Ugur Boylu

Natural orifice translumenal endoscopic surgery (NOTES) partial nephrectomy in a porcine model

BackgroundThis study aimed to evaluate the feasibility of natural orifice translumenal endoscopic surgery (NOTES) transgastric partial nephrectomy without hilar clamping in a porcine model.MethodsA 45-kg male pig was placed in the supine position after endotracheal general anesthesia. A therapeutic gastroscope was introduced through the esophagus, and a 2-cm gastrotomy was performed using a diathermy electrocautery needle at the junction of the fundus and the proximal body. After incision of Gerota’s fascia, the left kidney’s upper pole was excised using the thulium laser without hilar dissection or clamping. An endoscopic wire loop was used to entrap and extract the specimen into the stomach. The gastroscope was subsequently withdrawn with the intact specimen. After hemostasis via reinsertion of the endoscope was ensured, metal clips were applied endoscopically to close the gastrotomy.ResultsThe total operative time for the NOTES transgastric partial nephrectomy was 240xa0min. Use of the therapeutic double-channel gastroscope allowed for scarless NOTES. The available 3.7- and 2.8-mm gastroscope ports were used for gastrotomy, excision, removal of the specimen, and endoscopic clip application. The procedure was performed in a nonischemic fashion with application of the thulium laser, which provided adequate hemostasis. No further interventions such as suturing of the renal capsule or use of hemostatic agents were required. The final specimen was 3xa0cm in size, and the estimated blood loss was 200xa0ml. A major drawback of the thulium laser was excessive smoke produced by vaporization of the tissue, which was minimized with the use of external irrigation.ConclusionThe findings show that NOTES transgastric partial nephrectomy with thulium laser is feasible. Further studies are needed to demonstrate long-term efficacy and provide additional data regarding practical applications of this novel approach and technique.

Ureteropelvic Junction Obstruction Secondary to Crossing Vessels-To Transpose or Not? The Robotic Experience

PURPOSEnWe compared the surgical outcomes of robot assisted laparoscopic dismembered pyeloplasty in patients presenting with anterior crossing vessels with and without transposition of the crossing vessel.nnnMATERIALS AND METHODSnA total of 107 patients with ureteropelvic junction obstruction underwent robot assisted laparoscopic dismembered pyeloplasty. Evaluation of surgical success was based on validated pain scores, diuretic renography and imaging results, including excretory urography, computerized tomography or ultrasound.nnnRESULTSnAnterior crossing vessels were identified in 48 patients (44.9%) and vessels were transposed in 18 (37.5%) (group 1). No transposition was performed in 30 patients (62.5%) (group 2). Mean radiological followup was 52.9 weeks in group 1 and 65.3 weeks in group 2 (p = 0.181). Mean pain score on a scale of 10 was 0.82 in group 1 and 0.74 in group 2 (p = 0.917). A Whitaker test performed in 3 patients with persistent pain was negative. Preoperatively mean differential function on the affected side was 35.1% in group 1 and 36.9% in group 2 (p = 0.133). Half-time was calculated as a mean of 46.3 minutes in group 1 and 49.4 minutes in group 2 (p = 0.541). In groups 1 and 2 mean postoperative differential function improved to 41.1% and 40.9%, and mean half-time improved to 7.43 and 8.03 minutes, respectively (p = 0.491). A comparison of preoperative and postoperative differential function, and half-time in each group showed a statistically significant difference. The radiographic and symptomatic success rate was 100% with no open conversion and recurrence.nnnCONCLUSIONSnComparison of robot assisted laparoscopic dismembered pyeloplasty outcomes revealed similar success rates in terms of the change in symptoms and renal function in patients with or without anterior crossing vessel transposition. Transposition of crossing vessel should only be performed when the anatomical relation dictates and it should be an intraoperative decision.

Factors that impact the outcome of minimally invasive pyeloplasty: Results of the multi-institutional laparoscopic and robotic pyeloplasty collaborative group

PURPOSEnWe compared laparoscopic and robotic pyeloplasty to identify factors associated with procedural efficacy.nnnMATERIALS AND METHODSnWe conducted a retrospective multicenter trial incorporating 865 cases from 15 centers. We collected perioperative data including anatomical and procedural factors. Failure was defined subjectively as pain that was unchanged or worse per medical records after surgery. Radiographic failure was defined as unchanged or worsening drainage on renal scans or worsening hydronephrosis on computerized tomography. Bivariate analyses were performed on all outcomes and multivariate analysis was used to assess factors associated with decreased freedom from secondary procedures.nnnRESULTSnOf the cases 759 (274 laparoscopic pyeloplasties with a mean followup of 15 months and 465 robotic pyeloplasties with a mean followup of 11 months, p <0.001) had sufficient data. Laparoscopic pyeloplasty, previous endopyelotomy and intraoperative crossing vessels were associated with decreased freedom from secondary procedures on bivariate analysis, with a 2-year freedom from secondary procedures of 87% for laparoscopic pyeloplasty vs 95% for robotic pyeloplasty, 81% vs 93% for patients with vs without previous endopyelotomy and 88% vs 95% for patients with vs without intraoperative crossing vessels, respectively. However, on multivariate analysis only previous endopyelotomy (HR 4.35) and intraoperative crossing vessels (HR 2.73) significantly impacted freedom from secondary procedures.nnnCONCLUSIONSnLaparoscopic and robotic pyeloplasty are highly effective in treating ureteropelvic junction obstruction. There was no difference in their abilities to render the patient free from secondary procedures on multivariate analysis. Previous endopyelotomy and intraoperative crossing vessels reduced freedom from secondary procedures.

In Vitro Comparison of a Disposable Flexible Ureteroscope and Conventional Flexible Ureteroscopes

PURPOSEnWe compared and evaluated the objective characteristics (deflection characteristics, field of view and flow rate) of a disposable flexible ureteroscope and 6 established, commercially available flexible ureteroscopes.nnnMATERIAL AND METHODSnSix commonly used ureteroscopes, including Olympus URF-P3, Storz(R) 11278AU and 11274AAU, ACMI DUR-8 Elite and DUR-8, and Wolf 7331.001 (Richard Wolf Medical Instruments, Vernon Hills, Illinois), were compared with the recently introduced SemiFlex Scope disposable flexible ureteroscope. Specifications and purchase costs were acquired from each manufacturer. The disposable ureteroscope consisted of a reusable eyepiece and a semiflexible shaft with a 3.3Fr working channel. Active tip deflection was measured with and without the 3Fr basket, the 365 mum laser fiber and the 3Fr forceps. The flow rate and field of view of each scope were evaluated.nnnRESULTSnActive tip deflection (down/up) was highest in the disposable ureteroscope at 300/265 degrees. Although deflection was decreased by inserting the different endoscopic tools in all ureteroscopes, the disposable ureteroscope had the highest loss in flexion characteristics (35.7% down and 39.3% up). The flow rate, measured at 25 ml per minute in the disposable ureteroscope, was significantly lower than that of other ureteroscopes. The disposable ureteroscope had a 72-degree field of view, comparable to the optical characteristics of the other scopes. Compared to the other 6 flexible ureteroscopes the purchase price of the disposable scope was significantly lower and no further maintenance/repair expenses were required.nnnCONCLUSIONSnThe disposable flexible ureteroscope has acceptable active tip deflection, field of view and flow rate compared to those of other flexible ureteroscopes on the market. Further evaluation of surgical outcomes will help delineate the definitive usefulness of the disposable flexible ureteroscope.

Robotic-Assisted Laparoscopic Pyeloplasty and Nephropexy for Ureteropelvic Junction Obstruction and Nephroptosis

A 22-year-old female was referred with right flank pain and recurrent urinary infections. Flank pain was persistent while standing and relieved upon supine position. Intravenous urography demonstrated change of position with descent approximately 6-7 cm as the patient moved from the supine to the erect position. Diuretic renography corroborated the finding of right ureteropelvic junction obstruction (UPJO). A robotic-assisted laparoscopic dismembered pyeloplasty with simultaneous nephropexy was performed. The proximal ureter appeared to course posterior to the renal vein and then anterior to the lower pole renal artery. There was a significant nutcracker effect to the proximal ureter, which was causing the patients UPJO, and the concomitant nephroptosis contributed to increase the degree of obstruction. The robotic-assisted laparoscopic pyeloplasty and nephropexy offer advantages for patients and surgeons and can be used in challenging cases with an efficacy similar to that of open repair. The robotic-assisted laparoscopic pyeloplasty is the evolving standard for UPJO, especially in the presence of crossing vessels.

Transumbilical single‐port laparoscopic partial nephrectomy in a pig model

Study Type – Therapy (case series)u2028Level of Evidenceu20034

Robot-Assisted Laparoscopic Radical Prostatectomy in Patients with Previous Abdominal Surgery: A Novel Laparoscopic Adhesiolysis Technique

PURPOSEnWe evaluated the feasibility and outcomes of performing a novel laparoscopic adhesiolysis technique before robot-assisted laparoscopic radical prostatectomy (RALRP) in patients with previous abdominal surgery.nnnPATIENTS AND METHODSnA total of 18 men with incision scars from previous abdominal surgeries underwent RALRP. A 12-mm trocar was placed at the lateral lower quadrant away from the incision site, and a teaching laparoscope was introduced into the peritoneal cavity. Meticulous adhesiolysis was performed through a single trocar to subsequently allow safe placement of additional robotic trocars. Age, type of previous surgery, total operative time, console time, anastomosis time, estimated blood loss, transfusion rate, complications, and conversion rate were recorded.nnnRESULTSnAll patients had multiple abdominal surgeries. Mean operative time was 297 minutes, mean console time was 194 minutes, and mean estimated blood loss was 241 mL. No access-related complication and no conversion to open surgery occurred.nnnCONCLUSIONnThis novel laparoscopic technique of adhesiolysis with a teaching laparoscope through a single trocar facilitates safe placement of trocars and accomplishment of RALRP in patients with previous abdominal surgery.

Ureteroenteric Anastomotic Stricture: Novel Use of a Cutting Balloon Dilator

INTRODUCTIONnManagement of ureteroenteric strictures presents a significant challenge because of its intraabdominal location and morbidity associated with open surgical management. The peripheral cutting balloon microsurgical dilatation device (PCBD), approved by The United States Food and Drug Administration (USFDA) for use in coronary angioplasty, features a 2-cm noncompliant balloon with four microsurgical blades mounted longitudinally on its outer surface. We evaluated the feasibility and outcome of this cutting balloon dilator in the treatment of ureteroenteric anastomotic strictures.nnnMATERIALS AND METHODSnThree patients with a 1-cm or less ureteroenteric stricture underwent a transluminal incision under fluoroscopic guidance. Percutaneous access was obtained and a guidewire was introduced into the renal pelvis and ureter in antegrade fashion and passed through the stricture. The exact length of the strictured segment was measured. The PCBD was deployed over the guidewire and the balloon was inflated at the stricture site. The maximum diameter of the inflated balloon was 8 mm. Approximately 30 seconds later, the balloon was deflated and the enlarged passage from the ureter to the ileal loop was verified under fluoroscopy. A ureteral stent was placed and removed at 6 weeks after the procedure.nnnRESULTSnPostoperative computed tomography scans at 12 months revealed improved hydronephrosis. All patients were asymptomatic postoperatively. One patient had a solitary kidney and creatinine level decreased significantly following the procedure.nnnCONCLUSIONnDilatation and incision with PCBD is a novel approach for the treatment of the short ureteroenteric anastomotic strictures. Long-term data need to be obtained to establish the efficacy of this technique.

Renal Anatomy, Physiology and Its Clinical Relevance to Nephrectomy

Prior to performing partial nephrectomy, the surgeon must closely review the vascular supply of the involved kidney. If multiple arteries are present, each should be clamped, individually or en bloc, to provide a bloodless field. Prior to clamping the renal vasculature, the availability and functioning of all instruments, clamps, hemostatic agents, sutures, clips, etc. should be checked. The surgeon should not waste precious time trying to gather supplies after the renal vasculature has been clamped. Appropriate patient selection for the initial portion of one’s learning curve is crucial. With experience, the surgeon can tackle more difficult tumor locations within the kidney, and WIT should decrease. Although traditional teaching emphasizes a WIT limit of 30 min, our goal should be to try to limit WIT as much as possible.

Tubeless percutaneous nephrolithotomy: a prospective feasibility study and review of previous reports

Obesity is cited as a limiting factor in laparoscopy, and can limit instrument movements by the greater degree of port fixity, but this does not preclude this approach in obese patients. However, performing a radical or partial nephrectomy through an 8cm incision in an obese patient might compromise access and prove extremely difficult; the body mass index of the patients in the authors’ series is not mentioned. These patients often benefit the most from a laparoscopic procedure, having otherwise a greater risk of wound complications after open surgery.