Faculty Bibliography

PURPOSE: Laparoscopic partial/wedge nephrectomy, similar to laparoscopic radical prostatectomy, is a technically challenging procedure that is performed by a limited number of expert laparoscopic surgeons. The incorporation of a robotic surgical interface has dramatically increased the use of minimally invasive pelvic surgery such that robotic laparoscopic radical prostatectomy is commonly performed even by laparoscopically naive surgeons. This analysis compares the outcomes of our initial experience with robot-assisted laparoscopic partial nephrectomy (RLPN) performed by an experienced open surgeon to that of standard laparoscopic partial nephrectomy (LPN) performed by two experienced laparoscopic surgeons. PATIENTS AND METHODS: We reviewed the medical records of 11 consecutive patients who underwent 12 standard LPNs (EMM, RVC) (one patient had two unilateral tumors) and 10 consecutive patients (representing the first 11 of such robotic procedures performed at our institution) who underwent 11 RLPNs (one patient had bilateral tumors managed in an asynchronous manner) (DKO). RESULTS: The mean tumor size was 2.3 cm (range 1.7-6.2 cm) for LPN and 3.1 cm (range 2.5-4 cm) for RLPN. The mean total procedure time was 289.5 minutes (range 145-369 min) for LPN and 228.7 minutes (range 98-375 min) for RLPN (P=0.102). The mean estimated blood loss was 198 mL (range 75-500 mL) for LPN v 115 mL (25-300 mL) for RLPN (P=0.169). The mean warm ischemia time was 35.3 minutes (range 15-49 min) in the LPN group and 32.1 minutes (range 30-45 minutes) in the RLPN group (P=0.501). CONCLUSIONS: Introducing a robotic interface for laparoscopic partial/wedge resection allowed a fellowship-trained urologic oncologist with limited reconstructive laparoscopic experience to achieve results comparable to those for laparoscopic partial/wedge resection performed by experienced laparoscopic surgeons. In this regard, the learning curve appears truncated, similar to that with robot-assisted laparoscopic prostatectomy.

PURPOSE OF REVIEW: Concurrent with the rise of laparoscopic radical nephrectomy as the gold standard for managing renal cell carcinoma, awareness has increased regarding the value of nephron-sparing surgery, even in the presence of a normal contralateral kidney. Therefore, whereas fewer radical nephrectomies will be performed for T1a tumors, there is a move towards handling more advanced pathology laparoscopically; that is, very large tumors, T3b disease, and limited lymph-node involvement. This review will highlight the long-term outcomes and recent developments in laparoscopic radical nephrectomy reported over the past year. RECENT FINDINGS: There were several papers reiterating the excellent long-term outcomes of laparoscopic radical nephrectomy in the form of retrospective comparisons with cohorts of patients undergoing open radical nephrectomy. None of these studies demonstrated any differences in 5-year cancer-specific or overall survival. Surgeons continue to expand upon the current technique and indications. SUMMARY: Long-term studies repeatedly support the superiority of laparoscopic radical nephrectomy over open radical nephrectomy for the majority of renal cell cancers due to equivalent oncologic control, low morbidity and shorter convalescence time. Experienced surgeons are able to manage more advanced pathologies laparoscopically without compromising cancer control or patient safety.

PURPOSE: We compared healing after laparoscopic cystotomy using fibrin glue, sutures, or a combination to determine whether fibrin glue can obviate the need for sutures and whether there is any detriment when glue is used in the presence of sutures. MATERIALS AND METHODS: In 24 Yorkshire pigs, a 3.5 cm vertical cystotomy was created laparoscopically and repaired as follows: Group 1--no closure; group 2--fibrin glue closure; group 3--suture repair; group 4--combined fibrin glue and suture repair. All animals had a Foley catheter for 1 week. In each group, three animals were harvested at 1 week (acute) and three animals were harvested at 6 weeks (chronic). RESULTS: Acute: Group 1--all pigs had an unhealed defect that leaked when evaluated by cystography. Groups 2, 3, 4--mean leak pressures were 80, 97, and 60 cm H(2)O (P = 0.36), respectively. Mean bladder capacity was not significantly different between groups. Chronic: No leakage seen on a cystogram at 1 week; at 6 weeks, bladders were filled at > or =95 to 100 cm H(2)O without leakage. Histologically, there was more inflammation in the acute group v chronic group pigs. In the acute group pigs repaired with glue or suture + glue, there was more inflammation and less epithelial continuity than in the suture alone group. At 6 weeks, there was no difference between groups. CONCLUSION: Fibrin glue provoked an intense inflammatory response that might have delayed healing acutely, resulting in a lower burst pressure in both scenarios in which it was used (i.e., alone or in combination with sutures). However, by 6 weeks, there did not seem to be any difference between groups either clinically or histopathologically.

OBJECTIVES: The processing of standard flexible cystoscopes is time-consuming and potentially hazardous to healthcare staff. We evaluated a novel flexible cystoscope system containing a disposable sheath, which obviates the need for chemical processing. METHODS: A total of 100 patients undergoing office cystoscopy were randomized into a "sheath" or a control group (n = 50 for each group). Disposable Slide-On sheaths and the CST-2000 Flexible Cystoscope System were used in the former group. A standard 16F flexible cystoscope, manually cleaned and disinfected with Cidex OPA or Rapicide, was used in the control group and the preparation times were recorded. Questionnaires to assess cystoscope setup, handling, optical quality, and patient comfort were completed by the physician, nursing staff, and patients. RESULTS: Data were available for 97 patients. The mean total time required for preparation of the cystoscopes was 10.7, 14.7, and 42.2 minutes for the sheath (n = 49), Rapicide (n = 21), and Cidex OPA (n = 27), respectively (P <0.01 for all comparisons). The control group scored better than the sheath group with regard to ease of cystoscope insertion (9.1 versus 7.7), cystoscope handling (8.8 versus 8.1), and irrigation setup (8.8 versus 8.2; all P < or = 0.01). No statistically significant difference was found between groups for procedure time, optical quality, or patient comfort, either during or after the procedure. CONCLUSIONS: The EndoSheath System can save 4 to 31 minutes of processing time while avoiding exposure to irritants found in conventional soaking methods. Although maneuvering of the sheathed cystoscope was slightly more difficult, the optical quality and patient comfort were similar to those of standard flexible cystoscopy.

Intraperitoneal bladder rupture usually is caused by blunt external trauma to a distended bladder. Although such injuries generally necessitate a formal laparotomy, advances in minimally invasive surgery have allowed successful laparoscopic repair. We describe our preoperative evaluation and laparoscopic technique in a case of isolated intraperitoneal bladder rupture secondary to trauma.

BACKGROUND AND PURPOSE: The effects of commonly used reprocessing methods on flexible ureteroscope longevity have never been examined. We prospectively studied the effects of Steris 1 sterilization and Cidex ortho-phthalaldehyde (OPA) high-level disinfection (HLD) on the image quality, physical structure, and deflective properties of two new flexible ureteroscopes. MATERIALS AND METHODS: Two identical "out-of-the-box" Storz 11278AU1 flexible ureteroscopes (Karl Storz Endoscopy, Tuttlingen, Germany) were sterilized individually using the Steris 1 system (Steris Mentor, Ohio) or disinfected with Cidex OPA (Advanced Sterilization Products, J&J, Irvine, CA) for 100 trials followed by a crossover to the other method for another 100 trials over a period of 1 year. After every five trials, optical quality, angle of deflection, and fiber damage were analyzed in the laboratory. Throughout the study, neither of these ureteroscopes was used clinically. RESULTS: After 100 trials, ureteroscope 1, which was sterilized initially in the Steris system, had a 12-mm tear on its shaft (noted after the 17th trial), 297 damaged fibers, and a 37% drop in resolution (loss of 3.75 lines/mm). There was no change in deflection from baseline. In contrast, after 100 cycles, ureteroscope 2, which was subjected to HLD with Cidex OPA, had no visible external damage, a 0% change in resolution, 10 damaged fibers, and no change in deflection. After the crossover, ureteroscope 2 developed a semilunar defect that obscured the endoscopic view, whereas there was no further significant damage to ureteroscope 1. CONCLUSION: After 100 cycles, the Steris 1 system rendered the flexible ureteroscope unusable, whereas HLD with Cidex OPA had minimal adverse impact.

INTRODUCTION: We previously reported the benefit of meticulous apical dissection in reducing positive surgical margins (SM+) at the apex. Herein we assess whether a more aggressive urethral transection will reduce positive margins and whether reduced urethral length affects return to continence. TECHNICAL CONSIDERATIONS: All data were collected prospectively. A positive surgical margin was defined by the presence of cancer cells with ink on them. Continence, defined as no pads, was assessed with validated Expanded Prostate Cancer Instrument Composite questionnaires. Evaluation of 200 consecutive cases (group 1) revealed that 75% of surgical margins occurred at the apex. Concomitantly we assessed visual cues for urethral length, which demonstrated that even patients with very short urethral stumps requiring perineal pressure during anastomosis had equivalent times to continence as those with long, accessible stumps. We altered the point of transection, distally, to include 3 to 6 mm more of striated external urethral sphincter. The SM+ rate and time to continence for the ensuing 200 cases (group 2) were tracked. The overall SM+ and apical SM+ rates were significantly reduced (SM+ 17.6% versus 7.5%, P = 0.003; and apical SM+ 13% versus 5.5%, P = 0.01). Kaplan-Meier times to continence curves were not significantly different. CONCLUSIONS: A more aggressive apical resection resulted in marked reduction in overall SM+ rates without measurable change in time to continence or overall continence.

A percutaneous approach to cryoablation of renal masses is not without a risk of complications. We describe a case in which selective, single lung intubation of an obese patient with an upper pole left renal mass allowed for percutaneous cryoablation with avoidance of pleural and pulmonary injury. We accomplished this by minimizing the ventilation-induced renal motion and collapsing the ipsilateral lung so that it remained out of harm's way.

Image-guided percutaneous nephrostomy tube placement can be a challenging procedure, particularly in a nondilated system or in the morbidly obese patient. Herein, we report the routine use of ureteroscopy-guided percutaneous renal access. With this method, rapid, accurate creation and dilation of the nephrostomy tract is assured in all patients regardless of body habitus or stone burden.

Ureteral obstruction caused by extrinsic compression by a malignancy generally can be overcome initially with a ureteral stent. However, the long-term failure rate is high, usually necessitating placement of a nephrostomy tube. Herein, we present the initial case, in this country, of intractable ureteral obstruction managed successfully with the newly developed all-metal Resonance stent (Cook Ireland Ltd., Limerick, Ireland) constructed of MP35N alloy, a composite of nonmagnetic nickel-cobalt-chromium-molybdenum. The patient is a 64-year-old woman with metastatic breast cancer causing retroperitoneal fibrosis and ureteral obstruction diagnosed laparoscopically. The obstruction failed to respond to placement of a single 7F double-J stent and then of two 6F double-J stents in the left ureter. As a last resort, in order to avoid nephrostomy-tube placement, the 6F metal stent was placed; this provided unobstructed flow of urine, as documented on a subsequent Whitaker test and, most recently, on a renal scan, 4 months after initial stent placement.