoperative complications occurred (11.7%). The average subjective follow-up was 14.4 months (range 6 to 27), and the average objective follow-up was 7.8 months (range 3 to 12). Of 17 assessable patients, 16 (94%) had subjective and objective success (postoperative improvement in analog pain score and half-life of radiotracer washout). The average split renal function improved from 34.1% to 38.5% (P <0.01). CONCLUSIONS On the basis of our data, laparoscopic pyeloplasty has a similar success rate compared with the traditional open approach and better results than other minimally invasive techniques. Longer follow-up and further experience are needed to validate these data.

Holmium laser enucleation of the prostate: morbidity in a series of 206 patients

OBJECTIVES To review the complications associated with 206 holmium laser enucleation of the prostate (HoLEP) procedures. HoLEP is a minimally invasive surgical treatment for benign prostatic hyperplasia. METHODS A retrospective review was conducted of HoLEPs performed from April 1, 1999 to October 1, 2001. Patients with previous diagnoses of prostate carcinoma or who had undergone HoLEP after admission for unrelated problems were excluded. Demographic, intraoperative, and immediate postoperative data were recorded to determine the incidence of complications. Patients were also contacted by telephone or mailed surveys for documentation of longer term complications. RESULTS The mean age and procedure time was 70.5 years (range 45 to 91) and 133.6 minutes (range 25 to 473), respectively. The mean specimen weight was 68.2 g (range 3 to 376), with 20 (9.7%) of 206 patients diagnosed with adenocarcinoma. The mean hospital stay was 1.1 days, with 86.9% of patients discharged after an overnight stay without a catheter. Two patients required postoperative transfusions (1.0%). No deaths, major complications (myocardial infarction or pulmonary embolism), or transurethral resection syndrome episodes occurred. Intraoperative complications consisted of three capsular perforations (1.5%), one bladder neck false passage (0.5%), four incomplete morcellations (1.9%), and four minor bladder mucosal morcellation injuries (1.9%). Of 206 patients, 173 (84.0%) provided follow-up data (mean 19.0 +/- 8.4 months), allowing documentation of longer term complications, including five clot retention episodes (2.4%), five urethral strictures (2.4%), eight bladder neck contractures (3.9%), and 16 patients requiring re-catheterization (7.8%). CONCLUSIONS HoLEP can be performed with minimal complication risks and blood loss. Patients can expect an overnight hospital stay and discharge without an indwelling catheter.

MULTILAYERED SMALL INTESTINAL SUBMUCOSA IS INFERIOR TO AUTOLOGOUS BOWEL FOR LAPAROSCOPIC BLADDER AUGMENTATION

PURPOSE Bladder augmentation is most commonly performed with ileum. However, porcine small intestinal submucosa has been reported as a substitute for bowel for incorporation into the urinary tract. We assessed the feasibility and long-term 12-month results of laparoscopic bladder augmentation with ileum or multilayered small intestinal submucosa (Cook Biotech, Spencer, Indiana) in a porcine model. MATERIALS AND METHODS We performed laparoscopically assisted hemicystectomy and bladder augmentation in 24 female Yucatan mini-pigs using an ileal segment (12) or multilayered small intestinal submucosa (12). The followup protocol included anesthetic bladder capacity, renal ultrasonography and serum chemistry. At 3, 6 and 12 months, respectively, 4 animals per group were scheduled for sacrifice and pathological analysis. RESULTS Despite longer anastomotic time in the multilayered small intestinal submucosa group (120 versus 91 minutes, p = 0.026) total operative time was similar in the 2 groups. In each group bladder capacity increased with time but by 12 months bladder capacity was significantly better in the bowel than in the small intestinal submucosa group (825 versus 431 cc, p = 0.016). At 3 months pathological evaluation revealed that the multilayered regenerated bladder patch had shrunken and by 6 months it was replaced by dense calcified scar tissue. Long-term 6 and 12-month bladder capacity in the small intestinal submucosa group was the result of the regeneration of native bladder with exclusion of the whole multilayered patch in the majority of cases. CONCLUSIONS Laparoscopic bladder augmentation using multilayered small intestinal submucosa produced functional and pathological results inferior to those of bowel at 12-month followup in a porcine model.

Contribution of Renal Innervation to Hypertension in Rat Autosomal Dominant Polycystic Kidney Disease

The kidney has both afferent (sensory) and efferent (sympathetic) nerves that can influence renal function. Renal innervation has been shown to play a role in the pathogenesis of many forms of hypertension. Hypertension and flank pain are common clinical manifestations of autosomal dominant (AD) polycystic kidney disease (PKD). We hypothesize that renal innervation contributes to the hypertension and progression of cystic change in rodent PKD. In the present study, the contribution of renal innervation to hypertension and progression of renal histopathology and dysfunction was assessed in male Han:SPRD-Cy/+ rats with ADPKD. At 4 weeks of age, male offspring from crosses of heterozygotes (Cy/+) were randomized into either 1) bilateral surgical renal denervation, 2) surgical sham denervation control, or 3) nonoperated control groups. A midline laparotomy was performed to allow the renal denervation (i.e., physical stripping of the nerves and painting the artery with phenol/alcohol). Blood pressure (tail cuff method), renal function (BUN) and histology were assessed at 8 weeks of age. Bilateral renal denervation reduced the cystic kidney size, cyst volume density, systolic blood pressure, and improved renal function (BUN) as compared with nonoperated controls. Operated control cystic rats had kidney weights, cyst volume densities, systolic blood pressures, and plasma BUN levels that were intermediate between those in the denervated animals and the nonoperated controls. The denervated group had a reduced systolic blood pressure compared with the operated control animals, indicating that the renal innervations was a major contributor to the hypertension in this model of ADPKD. Renal denervation was efficacious in reducing some pathology, including hypertension, renal enlargement, and cystic pathology. However, sham operation also affected the cystic disease but to a lesser extent. We hypothesize that the amelioration of hypertension in Cy/+ rats was due to the effects of renal denervation on the renin angiotensin system.

Vesical metastasis of gastric adenocarcinoma

Metastatic vesical tumors are rare, and constitute approximately 1% of all neoplasias affecting this organ. The authors report the case of a 63-year old woman with vesical metastasis of gastric adenocarcinoma. Patient presented signs of cachexia and complained of left lumbar pain and dysuria unresponsive to antibiotic therapy for approximately 5 months. She reported a previous partial gastrectomy due to ulcerative undifferentiated gastric adenocarcinoma 1 year and 9 months before. Cystoscopy revealed an extensive vegetative lesion in bladder, occupying its entire mucosal surface. The biopsy revealed metastatic signet-ring cell adenocarcinoma.

One versus two proficient laparoscopic surgeons for laparoscopic live donor nephrectomy

OBJECTIVES To compare the laparoscopic donor nephrectomy (LDN) results obtained by two different surgical teams, one consisting of a proficient laparoscopic surgeon assisted by an inexperienced laparoscopic surgeon and another consisting of two proficient laparoscopic surgeons. With more centers embarking on LDN programs, it is important to identify the factors that can improve overall outcomes during the initial learning curve. METHODS A retrospective review was performed of the initial 70 sequential LDNs performed between October 1998 and March 2001 at our institutions. The procedures were stratified into two groups. Group 1 consisted of LDN cases performed by one proficient laparoscopic surgeon and an inexperienced laparoscopic surgeon (resident, fellow, or faculty) as the first assistant; group 2 consisted of cases performed by two proficient laparoscopic surgeons. RESULTS Twenty-six LDNs were performed by group 1 and 44 by group 2. The total operative time and estimated blood loss showed a statistically significant decrease in group 2 compared with group 1, 143 +/- 32 minutes versus 218 +/- 38 minutes (P <0.001) and 92 +/- 115 mL versus 158 +/- 148 mL (P = 0.044), respectively. Two major complications occurred in group 1 (7.7%) and two major complications occurred in group 2 (4.5%). The 3-month postoperative recipient creatinine levels were similar for both groups, 1.6 +/- 1.3 versus 1.4 +/- 0.4 (P = 0.408). CONCLUSIONS A surgical team composed of two proficient laparoscopic surgeons during the early learning curve of LDN may allow safe and efficient development of a laparoscopic live donor renal transplantation program.

Complete en bloc urinary exenteration for synchronous multicentric transitional cell carcinoma with sarcomatoid features in a hemodialysis patient

The incidence of transitional cell carcinoma (TCC) in patients submitted to hemodialysis is low. The presence of TCC with sarcomatoid features in this cohort is even scarcer. Herein, we describe a very rare case of synchronous multicentric muscle invasive bladder carcinoma with prostate invasion in a hemodialysis patient, submitted to complete en bloc urinary exenteration.

Laparoscopic Management of the Complex Renal Cyst

Renal cysts are present radiologically in approx 50% of adults over the age of 50 and the incidence rises with advancing age (1, 2). The majority of renal cysts are benign simple cysts and require no surgical intervention when asymptomatic. However, a minority of renal cysts can result in pain, hematuria, obstruction to renal drainage, infection, hypertension, and even compression of other intra-abdominal structures that necessitate radiologic or operative treatment. Additionally, cysts may have radiologic features that correlate with a higher likelihood of malignancy that necessitates definitive treatment (Table 1) (3, 4).