Faculty Bibliography

BACKGROUND AND PURPOSE: Most series on ureteroscopy for urolithiasis use postoperative plain radiography of the kidneys, ureters, and bladder (KUB) or intravenous urography (IVU) to determine outcomes. These imaging modalities, however, are not very sensitive and may overestimate stone-free rates (SFRs). The aim of our study was to assess SFRs after ureteroscopy for urolithiasis using CT follow-up. PATIENTS AND METHODS: A total of 92 patients underwent 113 ureteroscopic procedures for either renal or ureteral stones. Success of ureteroscopy was then determined by the absence of any stone fragments (stone-free). Stone-clearance rates (SCRs) were also calculated for < or = 2 mm and < or = 4 mm residual stone fragments. RESULTS: Each renal unit contained a mean of 1.87 stones with a mean stone diameter of 8 +/- 6 mm. The overall SFR was 50.4%. SFRs were significantly higher for ureteral stones (80%) than renal stones (34.8%) (P = 0.0001). Renal units with multiple stones were less likely to be stone free than those with single stones (P = 0.011). No difference in SFRs was found between lower pole and non-lower-pole stones. CONCLUSIONS: Overall SFRs by CT were lower than SFRs reported by radiography of the KUB or IVU criteria. Further studies to identify the clinical significance and natural history of residual stone fragments on CT scan after ureteroscopy are needed.

PURPOSE: As nephron sparing surgery is used more frequently for select renal tumors, the incidence of urine leaks will likely increase. To our knowledge the risk factors of and management strategies for urine leaks have not been studied. We report our experience with the risk factors of and management for urine leaks after open and laparoscopic partial nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the records of 127 consecutive patients who underwent partial nephrectomy between 2001 and 2007, including 70 with open and 57 with laparoscopic partial nephrectomy, as performed by 3 surgeons. Urine leak was defined as drain output consistent with urine greater than 48 hours after laparoscopic partial nephrectomy. RESULTS: Of the patients 21 experienced a urine leak after partial nephrectomy, including 13.3% overall, and 10.5% after laparoscopic and 18.5% after open partial nephrectomy. Patients with a urine leak had significantly greater tumor size (3.2 vs 2.4 cm, p <0.044), endophytic locations (57% vs 19%, p <0.00027) and repair of collecting system defects during partial nephrectomy (95% vs 56%, p <0.00072). There was no association with the number of tumors removed, estimated blood loss, ischemia time, body mass index, age or other surgical complications. The median duration of urine leak was 20 days. While most urine leaks resolved with prolonged drainage, 38% of cases required further intervention. Patient age at surgery was the only factor that correlated with prolonged (greater than 30 days) urine leak. CONCLUSIONS: Urine leak is a complication unique to partial nephrectomy that is more commonly noted when a larger endophytic mass involves the renal collecting system. Most leaks resolve with prolonged drainage or replacement of a ureteral stent.

PURPOSE: We present a single institutional experience over 6 years of intra and postoperative complications following urethral reconstructive surgery, and the impact of these complications on overall results. MATERIALS AND METHODS: From June 2000 through May 2006, 153 consecutive urethral reconstructive procedures were performed on 128 patients by one surgeon (CMG). Complication rates were determined, and subgroups were categorized based on stricture etiology, patient age, length of stricture, location of stricture, type of repair, and presence of various co-morbid conditions. RESULTS: Overall, 23 of 153 cases (15%) had an intra or postoperative complication with a mean follow-up time of 28.3 months (range 3 to 74). The most common complications were related to infection (n = 9). Other complications included repair breakdown (n = 4), bleeding (n = 4), fistulae (n = 3), thromboembolic (n = 2), positioning-related (n = 2), and Foley catheter malfunction (n = 1). Complication rates for anastomotic and substitution urethroplasty were 9.1% (4/44) and 17% (19/109), respectively. The number of patients with at least one year of follow-up who had a complication and eventual stricture recurrence was 20% (4/20), while only 7.4% (7/95) of those who did not have a complication recurred (p = 0.08). CONCLUSIONS: Complications following reconstructive surgery for urethral stricture disease were mostly related to infection or repair breakdown in the immediate postoperative period. It does not appear that an intra or postoperative complication following urethral reconstructive surgery impacts the chance of eventual stricture recurrence at intermediate follow-up.

Iatrogenic occurrences (including radiologically guided renal biopsy, shockwave lithotripsy, and minimally invasive ablative procedures) of subcapsular hematoma that lead to acute renal failure are rare but serious. The advancement of minimally invasive procedures has led to an increase in this complication, especially in patients with a solitary kidney. Fortunately, prompt surgical evacuation of the hematoma in these patients allows decompression of the renal parenchyma and recovery of renal function. We report a case of acute renal failure in a patient with a solitary kidney that resulted from a subcapsular hematoma as a complication of radiofrequency ablation.

PURPOSE: There is limited literature examining urethral reconstruction in patients with neurogenic bladder dysfunction. We describe our experience of urethral reconstruction in men with concurrent neurogenic bladder. MATERIALS AND METHODS: A prospectively maintained database of all urethral reconstruction procedures performed by 1 surgeon was analyzed for patients with neurogenic bladder dysfunction. Patient characteristics including the etiology of neurogenic bladder, urethral pathology, urethral reconstructive technique, complications and recurrences were evaluated. RESULTS: A total of 23 patients were included in the analysis. Urethral pathology included erosions (10), strictures (7), diverticula (3), urethrocutaneous fistulas (2), and a combination of diverticular and stricture disease (1). Median length of the urethral pathology was 5.0 cm (range 2.0 to 10.0). Overall urethral reconstruction was successful in 16 of 23 patients (69.6%) at a mean followup of 24.7 months (range 2 to 79). Success rates differed among the types of pathology with 60% for urethral erosions, 85.7% for urethral strictures, and 66.6% for urethral diverticula and fistulas. Of those cases of recurrence 4 of 7 (57%) were after urethral erosion repair. There was 1 (4.3%) postoperative complication and no patient underwent urinary diversion after recurrence. CONCLUSIONS: When identified at an early stage, urethral reconstruction in patients with neurogenic bladder dysfunction offers acceptable outcomes with limited morbidity. Men undergoing reconstruction for urethral erosion had inferior outcomes compared to those with other urethral pathology.

BACKGROUND AND PURPOSE: Specimen morcellation during laparoscopic radical nephrectomy for renal-cell carcinoma is controversial, and supporting literature remains sparse. We seek to evaluate the safety and efficacy of morcellation for specimen removal after laparoscopic radical nephrectomy for management of renal lesions of malignant potential at a single institution. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients who underwent laparoscopic radical nephrectomy at Northwestern Memorial and Evanston Hospital from 2001 to 2006. Twenty-two patients were identified who underwent specimen morcellation for extraction after laparoscopic nephrectomy that was performed for enhancing solid or cystic renal masses. RESULTS: Laparoscopic radical nephrectomy was performed on all the patients. Patient age ranged from 36 to 96 years old. All patients were clinical stage T(1)N(0)M(0). The specimen was mechanically morcellated within Cook Lap Sac under direct and laparoscopic vision. Average tumor size after morcellation was 3.0 cm. On histologic review of the morcellated specimen, 18 patients were confirmed to have renal-cell carcinoma, 2 had an oncocytoma, and 2 had benign cysts. One patient with renal-cell carcinoma had a pathologic upgrade to stage T(3b). Average operating time was 268 minutes (range 110 to 389 min). With the exception of the patient who became anephric after nephrectomy, average hospital stay was 2.6 days. A mean clinical and radiographic follow-up of 434 days failed to show any known disease progression or port site recurrence in patients with renal-cell carcinoma. CONCLUSIONS: Intracorporeal, mechanical morcellation after laparoscopic radical nephrectomy appears to be safe and effective in clinical stage T1 renal-cell carcinoma. This study adds to current literature that promotes the use of morcellation as an alternative for intact specimen removal in properly selected patients. Further prospective studies are necessary to show long-term oncologic outcomes.

BACKGROUND AND PURPOSE: The usefulness of plain film chest radiography (CXR) in evaluation for thoracic complications after laparoscopic urologic procedures is uncertain. Our objectives were to examine the association between radiographic findings and clinical manifestations of thoracic complications after laparoscopic urologic procedures and to determine the prevalence of postoperative CXR at our institution. PATIENTS AND METHODS: We performed a retrospective review of 195 patients who underwent laparoscopic renal/adrenal urologic procedures at our institution from 1998 to 2005. Chi-square analysis was used to compare the rate of radiographic abnormalities and thoracic complications between different types of laparoscopic procedures. RESULTS: A total of 96 patients (96/195, 49%) had postoperative CXR, and abnormalities were noted in 75 (75/96, 78%). The abnormalities seen on CXR included atelectasis, pleural effusions, pneumomediastinum, pneumothorax, subcutaneous emphysema, and pneumonia. Retroperitoneal laparoscopy had significantly more incidental subclinical pneumothoraces (P = 0.000469) and subcutaneous emphysema (P = 0.043) identified by CXR than either transperitoneal, hand-assisted, or cryosurgery. Overall, eight patients (8.3%) had clinical manifestations of a thoracic complication but only five (5.2%) were clinically significant complications detected by CXR. Thus, while 75 CXRs were noted as abnormal, 70 (93%) documented incidental findings that did not affect patient care. CONCLUSIONS: Thoracic complications after laparoscopic urologic procedures are uncommon events. Although the majority of CXRs after such procedures do contain abnormalities, most abnormalities are subclinical and do not affect postoperative management. Patients with significant radiographic findings demonstrated significant clinical symptoms. Thus, routine CXR after urologic laparoscopy does not appear to be necessary to identify thoracic complications and may be overused.

OBJECTIVE:We report our initial experience with 62 patients undergoing robotic-assisted laparoscopic prostatectomy (RALP), focusing on the primary parameter of positive surgical margins. The authors demonstrate that excellent oncologic outcomes can be attained with a less steep learning curve than previously hypothesized. MATERIALS AND METHODS/METHODS:The first 62 patients undergoing RALP by a single physician (DPD) at our institution between November 2005 and August 2007 were retrospectively assessed. Surgical pathology records were reviewed for Gleason score, pathologic tumor stage, nodal status, location of prostate cancer within the specimen, extracapsular extension, surgical margin status, presence of perineural invasion, tumor volume, and weight of the surgical specimen. Margin status was determined using surgical specimens only, and not intraoperative frozen sections. All cases in this series were completed using the four-arm da Vinci Robotic System (Intuitive Surgical, Sunnyvale, California). RESULTS:Sixty-one patients had prostate cancer on their final surgical pathology specimens. Pathologic stage T2 and stage T3 patients were 88.7% and 9.7% of all cases, respectively. The pathologic Gleason score was 7 or greater in 62.3%. Our overall positive surgical margin rate was 3.3%. Patients with pathologic T2 and T3 disease had a positive surgical margin rate of 1.8% and 16.7%, respectively. CONCLUSIONS:Our study suggests that RALP can have equal if not better pathologic outcomes compared to open radical prostatectomy even during the initial series of cases. We argue that the learning curve for RALP is shorter than previously thought with respect to oncologic outcomes, and concerns asserting that lack of tactile feedback leads to poor oncologic outcomes are unfounded.

PURPOSE: Although the use of stents after ureteroscopy has been studied extensively, relatively little has been published about stent placement before complicated ureteroscopic procedures. In this study, we examined our experience with stent placement before ureteroscopic management of renal and ureteral stone disease. PATIENTS AND METHODS: A total of 90 patients underwent ureteroscopic surgery on 115 renal units by a single surgeon from 2001 to 2006. All patients had documented follow-up with imaging either by CT or intravenous urography (IVU) with tomography. Patients were classified into two groups depending on whether they had a stent placed before ureteroscopy. Baseline characteristics, operative indications for stent placement, stone-free rates, and complications were compared between groups. RESULTS: Baseline characteristics were similar between the groups. The majority of patients received stents before stone management because of technical considerations during surgery (17/36, 47%) or infection (13/36, 37%). Strict stone-free rates after ureteroscopic treatment were 47% in the 79 procedures without previous stents, compared with 67% in the 36 procedures with prestenting (P < 0.05). Including small fragments (2 mm or smaller), stone-free rates improved to 54% v 78%, respectively (P < 0.02). Complications were not significantly different in the two groups (P = 0.70). CONCLUSION: Although routine stent placement is not necessary before all ureteroscopic procedures, we demonstrate that it is associated with good stone-free rates and few complications. In this retrospective cohort, prestenting was associated with significantly higher stone-free rates. Prestenting should be considered in challenging cases.