Diagnosis And Management

Due to the high solubility of CO2, in the select clinically stable patient with pneumothorax, pneumopericardium, and pneumomediastinum expectant management including close monitoring and serial chest X-rays is advocated. Subclinical gas collections in the chest are usually asymptomatic, and require no further intervention. These abnormal chest gas collections are incidentally detected on routine postoperative X-ray. Perhaps in the early laparoscopic experience, all patients should undergo chest...

References

Lund GO, Winfield HN, Donovan JF, Narepalem N. Laparoscopically-assisted penile revascular-ization for vasculogenic impotence abstr V5124 . J Endourol 1994 8 S64. 2. Jordan GH. Pediatric genitourinary laparoscopic surgery. AUA Today 1994 7(ll) l4-l5. 3. Denes FT, Mendonca BB, Arap S. Laparoscopic management of intersexual states. Urol Clin NA 2001 28 31-42. 4. Markovich R, Jacobson A, Aldana JP, Lee BR, Smith AD. Practice trends in contemporary management of adult ureteropelvic junction...

Obesity

Obesity poses a major challenge to the laparoscopic surgeon, both from the surgical (technical) and the medical aspect. Obesity has been recognized as an independent cardiovascular risk factor, and is associated with serious medical comorbidity including the metabolic syndrome, which is characterized by impaired glucose tolerance, dyslipi-demia, and hypertension. Other medical conditions caused or aggravated by obesity include sleep apnea, daytime sleepiness, asthma, and gastroesophageal...

Contraindications To Laparoscopic Radical Nephrectomy

There are general contraindications for performing surgical intervention, and specific clinical states which would prohibit a transperitoneal laparoscopic radical nephrec-tomy. General contraindications include those patients who cannot tolerate a general anesthetic, those who present with an uncorrectable bleeding diathesis, or patients with underlying severe cardiovascular or pulmonary disease, who are thus not ideal surgical candidates. Relative contraindications to transperitoneal...

The Indication For Dialysis

There are two modalities of dialysis hemodialysis and peritoneal dialysis. The indication for dialysis includes end-stage renal disease, acute renal failure, drug and chemical poisoning, acute hyperkalemia, metabolic disorder, and volume overload from congestive heart failure or lung diseases. In the case of renal failure, dialysis therapy is initiated when approximately 90 of normal renal function has been lost. The absolute contraindications for all forms of dialysis are irreversible dementia...

Left Transperitoneal Laparoscopic Technique

Laparoscopic Aspiration Needle Cyst

Table 3 lists the operative steps for a transperitoneal laparoscopic ablation of a simple renal cyst. Step 1 Trocar Configuration and Insertion Transperitoneal laparoscopic renal cyst ablation typically requires three trocars (5-mm, 10 12-mm, and 10 12-mm) as depicted in Fig. 7. After Veress needle insertion at the umbilicus and insufflation of the abdomen, a 10 12-mm trocar is placed at the umbilicus with the use of a Visiport b device and is utilized predominately for the laparoscope....

Contraindications To Peritoneal Dialysis Catheter Placement

There are relatively few contraindications to the placement of peritoneal dialysis catheters. The most important consideration is whether or not the abdominal cavity has previously been violated. Previous pelvic surgery that may lead to adhesions, colostomy, ileostomy, or urinary diversion would be a relative contraindication. Absolute contraindications include aortic vascular graft within three months, presence of ventriculoperitoneal shunt, ascites, and peritonitis. Previous retroperitoneal...

Immunologic Aspects Of Laparoscopic Urology

Fornara et al. (86) reported a prospective, controlled, nonrandomized animal and patient study to determine the systemic response to laparoscopic and open surgical procedures. In the animal study, 26 female pigs aged six months underwent either a laparoscopic bilateral varix ligation followed by bilateral nephrectomy (group I), introduction of trocars (group II), or establishment of an open surgical approach (group III). In the patient study, 145 patients underwent various laparoscopic...

Urologic Experience

A careful search of the urologic literature demonstrates a relatively low incidence of laparoscopic port site seeding from adrenal, renal, urothelial, testicular, or prostate carcinomas (Table 1). Dunn et al. demonstrated no port site recurrence or peritoneal seeding in their initial nine-year experience of 61 laparoscopic radical nephrectomies removed through both intact delivery and morcellation (38). As in other series (39), it is noteworthy that Clayman's group morcellated all specimens...

Rectal Injury During Radical Prostatectomy

Rectal injury during radical prostatectomy converts the case from a clean contaminated to a contaminated procedure and may increase the risk of septic complications, such as wound infection, pelvic abscess, peritonitis, rectourethral fistula, and death. The reported incidence of rectal injury during open radical prostatectomy ranges from 0 to 9 . The average incidence of rectal injuries reported in the larger series of laparoscopic radical prostatectomies is 1.7 (28 1647 procedures) (42)....

Incision of Gerotas Fascia Between the Upper Pole of the Kidney and the Adrenal Gland

The posterior aspect of Gerota's fascia is incised transversely at the level of the upper pole of the kidney (Fig. 6). The aim of the ensuing dissection is to circumferentially mobilize the upper pole and mid-region of the kidney and the covering Gerota's fascia. The upper pole is now dropped posteriorly onto the psoas muscle away from the adrenal gland. This dissection proceeds immediately adjacent to the parenchyma of the upper pole of the kidney. Care must be taken not to injure any...

Laparoscopic Anatomy Of The Male Pelvis

Touijer, and Jeffery W. Saranchuk Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, New York, U.S.A. INTRA-ABDOMINAL ANATOMY OF THE PELVIS The Medial Umbilical Ligament The Lateral Umbilical Ligament The Spermatic Cord The Iliac Vessels The Ureter THE RETROPUBIC SPACE The Pubis The Prostatic Neurovascular Plexuses Anatomy is the key element to surgery. This is true for open or...

Autosomal Dominant Polycystic Kidney Disease

In patients with autosomal dominant polycystic kidney disease, flank and or abdominal pain are the most common presenting symptom and have been noted in 60 of autosomal dominant polycystic kidney disease patients (31). These symptoms have been attributed to massive enlargement of the kidneys due to growth of a multitude of renal cysts with stretching of the renal capsule, traction on the renal pedicle, and or obstruction of the collecting system. These cysts have also been associated with the...

Robotic Adrenalectomy

Adrenalectomy has historically been a significantly morbid procedure due to the deep location of the adrenal glands in the retroperitoneum. Laparoscopy has significantly decreased the morbidity associated with this operation, and laparoscopic adrenalec-tomy is now the recommended gold standard for the majority of adrenal disorders requiring surgery. Despite this transition to minimally invasive surgery, the incidence of disease processes requiring laparoscopic adrenalectomy is quite low and can...

Transurethral Resection of the Prostate Skills A Potential Training Crisis

Transurethral resection of the prostate remains the gold standard surgical procedure for successfully treating medically refractory lower-urinary tract symptoms of benign prostatic hyperplasia or benign enlargement of the prostate (50,51), a chronic and potentially TURP is challenging to teach and iearn. Transurethral resection of the prostate outcomes vary widely in the community and are probably technically dependent. A decade ago, residents performed 120 TURPs on average prior to graduating...

Laparoscopic Radical Simple Nephrectomy Lesser or Greater Than One Day Duration of Hospital Stay Predictor

Univariate logistic regression analysis in the design group for duration of hospital stay lesser or greater than one day (Table 4) identified simple nephrectomy, hypertension and planned morcellation extraction incision as significant predictors of a duration of hospital stay of greater than one day. Multiple logistic regression analysis (Table 4) identified hypertension and planned extraction incision as independent significant predictors of a duration of hospital stay greater than one day....

Abdominal Accessrelated Bowel Injuries

The reported incidence of bowel injuries due to Veress needle and trocar insertion is 0.03 to 0.3 (7-10). Veress needle injuries are more common than trocar injuries. Correct Veress needle placement should be confirmed before proceeding with insufflation of the abdomen (Table 1). Bowel insufflation through a Veress needle may produce asymmetrical abdominal distension, insufflation of only a small amount of CO2 (less than 2 L) before high intra-abdominal pressures are reached, and passage of...

Initial Intraoperative Steps and Patient Positioning

The patient is brought into the operating theater and a general endotracheal anesthesia is administered. Combined team efforts of the operating surgeon and the attending anesthesi-ology staff lead to the best outcomes. Complete muscle relaxation is essential. In addition, the anesthesiologist should be experienced with the management of anesthetic agents and the monitoring of the patient during complex laparoscopic procedures, which may take several hours to complete. CO2 monitoring and...

Concomitant Adrenalectomy

Incidence of adrenal involvement from renal cell carcinoma is 1-2 (70). Candidates for nephron-sparing surgery for an upper pole tumor may present with contiguous involvement of the adrenal gland (pT3a tumor) or hematogenous involvement of the gland (Mi tumors) (71). In such cases, partial or radical nephrectomy with concomitant adrenalectomy is indicated. Ramani et al. (72) reported concomitant ipsilateral adrenalectomy during laparoscopic partial nephrectomy in four patients with an upper...

Laparoscopic Evaluation

As mentioned, laparoscopy has proven itself to be an excellent localization and diagnostic tool (23-26). It is useful in patients with bilateral undescended testicles as well as in cases of unilateral undescended testicles. It also has been helpful in allowing the surgeon to plan subsequent therapy (i.e., to decide whether orchidopexy or testicular removal is indicated). Motility of the testis and its vas deferens as well as the vascular supply can be assessed on laparoscopic diagnosis....

Da Vinci Surgical System

The da Vinci Surgical System is the most successful and most widely used surgeon-driven robot to date. Since its introduction in Europe in 2000 by cardiovascular surgeons, its applications have been expanding to include a number of surgical procedures, such as Nissen fundoplication, cholecystectomy, hernia repair, gastroplasty, appendectomy, and hysterectomy. The use of the da Vinci Surgical System in urologic surgery, including radical prostatectomy, radical cystectomy, adrenalectomy,...

Laparoscopic Extracorporeal Knotting

Ligatures Medical

Extracorporeal knotting techniques have evolved for a diverse variety of laparoscopic purposes. First, they can be utilized to secure hemostasis of the anterior abdominal wall (106). Best described as a sling suture technique, the utility in stopping active hemorrhage from trocar sites has been demonstrated by several authors. The technique of sling suturing extracorporeally, includes both straight and curved needles of various sizes (107). For control of anterior abdominal wall hemorrhage, a...

Laparoscopic Partial Nephrectomy For Cystic Masses

Scant data are available as regards laparoscopic nephron-sparing surgery for cystic lesions. Many centers employ laparoscopic techniques for the management of symptomatic renal cysts. However, the risk of potential seeding of cells due to inadvertent tumor spillage during laparoscopic cyst manipulation remains a concern in laparo-scopic partial nephrectomy for indeterminate renal cysts. Thirty-five patients with a complex renal cyst were evaluated laparoscopically by Santiago et al. (121). No...

Differences In Laparoscopic Retroperitoneal Lymph Node Dissections

Laparoscopic retroperitoneal lymph node dissection may be used as a staging or a therapeutic procedure. As most patients undergoing open retroperitoneal lymph node dissection or chemotherapy are treated unnecessarily (as they have no metastases), a minimally morbid approach to staging the retroperitoneum is highly attractive. In European series, laparoscopic retroperitoneal lymph node dissection serves this purpose and helps delineate those who have metastases and require chemotherapy versus...

Control of Lateral Pedicles and Preservation of the Neurovascular Bundles

This portion of the operation is typically performed with the bipolar cautery on the left and the scissors on the right, but the cautery hook and forceps can be used. An assistant provides contralateral traction by grasping either the ipsilateral seminal vesicle or the edge of the prostate (Fig. 7). The proximal pedicles are sharply dissected free from FIGURE4 Endopelvic fascia dissection. After the endopelvic fascia is incised (arrow indicating edge of fascia), a space is developed lateral to...

Indications And Contraindications

Following radical cystectomy, and in certain cases for benign conditions, the flow of urine is directed either through a conduit, the so-called noncontinent diversion, or a continent reservoir. The latter includes continent reservoirs with catheterizable stomas in which a low-pressure reservoir is fashioned from a detubularized bowel segment. When the urethra is not involved with cancer, appropriate patients may have a reservoir attached to their native urethra as an orthotopic neobladder. The...

Clinical Presentation And Diagnosis

Clinical manifestations of paraganglioma are varied and related to tumor function. Micturitional headaches have been reported with functional bladder pheochromo-cytoma (9). Functional tumors can cause classic paroxysmal hypertension, tachycardia, hypovolemia, and flushing. Nonfunctioning tumors may only be diagnosed when symptoms from local growth develop, i.e., palpable mass or abdominal pain. Patients with hereditary pheochromocytoma typically present at younger ages, in the second to third...

Burying The Peritoneal Dialysis Catheter

Traditional surgical implantation of Tenckhoff catheters involves immediate exteri-orization of the external segment through the skin, so that the catheter can be used for supportive peritoneal dialysis or for intermittent infusions during the break-in period. To prevent blockage and to confirm function, the catheter is flushed weekly with saline or dialysate each exchange carries the same risk of peritonitis as in continuous ambulatory peritoneal dialysis therapy to avoid bacterial...

Laparoscopic Partial Nephrectomy Greater or Lesser Than Two Days Duration of Hospital Stay Predictor

Univariate logistic regression analysis in the design group for duration of hospital stay greater or lesser than two days (Table 5) identified increased age, diabetes mellitus, planned transperitoneal approach, increased tumor size, parenchymal tumor, tumor extending up to renal sinus and tumor abutting the collecting system as significant predictors of a duration of hospital stay of greater than two days. TABLE4 Laparoscopic Radical Simple Nephrectomy Group Analysis for Duration of Hospital...

Extracorporeal High Intensity Focused Ultrasound Tissue Tripsy in Prostatic Disease

All systems presently used for therapeutic high-intensity focused ultrasound for urologic indications have a single transducer, which is focused either by having a concave shape or with acoustic lenses. The former are smaller and therefore have mainly been utilized for intracavitary use, such as transrectal high-intensity focused ultrasound of prostate cancer. As the focal lengths thus needed are smaller, frequencies in the 3-4 MHz range can be used. They produce small but very precisely...

Steps

The steps involved in transperitoneal laparoscopic adrenalectomy include 5. Mobilization of the adrenal gland The aim of a right-sided laparoscopic adrenalectomy is to remove the adrenal gland with early ligation of the adrenal vein. It is essentially a dissection of the inferior vena cava. Following induction, the patient is catheterized with a 16 French urethral catheter. A nonsteroidal analgesic suppository is then placed if there is no contraindication. A nasogastric tube is placed to...

Thoracoscopic Transdiaphragmatic Adrenalectomy Patient Selection

Although a history of major open abdominal surgery is no longer a contraindication to transabdominal laparoscopic adrenalectomy, significant technical difficulty may be encountered in patients with such a history. In fact, the presence of extensive adhesions might preclude transperitoneal laparoscopy in these patients. In these cases, the virgin retroperitoneal space may be directly and successfully accessed using retroperitoneal laparoscopy (6,21). Nevertheless, neither the transperitoneal nor...