Xing Ai

Long-Term Results of a Prospective, Randomized Trial Comparing Retroperitoneoscopic Partial Versus Total Adrenalectomy for Aldosterone Producing Adenoma

PURPOSE The indication for laparoscopic total or partial adrenalectomy in patients with aldosterone producing adrenal adenoma remains controversial. We compared retroperitoneoscopic partial and total adrenalectomy for aldosterone producing adrenal adenoma in a prospective, randomized, multicenter trial. MATERIALS AND METHODS Patients with aldosterone producing adrenal adenoma were randomized to retroperitoneoscopic partial or total adrenalectomy. Patient characteristics, surgical data, complications and postoperative clinical results were analyzed statistically. RESULTS From July 2000 to March 2004, 212 patients were enrolled in this study, including 108 and 104 who underwent total and partial adrenalectomy, respectively. The 2 groups were comparable in patient age, gender, body mass index and tumor site. Mean followup was 96 months in each group. No conversion to open surgery was needed and no major complications developed. Partial adrenalectomy required a shorter operative time than total adrenalectomy but this did not attain statistical significance. Intraoperative blood loss in the partial adrenalectomy group was significant higher than in the total adrenalectomy group (p <0.05) but no patient needed blood transfusion. All patients in each group showed improvement in hypertension, and in all plasma renin activity and aldosterone returned to normal after surgery. No patient required potassium supplements postoperatively. In the total and partial adrenalectomy groups 32 (29.6%) and 29 patients (27.9%), respectively, were prescribed a decreased dose of or fewer antihypertensive medicines at final followup. CONCLUSIONS Retroperitoneoscopic partial adrenalectomy is technically safe. It has therapeutic results similar to those of total adrenalectomy in patients with primary aldosteronism due to aldosteronoma.

Association of Low Expression of Notch-1 and Jagged-1 in Human Papillary Bladder Cancer and Shorter Survival

PURPOSE We investigated the expression of Notch receptors and ligands in normal bladder transitional epithelium and transitional cell carcinoma of the bladder. We also explored its clinical and pathological implications. MATERIALS AND METHODS The expression of Notch-1 to 3, Jagged-1 and Delta-like-1 was detected respectively in 70 cases of bladder carcinoma, 10 of normal urothelium and the 2 cell lines T24 and BIU-87 using immunohistochemistry. Reverse transcriptase-polymerase chain reaction and Western blot were used to assay the expression level of Notch-1 and Jagged-1. The predictive value of this expression for prognosis was investigated by Kaplan-Meier curves and Cox proportional hazards analysis in a multivariate model. RESULTS All 5 kinds of Notch factors were intensively stained in normal bladder transitional epithelium immunohistochemically but expression was significantly decreased in tumor tissues. Moreover, expression of the 5 genes in papillary tumors was lower than in invasive tumors but only Notch-1 and Jagged-1 showed a statistically significant difference. Postoperative disease-free survival time in patients with low Notch-1 plus Jagged-1 expression was significantly shorter than that in patients with other expression patterns in papillary tumors (p = 0.014). Multivariate Cox proportional hazards model analysis identified Jagged-1 expression as an independent prognostic factor for disease-free survival (RR 3.09, p = 0.011). CONCLUSIONS The Notch family expression pattern in papillary bladder transitional cell carcinoma is different from that in invasive bladder transitional cell carcinoma. Low expression of Notch-1 as well as Jagged-1 is potentially a useful marker for survival in patients with papillary bladder transitional cell carcinoma.

The retroperitoneal laparoscopic Hellström technique for pelvi-ureteric junction obstruction from a crossing vessel

Associate Editor

Laparoscopic Adrenalectomy for Beginners Without Open Counterpart Experience: Initial Results Under Staged Training

OBJECTIVES To develop a staged laparoscopic training program for beginners to perform laparoscopic adrenalectomy (LA) and to determine its safety and feasibility. METHODS From January 2002 to October 2007, 5 beginners (postgraduate years 1-5) without previous experience in open adrenalectomy were selected randomly to receive the staged laparoscopic training, including box-trainer, animal model, and mentor-initiated clinical training. During the clinical training, the trainees acted as the camera holder first, and then selectively performed simple operations, such as laparoscopic renal cyst unroofing. Finally, they performed 30 LAs independently under the mentors supervision using the technique of anatomic retroperitoneoscopic adrenalectomy. The clinical data of the 30 LAs performed by each the trainees (150 LAs total) were collected and compared with the data from the initial 30 LAs of the mentor. RESULTS All LAs were completed successfully. No procedure required conversion to open surgery. The median operative time of the trainees was 82.3 minutes (range 59-133), which was obviously shorten than the mentors (median operative time 131.5 minutes, range 73-230, P < .001). The learning curve among the trainees was shorter compared with that of the mentor. No major complications were observed. The minor intraoperative and postoperative complication rate for the trainees was 0.67% and 6.7%, respectively, not significantly different from those of the mentor (0% and 3.3%, respectively; both P > .05). All complications developing in patients treated by the trainees required only conservative therapy. CONCLUSIONS It was safe and feasible for beginners without previous open counterpart experience to perform LA using staged training.

The single needle method for urethrovesical anastomosis with strengthened posterior fixation during laparoscopic radical prostatectomy

SummaryThe single needle method for urethrovesical anastomosis with strengthened posterior fixation during laparoscopic radical prostatectomy was explored. The method was initiated by performing a fixing suture with a knot at 4 o’clock of the posterior lip of bladder neck, and another suture at nearby position was performed to leave the knot outside. From 5 o’clock to 8 o’clock, sutures were performed every one o’clock to secure posterior approximation, then every two o’clock a suture. To avoid a loose anastomosis, lock sutures were performed every 3 sutures. The needle was always driven full-thickness outside-in in the bladder neck and inside-out on the urethra. After completing the full circumference, the needle was drawn near the 4 o’clock and tied at the tail end. Any leakage could be closed with additional interrupted sutures. The clinical data of 89 patients who underwent this method were retrospectively compared with those of 23 patients who underwent the single knot method. The results showed that the anastomosis, operative and catheterization time was 17.6±4.7 min, 134.0±10.7 min and 6.5+1.6 days respectively. There were 3 temporal urinary leakages identified in 89 cases requiring prolonged catheterization. No urinary leak and anastomotic stricture was confirmed, and 95.2% patients had total urinary control. It was concluded that this method was simple and safe for urethrovesical anastomosis.The single needle method for urethrovesical anastomosis with strengthened posterior fixation during laparoscopic radical prostatectomy was explored. The method was initiated by performing a fixing suture with a knot at 4 o’clock of the posterior lip of bladder neck, and another suture at nearby position was performed to leave the knot outside. From 5 o’clock to 8 o’clock, sutures were performed every one o’clock to secure posterior approximation, then every two o’clock a suture. To avoid a loose anastomosis, lock sutures were performed every 3 sutures. The needle was always driven full-thickness outside-in in the bladder neck and inside-out on the urethra. After completing the full circumference, the needle was drawn near the 4 o’clock and tied at the tail end. Any leakage could be closed with additional interrupted sutures. The clinical data of 89 patients who underwent this method were retrospectively compared with those of 23 patients who underwent the single knot method. The results showed that the anastomosis, operative and catheterization time was 17.6±4.7 min, 134.0±10.7 min and 6.5+1.6 days respectively. There were 3 temporal urinary leakages identified in 89 cases requiring prolonged catheterization. No urinary leak and anastomotic stricture was confirmed, and 95.2% patients had total urinary control. It was concluded that this method was simple and safe for urethrovesical anastomosis.

A Multimodal Training Program for Laparoscopic Pyeloplasty

PURPOSE We introduced a multimodal training program for laparoscopic pyeloplasty (LP) and evaluated its safety, feasibility, and efficacy. METHODS The program consisted of box-trainer training, animal-model training, and operative training. Five trainees with different experiences in open pyeloplasty and laparoscopy were exposed to the program. The mentor performed objective and subjective evaluations at each stage to ensure the training quality and operation safety. The perioperative parameters of five groups of patients who underwent LP by the trainees independently were evaluated. RESULTS All trainees successfully finished the training program and independently performed five LPs under the supervision of the mentor. Five trainees spent different training times on the box-trainer and animal-model training,but acquired similar laparoscopic proficiency. There were no conversions to open procedures, transfusions, or deaths among the patients. No statistically significant difference was found in the operative time, estimated blood loss, postoperative hospital stay, and perioperative complications among the five trainees (P > 0.05). CONCLUSION The multimodal training program can be used to train residents to perform advanced LP through step-by-step training from box trainer to animal model to clinical practice. The mentor-initiated approach is important to guarantee the training quality and safety.

Retroperitoneal Laparoscopic Upper-pole Nephroureterectomy for Duplex Kidney Anomalies in Adult Patients

OBJECTIVES To present our surgical techniques and experience with retroperitoneal laparoscopic upper pole nephroureterectomy for a duplex kidney in adult patients without vesicoureteral reflux. METHODS A total of 32 adult patients with a duplex kidney underwent laparoscopic upper pole nephroureterectomy. A 3-port, finger- and balloon-dissecting, retroperitoneal approach was used. The upper pole renal parenchyma was divided circumferentially between the upper and lower poles using a harmonic scalpel, maintaining a margin around the upper pole parenchyma to avoid any possible injury to the lower pole functioning moiety. The urothelium of the remnant upper pole parenchyma was stripped off, and the edges of the remnant upper pole parenchyma were approximated with figure-of-8 stitches. The distal upper pole ureter was mobilized and transected at the point at which the ureter crossed anterior to the iliac vessels. Intravenous urography and renal ultrasonography were performed at 3 and 6 months postoperatively. RESULTS All laparoscopic operations were performed successfully without conversion to open surgery. The mean operative time was 83 minutes. The mean blood loss was 18 mL. The mean postoperative hospital stay was 7 days. No intraoperative or major postoperative complications occurred. The intravenous urography and renal ultrasound findings 3 and 6 months postoperatively demonstrated normal pyelography findings and renal function of the preserved lower pole in all patients. CONCLUSIONS Retroperitoneal laparoscopic upper pole nephroureterectomy is a safe and effective procedure and an excellent minimally invasive treatment option for the adult patient with a duplex kidney.

Expression of KAI1/CD82 and MRP-1/CD9 in transitional cell carcinoma of bladder.

The expression of KAI1/CD82 and MRP-1/CD9 in transitional cell carcinoma of bladder (TCCB) and its clinical significance were investigated. Immunohistochemistry was used to detect KAI1/CD82 and MRP-1/CD9 protein expression in 52 TCCB specimens. Correlation between the expression of KAI1/CD82 and MRP-1/CD9 to clinicopathologic factors was statistically analyzed. The results showed that the positive rate of KAI1/CD82 and MRP-1/CD9 in TCCB was 50% and 61.5%, respectively. The MRP-1/CD9 and KAI1/CD82 expression was significantly associated with grade of TCCB (P<0.05), but no correlation was found between MRP-1/CD9 or KAI1/CD82 expression and clinical stage of TCCB (P>0.05). The expression level of MRP-1/CD9 and KAI1/CD82 in recurrent TCCB samples was lower than that in non-recurrent samples (P<0.05). Meanwhile, the correlation between the KAI1/CD82 expression and MRP-1/CD9 expression was statistically significant (r=0.316, P<0.05). It was concluded that KAI1/CD82 and MRP-1/CD9 expression may be important prognostic indicators and potentially useful for assessing the biological behavior of TCCB.