William K. Johnston

Acute Integrity of Closure for Partial Nephrectomy: Comparison of 7 Agents in a Hypertensive Porcine Model

PURPOSE We assessed the acute effectiveness of closure after partial nephrectomy of 7 techniques in a large hypertensive porcine model using shallow and deep resections to approximate clinical situations. MATERIALS AND METHODS Open surgical partial nephrectomy with hilar clamping was performed in pigs weighing 150 to 200 lbs, including small-a quarter length and a quarter width of kidney, medium-a third length and a third width of kidney, and into the renal sinus and up to the collecting system, and large-lower pole heminephrectomy at the renal sinus. Seven agents were compared after a single application, namely thrombin/collagen granules, polyethylene glycol hydrogel, fibrin glue, thrombin/gelatin granules, cyanoacrylate glue, fibrin glue/gelatin sponge and sutured bolster. Failure and success were determined by the presence or absence of bleeding, respectively, after unclamping and by an increase in SBP to 100 and then to 200 mm Hg with dopamine infusion. RESULTS Of 70 partial nephrectomies the success rates were 33% and 14% for thrombin/collagen granules, and 67% and 0% for polyethylene glycol hydrogel in small and medium resections; 100%, 71% and 0% for fibrin glue, and 100%, 86% and 0% for thrombin/gelatin granules in small, medium and large resections; and 67% and 80% for cyanoacrylate glue, 100% and 20% for fibrin glue/gelatin sponge, and 100% for sutured bolster in medium and large resections, respectively. Of the kidneys that did not bleed at an SBP of 100 mm Hg 31% bled at 200 mm Hg. CONCLUSIONS There is considerable variability among agents. Most were effective for small resections and some worked for medium resections but for large resections only sutured bolster was consistently effective. SBP also appears to be an important factor. These results bear on the selection of techniques during laparoscopic partial nephrectomy.

200 consecutive hand assisted laparoscopic donor nephrectomies : Evolution of operative technique and outcomes

PURPOSE Despite the popularity of hand assisted laparoscopic donor nephrectomy published experience is less than that with standard laparoscopic donor nephrectomy and few critical assessments of operative maneuvers have been described. MATERIALS AND METHODS We describe the impact of changes in operative technique made by a single surgeon during 200 hand assisted laparoscopic donor nephrectomies. RESULTS With a mean operative time of 229 minutes and hospital stay of 1.9 days the rates of conversion to open surgery, intraoperative complications and major postoperative complications were 1%, 1.5% and 6%, respectively. Lasting changes in technique were dissection of a ureteral/gonadal packet, bipolar cautery use on gonadal/adrenal/lumbar veins and resting the kidney before removal. The incidence of ureteral complications decreased from 8% to 5.1% with dissection of the ureter in conjunction with the gonadal vein rather than isolating it. Warm ischemia time decreased from a mean of 186 to 143 seconds with bipolar electrocautery instead of clips to control gonadal/adrenal/lumbar veins. After starting to rest the kidney before removal the incidence of primary graft nonfunction and delayed function decreased from 6.7% to 0% and 30% to 11.8%, respectively, with a corresponding improvement in 2-year graft survival from 83% to 95%. CONCLUSIONS This large series of hand assisted donor laparoscopic nephrectomies with a mean followup approaching 3 years demonstrates that the procedure is safe for the donor and procures a good specimen. Decreases in ureteral complications, warm ischemia time and graft dysfunction might be attributable to specific changes in our operative technique.

The Birth of Fiberoptics from "Light Guiding"

VISUAL EXAMINATION OF AND INTERVENTION IN the urinary crannies, crevices, and cavities constitute the cornerstones of endourology. In this endeavor, adequate light transfer for proper visibility has been a perennial hurdle. From the early attempts at reflecting sunlight onto head mirrors to the use of candles and oil wick lamps to incandescent light bulbs, it has been an uphill journey until the advent of rod lenses and fiberoptic light transmission. Thanks to the fiberoptic principles, we now have near-natural quality and quantity of illumination for our endoscopic examinations. Yet this monumental invention began as a mere eye-catching gimmick or parlor trick more than 160 years ago.1 It was 1841. Daniel Colladon, a young professor of physics at the University of Geneva, was to demonstrate fluid flow through various holes of a cistern as part of his lecture on fluid dynamics. However, the lighting in the 19th Century lecture hall was inadequate for such demonstration. Colladon decided to illuminate his display by focusing sunlight with a lens onto the water tank. To his surprise, and the amusement of the assembled, the light spectacularly illuminated the water jets squirting out through the holes of the tank. The light rays trapped in the fluid by total internal reflection traveled along the curving arc of the water until the jets broke up in sparkles of light. It was thus demonstrated that light, which was believed to travel only in a straight line, could be made to follow a curve. The show was impressive, “one of the most beautiful and most curious experiments that one can perform in a course on optics,” wrote Colladon, who coined the term “light guiding” for the physical phenomenon.2 Enamored of and amused by the display, Colladon popularized his show as part of his lecturing repertoire to the intelligentia. The light source was modified into an electric arc light instead of the sun by his contemporary August de la Rive. To establish his claim as the originator of “light guiding,” Colladon submitted a report to Comptes Rendu, the official journal of the French Academy of Sciences. Francois Arago, the editor of the journal, recalled a recent demonstration of a similar phenomenon by Jacque Babinet in Paris and invited him also to write a report. Colladon and Babinet’s separate papers were published in the same issue of Comptes Rendu.2,3 Colladon happened to be a more eager promoter than Babinet, who was already an established academician and not so hungry for publicity. Babinet specialized in optics and extended the phenomenon of guiding light along bent glass rods. He mentioned in passing that the idea works well with glass shafts curved in whatever manner and could be used to illuminate the inside of the mouth, thereby hinting at what would evolve as fiberoptics.3 Although Babinet did not pursue light guiding experiments any further, Colladon’s interest showed sporadic sparks of practical application of his trick. In 1853, he used light guiding as

Diet and Urolithiasis

Nephrolithiasis is a common disorder affecting approx 8–13% of the US population (1,2). After experiencing renal colic and/or treatment for urinary stones, nearly every patient expresses interest in diet and specific dietary changes useful in lowering the risk for future stones.

PD56-12 SURVEY OF ABDOMINAL ACCESS AND ASSOCIATED MORBIDITY FOR ROBOT-ASSISTED RADICAL PROSTATECTOMY (RARP)- DOES PALMER's POINT WARRANT FURTHER AWARENESS AND STUDY?

CONCLUSIONS: Only a quarter of our respondents utilize FT in their practice with surgeon’s experience being the only independent predictor for utilizing FT. Majority of respondents though consider FT to be beneficial in prostate cancer management and would use it more often if provided more reliable and cost effective options. Over time, experience and accessibility to reliable methods to perform FT may lead to further utilization of this novel treatment strategy.

Editorial Comment for Cormio et al.

Upper tract urothelial carcinomas have a reputation for behaving aggressively with an increasingly poor prognosis for the more invasive or high-grade lesions. The inherent nature of the cancer itself and the delay in presentation are usually blamed, but the unique anatomic conditions of the upper tract may contribute to the prognosis (thin-walled urothelium, possibility of lymphatic and hematologic tumor seeding with an obstructed upper tract). Because of the relative paucity of cases and the wide variation in presentation, retrospective studies to determine optimal management are often conflicting. The standard of care for upper tract urothelial carcinomas is nephroureterectomy, but there is no consensus on the ‘‘best method’’ for distal ureteral/bladder cuff removal, although most agree it is an important oncologic principle in an otherwise uncompromised patient. Numerous methods have been proposed for management of the distal ureter during open, laparoscopic, and robot-assisted nephroureterectomy (OLR-NUx). Some techniques may necessitate advanced instrumentations (robot-assisted) and/or are technically demanding (transvesical, flexible cystoscopy/laser incision). Many urologists choose to complete transurethral incision of the bladder cuff into perivesical fat before OLR-NUx. Technically, a transurethral approach is often more familiar to the urologist and almost assures complete removal of the distal ureter; however, this potentially exposes the perivesical space to tumor spillage during the nephrectomy phase. Cormio and associates present a novel method to potentially decrease tumor spillage during distal ureter bladder cuff excision using a Fogarty balloon catheter to occlude the ureter. There are several attractive benefits of the group’s technique: it is relatively inexpensive, uses skills familiar to most urologists, and needs minimal additional time or resources. Patient risk appears low, especially when the technique is avoided with distal ureteral tumors. While their technique aims to eliminate extravesical escape of tumor cells from the upper tract during surgery, potential exposure from tumor cells that migrated into the bladder before obstruction still exist. The authors attempt to minimize this exposure by limiting extravasation during resection. In the authors’ series, the additional time to complete incision surrounding the ureter appeared short (mean time for excision and repositioning of 21.3 minutes and 19.8 minutes, respectively). Beyond introducing a novel technique, the article by Cormio and colleagues stimulates thought into another aspect of upper tract urothelial carcinoma management: What influence does upper tract hydraulic pressure have in tumor advancement, both locally and into lymphatic and venous systems? Intuitively, upper tract pressure has always concerned me. Retrograde pyelography can lead to extravasation and lymphatic entry, and bacteremia is common in obstructed urolithiasis or during stone manipulation with ureteroscopy. Urologists attempt to avoid high pressures in all of these situations. Auge and coworkers demonstrated pressures of 94.4 mm Hg with ureteroscopy in the renal pelvis during stone treatment, a pressure that was reduced to 40.6 mm Hg with an access sheath. Opposing any apparent parallels are retrospective studies failing to support the hypothesis that upper tract hydraulic pressure influences tumor spread. In fact, a study by Ishikawa and associates demonstrated an improved cancerspecific survival after ureteroscopy; however, the authors acknowledge that the result more likely represents selective bias (smaller, indeterminate tumors underwent ureteroscopy/ biopsy vs nonbiopsied, larger masses). Even more perplexing are the studies on ureteral tumors vs pelvic tumors: Some studies demonstrate a worse prognosis while others show no significant difference, respectively. Measurement of the level of obstruction was not made, however. Circling back to the bacteremia analogy, not all infected upper tracts result in bacteremia with obstruction or ureteroscopy. Perhaps not all upper tract tumors seed the vascular and lymphatics, but does the risk exist? At the very least, should we be more judicious with ureteroscopy and biopsy of enhancing upper tract tumors, reserving it for indeterminate lesions or in morbid patients where endoscopic/nephron-sparing treatment is being considered? Moreover, does preoperative and intraoperative fluid administration alter upper tract pressure when the ureter is clipped or obstructed during surgery? Certainly, these topics warrant further study. Perhaps using the technique of Cormio and colleagues, the ureter can be obstructed with the Fogarty but attached to a bag and drained, thereby reducing pressure and allowing analysis of time-phased samples for tumor cells and pressure transducer measurements. Cormio and coworkers should be applauded for sharing their ingenuity that may not only stimulate thought and debate, but also challenge us to further study our techniques and refine our management of upper tract urothelial carcinomas to accommodate future improved oncologic outcomes.

Improvised method to retrieve a proximally displaced ureteral stent in a remote surgical setting.

PURPOSE To present an improvised method for repositioning a proximally displaced stent using only a cystoscope and a guidewire. METHODS A Glidewire guidewire (Boston Scientific) was passed through a cystoscope and into the distal ureter, and manipulated up the ureteral stent into the renal pelvis, reflected, and passed antegrade down the ureter and into the bladder. The guidewire was then grasped in the bladder, clamped at the penis, and retracted, pulling the stent back into the bladder. RESULTS The patient proceeded with lithotripsy, and the stent was removed in 2 weeks without complication. CONCLUSION Methods at retrieving proximally displaced ureteral stents after deployment have been previously reported; however, these methods necessitated access to a ureteroscope and special graspers/baskets that may not be available in an outpatient surgical center setting. Here, an improvised method for stent repositioning using only a cystoscope and a guidewire allowed successful retrieval of a proximally migrated stent.