Laparoscopic Radical Simple Nephrectomy Models

The following patient parameters were recorded during the retrospective chart review (392 patients) age, sex, surgeon, radical versus simple, unilateral versus bilateral, Our goal was to design algorithms to predict the duration of hospital stay after laparoscopic renal surgery based on preoperative patient parameters. planned adrenalectomy, planned lymph node dissection, gastro-esophageal reflux disease, hypertension, smoking, diabetes mellitus, hyperlipidemia, chronic obstructive pulmonary...

Laparoscopic Partial Nephrectomy Models

The following patient parameters were recorded during the retrospective chart review (334 patients) age, sex, surgeon, body mass index, American society in anesthasiology grade, hypertension, prior pancreatitis, prior abdominal surgery, prior deep venous thrombus, peripheral vascular disease, smoking, coronary astery disease, gastic erophageal refull disease, anxiety, hyperlipidemia, depression, renal stone disease, constipation, liver cirrhosis, hepatitis C, hematuria (micro or gross), chronic...

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

Univariate logistic regression analysis in the design group for duration of hospital stay greater or lesser than one day identified 24 patient characteristics as significant predictors for a duration of hospital stay of greater than one day as listed in Table 6. As there were only 28 patients in the design group who had a duration of hospital stay of less than or equal to one day, the statistical significance of some of these parameters may be overstated. Multiple logistic regression analysis...

Visceral Injury

The transabdominal preperitoneal repair has the potential of injuring bowel and vascular structures during initial trocar placement as well as during hernia repair. It is imperative that appropriate patient selection be used when choosing a laparoscopic repair. Patients with multiple prior laparotomies or previous pelvic surgery may be better served through open repair. During totally extraperitoneal repair, there is also the potential for bladder injury with initial balloon dissection. A bowel...

Access to Retzius Space

Following the inspection of the abdomen, we divide the urachus and the both umbilical ligaments using monopolar endoscissor and bipolar endodissector, followed by incision of the peritoneum to the internal inguinal rings laterally. Traversing the light prepubic areolar tissue of the space of Retzius using sharp and blunt dissection exposing the pubic bone caudally as the first landmark and the external iliac vessels laterally, freeing the bladder from its anterior attachments. Then a sixth port...

Access Veress Access

Access using the Veress method is applicable to children as long as the operator recognizes several issues. FIGURE2 Diagram of surgical setup with the surgeon at the patient's feet for an upper abdominal procedure in a small child. The surgeon is orientated in a straight line with the operative area. Abbreviations S, surgeon SN, scrub nurse SA, surgical assistant A, anesthesiologist M, monitor. FIGURE3 Diagram showing the surgical setup in a larger child for a renal procedure with the surgeon...

Adjacent Organ Injury

As in any laparoscopic renal procedure, injury to surrounding structures such as the bowel, spleen, liver, pancreas, pleura, and adrenals can occur. Use of a preoperative bowel preparation especially in more challenging cases such as autosomal dominant polycystic kidney disease can decompress the bowel, improve visualization, and reduce the chance of iatrogenic injury from laparoscopic instrumentation. During mobilization of the colon and small bowel, the use of elec-trocautery should be...

Adjunctive Procedures During Laparoscopic Radical Nephroureterectomy Lymphadenectomy And Adrenalectomy

Up to one-third of patients who undergo nephroureterectomy may be found to have lymph node metastasis (48). No specific data are available to assess the impact of lym-phadenectomy for upper tract transitional cell carcinoma during laparoscopic radical nephroureterectomy. However, data from open series and data from the treatment of bladder transitional cell carcinoma, from which some of the natural history of disease can be extrapolated, suggest an important role for lymphadenectomy in these...

Advantages Of Laparoscopy

As the open surgical procedure requires extensive mobilization within the retroperitoneum over a large area, it necessitates a large flank or midline incision. The objectives of open surgery can be easily met with minimally invasive technique of laparoscopy (Table 4) (11-13). Laparoscopy provides optical magnification that facilitates the identification of small lymphatics easily, thus increasing the chances of success with lesser blood loss and operative time. Postoperative recovery is rapid...

Age

Aging of the general population and the attendant increase in End stage renal disease has widened the gap between available cadaver kidneys and demand. It appears that there is the development of an organ social security system in which younger donors TABLE 4 Contraindications for Live Kidney Donation Abbreviation CT, computed tomography. There is no difference in recipient graft function when received from obese donors. However, the future health and well-being of obese donors is a real...

Aldosteronomas

Primary hyperaldosteronism (Conn's syndrome) is a rare etiology of hypertension (< 1 ). Other clinical manifestations of Conn's syndrome arise from an increased total body sodium content and a deficit in total body potassium. Symptoms include urinary urgency or frequency, nocturia, muscle weakness, paresthesias, or visual disturbances (4,11). Computed tomography scan or magnetic resonance imaging can detect adrenal adenomas as small as 1 cm in size. Laboratory manifestations include...

Alternative Sites for Introducing the Veress Needle

For a previously operated abdomen with a midline incision, the Veress needle should be placed in the upper left quadrant of the abdomen just lateral to the rectus sheath. Transrectus insertion of the Veress needle is discouraged because of risk of injury to the inferior epigastric vessels. The Veress needle at the upper quadrant region needs to be passed more deeply into the abdomen in order to enter the peritoneal cavity because all layers of the abdominal wall are present here and the risk of...

Alternative Techniques Renal Hilar Clamping

Renal hilar clamping is not necessary for every laparoscopic partial nephrectomy. Several centers have reported wedge-resection without hilar clamping for excision of small exophytic tumors with minimal parenchymal extension (6-8). FIGURE9 Three ports are needed during retroperitoneal laparoscopic partial nephrectomy. The initial port is at the tip of the 12th rib. The posterior port is at the junction of the costal margin and the paraspinal muscle. The anterior port is 3-5 cm cephalad to...

Anatomy Embryology And Function

The seminal vesicles are paired structures lying obliquely from inferomedial to supero-lateral at the posterior junction of the prostate and bladder. They contribute approximately 70 of the seminal fluid to the ejaculate (7). The right seminal vesicle is larger than the left in approximately one-third of men (8). The blood supply enters at the tip of the seminal vesicle and is usually from the vesiculodeferential artery, a branch of the superior vesical artery (9). Occasionally, there may also...

Anatomy Of The Abdominal Wall And Peritoneum

FIGURE 1 The anterior abdominal wall. The peritoneal circulation plays a major role in the exchange of fluid and solutes draining peritoneal dialysis. abdominis muscle). The parietal peritoneum is the innermost layer of the abdominal wall. It is a thin layer of dense, irregular connective tissue and is covered on the inside by a layer of simple squamous mesothelium. The peritoneum provides little strength in wound closure, but it affords remarkable protection from infection if it remains...

Anterior Abdominal Wall Injury

This has been attributed to the more lateral course of the inferior epigastrics along the rectus muscles compared to the more medial distribution for the superior epigastrics. The inferior epigastric artery is also larger than the superior epigastric. It has been reported that injuries to the superior epigastric artery are more likely to stop on its own than the inferior epigastric. Multiple techniques have been described for controlling bleeding from these sites. Resectoscopes have been placed...

Anterior Approach and Development of the Retzius Space

The bladder is filled with 120-200 mL of saline to help delineate its contours. The peritoneum is opened from one umbilical ligament to the other and the incision is extended upward to include the urachus, which is divided near the umbilicus (Fig. 7). The anterior surface of the bladder is mobilized and the prevesical and preprostatic space entered. The endopelvic fascia exposed is opened, uncovering the levator ani fibers. The latter are bluntly pushed away from the prostate the puboprostatic...

Apical Dissection

Following division of the Santorini plexus, both neurovascular bundles are exposed lateral to the rectum by blunt dissection. The approach to the apex of the prostate is determined by a decision to proceed with nerve-sparing or with the nonnerve-sparing technique. The criteria for carrying out nerve-sparing technique are listed in Table 3. After transection of the dorsal vein complex, the anterior striated sphincteric urethral complex is demonstrated. The fibers of this complex at the apex are...

Ascites

Presence of ascites is considered a contraindication to laparoscopic surgery because of the increased risk of port site metastasis. Neoplasic ascites is usually secondary to primary hepatic neoplasms, metastases to liver or peritoneum, lymphomas, leukemias, or myeloid metaplasia. The differential diagnosis of ascites is shown in Table 3 (19). The diagnosis of ascites is obtained by paracentesis and fluid analysis. Peritoneal effusion, like pleural effusion, can be subdivided as exudative or...

Background

And time-consuming moreover, it is important to note that the application pertained solely to extirpative laparoscopy for benign uterine diseases and morcellation was performed without specimen isolation. Thus, issues of tumor dissemination have been secondary in the removal of uterine tissue. Several principles and lessons emerge from the existing experience. First, little data address the application of laparoscopy to the removal of solid organs harboring tumor. The majority of minimally...

Basic Principles Of Immunology

We are all exposed to a large variety of infectious agents that would cause pathological damage if left unchecked. In majority of normal individuals, these infections are of limited duration and leave little damage because of the human defense mechanisms in the form of the immune system. The human immune system has two major functional divisions the innate and adaptive systems. Both act in concert, with innate immunity forming the first line of defense. Breaching of innate defenses leads to...

Basic Principles Of Tissue Engineering

The source of donor tissue can be heterologous, allogenic, or autologous autologous is preferred as this method avoids tissue rejection by the immune system and immunosuppressive drugs can be avoided. When autologous cells are used, a biopsy is obtained from the host and the cells are dissociated and expanded, and later returned to the same host as new tissue that is not immunogenic. Tissue engineering entails the use of donor tissue that is dissociated into individual cells. The cells are...

Bladder

Neobladders and bladder augmentations are being performed with increasing frequency. Obviously, there is an enormous need for bladder replacement tissue. The gastrointestinal segments that are currently used lack the physiologic and mechanical properties of urothelium. While gastrointestinal tissues are designed to absorb specific solutes, the urothelium is designed for urine storage, not the transfer of electrolytes. Despite the acceptable functional results of enterocystoplasty and orthotopic...

Bladder Neck Incision

After detaching the prostate from the rectum, the gland is gently pulled ventrally by applying traction on the intra-abdominal Foley catheter. The balloon helps to identify the vesicoprostatic comissure. Starting at the prostate-vesical junction, the anterior wall of the bladder neck is incised using bipolar coagulation and endoscissors, with the balloon becoming visible. Now the balloon is deflated by cutting the suture at the end of the catheter so that it can be now used as a loop-like...

Bleeding

Bleeding during laparoscopic renal cyst ablation can occur during many steps of the operation including (i) mobilization and dissection of the kidney, (ii) cyst wall excision and fulguration, and (iii) dissection around the renal hilum. Dissection of Gerota's fascia and perinephric fat and mobilization of the kidney, especially along the hilum and adrenal gland, can lead to bleeding. In cases of simple, solitary renal cyst, only limited dissection of Gerota's and perirenal fat should be...

Blind or Seldinger Technique

In the blind or modified Seldinger technique, a needle is inserted into the abdomen, a guidewire placed, a tract dilated, and the catheter inserted through a split-sheath all maneuvers are performed without visualization of the peritoneal cavity (11). The deep cuff usually remains outside the outer rectus sheath after implantation. The blind technique is not widely used in the United States. The bedside blind insertion technique is associated with a significant risk of visceral damage and high...

Blunt Trauma

Computed tomography scan is the mode of choice in evaluating the hemodynamically stable patient with blunt trauma. Certain circumstances have been described in which computed tomography scan results cannot completely rule out abdominal organ injury. For example, patients with pelvic fractures or retroperitoneal hematomas, who already have abdominal tenderness (thereby limiting clinical evaluation), are at increased risk for missed blunt hollow organ injury. Similarly, such occult findings may...

Bowel Preparation

In cases of symptomatic simple renal cysts, no specific bowel preparation is required prior to surgery. However in patients with autosomal dominant polycystic kidney disease, the typically large-sized kidneys can at times occupy the majority of the peritoneal cavity. Therefore, use of a preoperative bowel preparation (e.g., citrate of magnesium) is advised to decompress the bowel and provide more working space during laparoscopy. Patients should partake of only clear liquids 24 hours prior to...

Burch Colposuspension The Evolution of a Procedure

In 1961, Burch (1) published the development of a new technique for colposuspension, based on a technique started in 1958. A paramedian incision was used to enter the abdomen and space of Retzius. He instilled 50 cc of milk in the bladder to identify possible perforations. The periurethral tissue was cleaned off and then three 2.0 chromic sutures were placed at the midurethra and the bladder neck. These sutures were fixed to Cooper's ligament. In 1968, Burch (2) reported a subjective cure rate...

Carbon Dioxide

Carbon dioxide (CO2), introduced for insufflation by Zollikofer in 1924, is the most popular insufflant for laparoscopy under anesthesia (40). The primary advantages of using CO2 during laparoscopy include its rapid absorption and its noncombustible nature. The absorption of CO2 has contradictory effects at different sites. CO2 is directly cardioinhibitory, reducing heart rate, cardiac contractility, and vascular resistance (41). However, CO2 also stimulates the sympathetic nervous system, and...

Center for Minimal Access Surgery Telementoring Program

In Canada, telementoring is currently in routine clinical use, providing community surgeons in two rural cities with access to the expertise of expert laparoscopic surgeons, without the need for extensive travel. Surgeons at the Centre for Minimal Access Surgery (St. Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada) routinely mentor surgeons at two community hospitals, one in Northern Ontario and the other in Northern Quebec. Procedures performed to date include laparoscopic...

Central Vs Peripheral Tumor

Centrally located tumors typically require precise intracorporeal suturing and complex reconstruction. As such, in the past they have not been approached laparoscopically due to the added time constraints imposed by renal ischemia. Only a limited experience in eight patients with central tumors using a hand-assisted technique has been reported (115). Open partial nephrectomy remains the gold standard for the treatment of centrally located tumors (116,117). Frank et al. (118) specifically...

Clinical Applications In Urology

Limited clinical applications have been reported in urology for partial nephrectomy, radical prostatectomy and retroperitoneal lymphadenectomy using the hydro-jet technique. The majority of these procedures were completed using open technique. In a clinical study, 24 patients underwent open renal sparing surgery for various indications including renal tumors (21). The dissection was performed without hilar control. The dissection time was 14 to 40 minutes with no significant blood loss. A...

Clinical Practice

Most practicing surgeons have already seen at least one significant revolution during their careers, the radical changes brought by the many discoveries of the Information Age. The most dramatic has been the shift to minimal access surgery (laparoscopic, endoscopic, etc). The surgeon of the near future will be trying to decide (just as was the case with the introduction of laparoscopic surgery) whether it will be necessary to train and practice with robotic surgical systems. Surgeons already...

Clinical Presentation And Evaluation

Chyluria has an unpredictable course associated with remission and exacerbation. The disease usually affects young adults presenting with complaints of passage of whitish urine, white clots, or hematuria (hematochyluria). Sometimes chylous clots can lead to obstruction in the urinary tract, leading to clot colic (flank pain), retention of urine, or even anuria. Although not life threatening, the disease can be debilitating. Chyluria can lead to considerable weakness and weight loss secondary to...

Clips and Staplers

Surgical clips and staplers are predominantly used for securing medium and large caliber vessels during laparoscopic surgery. Surgical clips may be either titanium (Fig. 7) or polymer-plastic and are available in various sizes. Titanium clips can be applied through manual loading (reusable applicator) or automatic self-loading (disposable) applicators. The titanium clips may fall off during subsequent dissection and manipulation and hence multiple clips should be applied, especially during...

Collecting System Injury

Injury to the collecting system can occur during aggressive biopsy and fulguration of the base of the cyst wall or during attempts at cyst wall excision of a peripelvic or autosomal dominant polycystic kidney disease cysts. When biopsy of the cyst base is indicated, only superficial samples should be taken especially in the case of peripelvic cysts or cysts located close to the collecting system. Reference to preoperative radiologic films may be helpful in assessing the depth of the cyst and...

Common Gynecologic Laparoscopic Procedures Adnexal Mass and Adnexal Torsion

The incidence of adnexal masses during pregnancy is 2 (123). Adnexal torsion, which is more common during pregnancy, occurs in about one in 1800 pregnancies (34,124). Most adnexal masses discovered during the first trimester of pregnancy are functional cysts and resolve spontaneously by the second trimester (18). Persistent masses are most commonly functional cysts or mature cystic teratomas, with the incidence of malignancy reported at 2 to 6 (125). Presenting symptoms of adnexal torsion...

Comparative Analysis of Open and Laparascopic Approaches

In order to define the clinical outcomes of a laparascopic approach to bladder reconstruction, we compared prospectively, our initial experience in laparoscopic augmentation cystoplasty with continent catheterizable ileal stoma to a similar cohort of patients who underwent an open approach. Eighteen consecutive cases of augmentation colocysto-plasty with continent catheterizable ileal stoma were performed at our Institute nine patients underwent the open approach (eight women and one man mean...

Comparison of Approaches

Transperitoneal and extraperitoneal laparoscopic radical prostatectomy were compared by Hoznek et al. (25). In this retrospective study, the last 20 patients receiving transperitoneal laparoscopic radical prostatectomy were compared with the first 20 patients undergoing extraperitoneal laparoscopic radical prostatectomy. The operative time for extraperitoneal laparoscopic radical prostatectomy was significantly shorter (2.9 vs. 3.8 hours, P < 0.001), and resumption of a regular diet was...

Comparison Of Handassisted Laparoscopy To Other Laparoscopic Techniques

The first comparison of hand-assisted laparoscopy and standard laparoscopy in urology was reported by the two authors in 1998, describing the first 13 hand-assisted and eight standard transperitoneal laparoscopic nephrectomies performed at the University of Michigan and the University of Wisconsin (5). The mean operative time for handassisted laparoscopy was 1.5 hour less than that for of standard laparoscopy, and there were fewer major complications in the hand-assisted laparoscopy group....

Complications Of Handassisted Laparoscopy Specific Complications

Hedican et al. reported a multi-institutional complications report including 196 patients undergoing various hand-assisted laparoscopy renal procedures (56). Procedures included 57 radical nephrectomies, 50 donor nephrectomies, 38 nephrouretectomies, 24 partial nephrectomies, 2 simple nephrectomies, and 2 other renal procedures. The data showed that 28 patients (14 ) had minor complications, including urinary retention in 11 and prolonged ileus in four. Of the patients, 9.2 suffered major...

Complications

Numerous studies regarding open nephron-sparing surgery present data on technical and renal-related complications secondary to partial nephrectomy (Table 5) (76,77). Urinary fistula is the most frequent complication following nephron-sparing surgery. Other complications include hemorrhage, ureteral obstruction, and acute or chronic renal insufficiency. Corman et al. (78) compared complications after open radical (n 1373) and open partial (n 512) nephrectomy. Analyzing surrogate-to-complication...

Computed Tomography Protocol For Laparoscopic Surgical Planning

Three-phase computed tomography protocols are the state-of-the-art for imaging the kidneys and provide all the necessary information for surgical planning for laparoscopic surgery (Fig. 1) (3-5). These scans should be performed on a multidetector helical scanner, which allows efficient use of intravenous contrast and facilitates creating thin-slice datasets for smooth two-dimensional and three-dimensional reformations. The first scan phase is a noncontrast computed tomography scanning of the...

Computerized Education

The explosion in computer performance, hardware, and software has had profound effects on education, data management, communication, and entertainment. The impact FIGURE 3 Virtual reality laparoscopic reconstructive training (Karlsruhe Endoscopic Surgery Trainer). FIGURE 3 Virtual reality laparoscopic reconstructive training (Karlsruhe Endoscopic Surgery Trainer). of this modality on surgical education is just beginning to be felt (90). The information age has quietly crept into the surgical...

Conclusion

Urologic laparoscopic reconstructive surgery is rapidly expanding at numerous centers around the world. The ability to reconstruct every urologic organ by laparoscopic methods have been reported. The technology to accomplish these dextrous maneuvers is changing rapidly with logarithmic rises in the number of cases. Suturing technology and techniques are the leading methods that are fostering these reconstructions, but the skills and talents of innovators in this field cannot be denied....

Continence

Guillonneau et al. reported an 82.3 continence rate at 12 months including only pad-free patients as continent and using a validated questionnaire as a measurement tool. Using the same definition, Rassweiller et al. and Eden et al. reported a 91 and 90 continence rate at 12 months, respectively. In the Creteil's experience, the reported rates of urinary continence defined as no pad required at one year, improved from 78 to 90 in subsequent reports (50,59). In an evaluation of short-term...

Contraindications

Untreated infection and coagulopathy are the only absolute contraindications to laparoscopic nephrectomy. Complication and conversion rates are highest in patients undergoing laparoscopic nephrectomy for severe inflammatory conditions of the kidney (e.g., xanthogranulomatous pyelonephritis, pyonephrosis) and should be regarded as relative contraindications for the inexperienced laparoscopist (1-4). Renal tuberculosis can be dealt with safely by laparoscopy, although operating times are longer...

Convalescence

Most series reported thus far lack detailed data on convalescence and return to normal activities. In addition, few reports have described the degree and duration of postoperative pain and use of analgesics using validated questionnaires. In a small series from Johns Hopkins, postoperative analgesic requirements and time to complete convalescence after laparoscopic radical prostatectomy were significantly improved compared to open retropubic radical prostatectomy (41). In a prospective study...

Corporate Support and Marketing

Corporate support is also a very important aspect in developing a laparoscopic practice. Equipment companies, hospitals, and one's own practice are great facilitators. This support comes in the form of training, educational materials, marketing opportunities, financial support, and patient referrals. An entire chapter could be dedicated to marketing a laparoscopic practice. To a large degree, laparoscopy markets itself. However, one must take care to promote accurate expectations. Aggressive...

Costs of Training Ethical Considerations of Certification

Following initial reports of laparoscopic cholecystectomy, surgical practice in the United States has undergone substantial change. There has been a torrential outpouring of interest to learn new endoscopic techniques. The costs absorbed by practitioners to attend courses were hefty and few academic centers availed themselves of the early training experience (156). Some groups started small businesses of training surgeons, as the demand was so acute and the courses themselves proved financially...

Current Applications of Robot Assisted Remote Telepresence Surgery

In 2001, Marescaux et al. successfully utilized the Zeus TS system to perform the world's first transatlantic telerobotic surgery in which the remote surgeon, working from a Since the inaugural surgery on February 28,2003,22 telerobotic surgeries have taken place with no major complications, no conversions to open procedures, and lengths of stay comparable to those seen in tertiary care centers. Surgeons have been shown to have the capability to adapt to latencies of 500-700 msec but Fabrizio...

Current Financial State Of Laparoscopic Procedures

As experience with laparoscopy has increased and operative times have improved, some laparoscopic procedures such as laparoscopic nephrectomy and partial nephrec-tomy have been shown to be cost superior despite higher equipment costs (2,8). On the other hand, procedures such as laparoscopic pyeloplasty, hand-assisted nephrectomy, donor nephrectomy, retroperitoneal lymph node dissection, and prostatectomy are more expensive but can reach cost-equivalence depending on a surgeon's individual...

Current Indications And Contraindications Of Laparoscopic Adrenalectomy

Laparoscopic adrenalectomy has become the gold standard approach for the treatment of select patients with aldosteroma, pheochromocytoma, Cushing's disease, nonfunc-tioning adenoma, and rarely, adrenal cyst or myelolipoma. Laparoscopic radical adrenalectomy for primary or metastatic malignancy, has been reported (4). Unacceptable cardiopulmonary risk, uncorrected coagulopathy, abdominal sepsis, and bowel obstruction represent general contraindications for laparoscopy. Laparoscopic adrenalectomy...

Current Status Of Laparoscopic Approach

It has long been documented that grafts from living kidney donors show superior function and survival when compared to those from cadaver donors. Open donor nephrec-tomy has been performed successfully for nearly five decades with low rates of complications and graft loss. Donor nephrectomy is a unique surgery because the outcomes and complications affect both the donor and the recipient. Mis-steps that occur during the harvest may ultimately affect the donor and graft function. The initial...

Cushings Syndrome

Cushing's syndrome comprises the symptom complex resulting from excess circulating glucocorticoids, regardless of etiology (3). Non-adrenal causes of hypercortisolism include pituitary adenomas, ectopic corticotrophin production, and exogenous steroid use. The urologist is most often confronted with an adrenal lesion as the etiology of Cushing's syndrome. Cushing's syndrome manifests with a variety of well recognized clinical features, including hypertension, truncal obesity, moon facies, easy...

Cutaneous Ureterostomy

This technique is covered elsewhere in this book, but is included for the sake of completeness. In patients with advanced bladder cancer or other pelvic malignancy, a palliative urinary diversion such as a cutaneous ureterostomy may be considered as an alternative to percutaneous nephrostomy tube drainage, or where such drainage may be poorly tolerated long term. Patients may be candidates to undergo general anesthesia but comorbidities preclude extensive or prolonged surgery. In other...

Cystectomy

Hand-assisted laparoscopy in urology was initially (4) and has been most frequently applied to renal disease. Concurrent with the more recent interest in laparoscopic prostatectomy and cystectomy, hand-assisted laparoscopy has been applied as well. A pure hand-assisted laparoscopy radical prostatectomy has not been reported, although authors have described open surgical prostatectomy through the lower midline incision used to place the hand-assisted laparoscopy device for concomitant radical...

Delivery Systems For Drug And Gene Therapy

Delivery systems for drug and gene therapy are particularly attractive targets in uro-logical practice. Novel drug delivery for prostate cancer using ceramic nanoparticles, carbon magnetic nanoparticles, protospheres and nanogold particles has been investigated in prostate cancer. Paclitaxel loaded biodegradable nanoparticles have been shown to be effective inhibitors of human prostate cancer cell lines in a murine model (4). In addition, enhanced cellular uptake of a triplex-forming...

Detailed Laparoscopic Technique Equipment and Hand Assist Devices

Gelport Device

The operating room is assembled in a similar manner as for any laparascopic procedure. Equipment used in hand-assisted cases versus pure laparascopic cases is similar as well. Two important instruments exclusive to hand-assisted surgery include a ringless laparotomy pad and the hand-assist device. A clean, rolled up laparotomy pad with the ring removed is placed into the abdomen through the hand incision. The laparotomy pad is used to help retract and dry tissues. Drier tissues are easier to...

Discussion

Renal biopsy remains indispensable in the diagnosis of medical renal disease manifesting as proteinuria, hematuria, or renal failure. Most biopsies can be accomplished per-cutaneously with ultrasound guidance and a spring-loaded biopsy gun. Reported complications rates with this procedure including postoperative bleeding (the most common complication) are between 11 (23) and 34.1 (24). Manno et al. (24) reported a major complication rate of 1.2 in their series of 471 patients including 1...

Division of Cranial Pedicles and Seminal Vesicle Dissection

Both lateral pedicles are divided stepwise starting to divide the superficial portions of pedicle and then the deeper portions using two or three lockable 10-mm Hem-O-Lok clips to secure it. In case of a nonnerve-sparing technique, the clips are placed proximally, while in the nerve-sparing technique they are placed close to the base of the prostate. After division of both proximal pedicles each vas deferens is transected. Finally, the seminal vesicles are completely isolated and divided after...

Electrocautery Bowel Injury

Thermal or energy-based bowel injuries represent some of the most serious complications of laparoscopic surgery (6). Monopolar electrosurgical current is attributed with the greatest number of instrument-related mishaps. In the 1990s, the incidence of complications related to laparoscopic electrosurgery has been reported to be 2 to 5 per 1000. The most feared electrosurgical are bowel related and result from stray monopolar electrosurgical current. However, by using only metal ports and by...

Elevated Intracranial Pressure and Cerebral Ischemia

In a small study of pigs insufflated with CO2 at a pressure of 15 mmHg, the intracranial pressure increased by 5 mmHg (169). In two myelomeningocele patients with ventriculoperitoneal shunts, the intracranial pressure increased more than 15 mmHg above baseline during a CO2 pneumoperitoneum of 10 mmHg pressure only (170). In another study of 18 patients with ventriculoperitoneal shunts undergoing 19 laparo-scopic procedures, however, bradycardia and hypertension, which would be expected if the...

Endoscopic Camera Systems and Charged Coupled Device

The current generation of endoscopic cameras employs the charge coupled device chip. The digital image is captured on a charge coupled device using either a digital still or a digital video camera. Photoreceptors, within the charge coupled device , rapidly assess the different light intensities that make up the endoscopic image. The charge coupled device generates pixels by converting unique light intensities within an image into corresponding electronic signals, which are then transmitted to a...

Energy Sources for Laparoscopic Surgery

Apart from monopolar and bipolar electrocautery, a variety of different energy sources have been introduced for tissue cutting and or hemostasis that can be used laparoscop-ically. These include ultrasonic energy, LigaSure,c hydrodissector, and argon beam coagulator. Ultrasonic energy has been successfully used for tissue dissection and hemostasis during laparoscopic procedures (4). The commercially available ultrasonic generators provide a variety of effecter tips (5 and 10 mm) for...

Enterovesical Anastomosis

Although different approaches can be used for intracorporeal suturing of the bowel segment to the bladder as shown in Figure 6, we prefer to begin by running the preplaced suture on the posterior wall of the reconfigured bowel patch to the apical aspect of the bladder flap in a medial to lateral direction on each side. Completion of the posterior wall of the reconfigured bowel segment from an intravesical approach beginning medially (point A) and finishing laterally (points B and C,...

Equipment And Technique

Gasless laparoscopy creates a working space in the abdominal cavity by lifting the abdominal wall instead of using carbon dioxide. To lift the abdominal wall, the following three methods are available subcutaneous wire lifting in which a thin steel wire is passed subcutaneously to lift the abdominal wall peritoneal planar lifting in which by a retractor is inserted into the abdominal cavity to lift the whole abdominal wall and abdominal wall lifting in which the abdominal wall is lifted by a...

Estimated Blood Loss

The average estimated blood loss for the reported series of laparoscopic radical prostatectomy varies widely, as shown in Table 1. The average estimated blood loss in the series from Montsouris was 380 mL for all 550 patients, declining to 290 mL for the last 350 patients (17). The overall transfusion rate was 5.3 in this series, declining to 2.6 TABLE 1 Summary of Surgical Parameters of Laparoscopic Radial Prostatectomy Experiences Worldwide TABLE 1 Summary of Surgical Parameters of...

Experimental Data

The porcine model was used by Pompeo et al. to describe transthoracic (TT) left adrenalectomy in 1997 (13). After inserting four 10-mm laparoscopic trocars into the left pleural cavity, left pneumothorax was created insufflating CO2 at a mean pressure of 10 mmHg. A 6-cm phrenotomy was performed starting from the lateral side of the aorta and retroperitoneal space entry was achieved. Carbon dioxide-induced positive intrapleural pressure facilitated this maneuver. After Gerota's fascia opening...

Extraperitoneal Approach

Concerns of potential intraperitoneal complications (bowel injury, uroperitonitis, and ileus) led investigators to develop extraperitoneal approaches to laparoscopic radical prostatectomy (7). The initial report, by Raboy et al. (13), described a single extraperi-toneal laparoscopic radical prostatectomy that duplicated the open retropubic radical prostatectomy as described by Walsh and Donker (21). Subsequent reports from Belgium and Germany have demonstrated the feasibility of the antegrade...

Extraperitoneal Gas Collections

Intraperitoneal gas may leak into several extraperitoneal tissue planes or spaces. Subcutaneous emphysema is the most common site. Etiology of extraperitoneal gas collections may be a technical error such as incorrect insufflation due to superficial needle placement, excessive intra-abdominal pressure, or a malfunctioning insufflator. However, subcutaneous emphysema most commonly occurs due to leakage around a laparoscopic port. Subcutaneous gas is a risk factor for hypercapnia, so its presence...

Fasciectomy Excision of Perinephric Fat and Fascia Gerota

The kidney is bared of its coverings. As much of perirenal fat as possible is removed. This maneuver removes the perinephric group of lymphatics, which freely communicate with subcapsular group of lymphatics and drain in to the lateral aortic nodes. FIGURE 6 Stripping of hilar vessels. FIGURE 7 Dissection of ureter all around with transverse FIGURE 6 Stripping of hilar vessels. FIGURE 7 Dissection of ureter all around with transverse

Fistula

The most common form of vesicovaginal fistula in North America is injury to the bladder during hysterectomy. In developing countries, the main cause is childbirth. Invasive cervical cancer or radiation therapy for this disease is also a contributor to the formation of vesicovaginal fistulas. Most fistulas resulting from hysterectomy occur during removal of the uterine cervix. The vaginal portion is usually located at the area where the vaginal cuff was sutured together, identified by the linear...

Frequency Of Laparoscopic Vascular Injury

TABLE 1 Laparoscopic Vascular Injuries from Urologic Series TABLE 1 Laparoscopic Vascular Injuries from Urologic Series 4-Dissection injury 2-Stapler misfire 2-Clip dislodgment 4-Dissection injury 3-Access injury 2-Stapler misfire 1-Clip dislodgement and three were related to problems with access. Five of the seven dissection injuries resulted in emergent open conversion. In nonurologic laparoscopy, vascular injury appears to be less frequent and is usually associated with access-related...

Fresh Frozen Plasma

Fresh frozen plasma is used to replace labile clotting factors in patients with coagulopathy and documented deficiency of clotting factors. This condition may derive from liver dysfunction, congenital absence of clotting factor, or transfusion of factor-deficient blood products. A unit of fresh frozen plasma contains near-normal levels of all clotting factors. A unit of fresh frozen plasma increases clotting factor levels by about 3 . Adequate clotting is usually achieved with factor levels...

Future Directions Hydrojet Technology

Future directions include potentially bloodless renal parenchymal incision without hilar clamping with the use of hydro-jet technology. This technology employs a high-pressure water jet to perform selective tissue dissection in a relatively bloodless manner. Spared intrarenal vessels may then be controlled with clips or bipolar coagulation, and the renal collecting system suture repaired (130). Basting et al. (131) reported the initial clinical experience using water jet resection in 24...

Future Robotic Surgery Systems

As previously mentioned, one of the major points of criticism of robotic telemanipula-tors is the lack of haptic feedback from the operating instruments. While some surgeons using the current systems on a regular basis feel that this is partly compensated for by the superior three-dimensional visual feedback, others differ. Future robotic systems are likely to include improved haptic feedback data. The enormous size of the systems compromises their proper positioning, thus either...

Gasless Vs Pneumoperitoneum Basic Research

Many basic studies have compared gasless laparoscopic surgery and laparoscopic surgery using pneumoperitoneum in terms of invasiveness and effects on the patient. Gasless surgery without carbon dioxide pneumoperitoneum is not associated with compression of the inferior vena cava and intestinal vessels, elevation of the diaphragm, and absorption of carbon dioxide gas into the blood. Therefore, the gasless laparoscopic surgery is superior with regard to the effects on hemodynamics and respiratory...

Gastrointestinal Effects of Pneumoperitoneum

Halevy et al., in a series comparing open and laparoscopic cholecystectomy, have demonstrated that laparoscopic surgery results in significantly less disruption of normal gastrointestinal motility when compared to open surgery (18). The mechanism(s) of decreased ileus with laparoscopic surgery remain(s) unclear. Another concern with abdominal laparoscopy has been gastroesophageal reflux. Despite the increased intra-abdominal pressures associated with insufflation, there has been no increased...

Hand Assisted Laparoscopic Adrenalectomy

This technique, described by Bennett and Ray, is reported to be associated with short operative times and has the advantage of introducing tactile feedback in locating the adrenal gland. This technique utilizes the Handport f, which is placed in the upper midline for left-sided lesions and via an oblique right lower subcostal incision for right-sided procedures. The procedure then follows the same dissection as for open surgery with Kocherization of the duodenum on the right prior to control of...

Hand Assisted Laparoscopic Live Donor Nephrectomy

Hand-assisted laparoscopy combines the principles of open and laparoscopic surgery to create a hybrid technique that was initially developed to shorten the learning curve for surgeons not trained in conventional laparoscopy. In addition, more complex laparoscopic procedures that failed to progress with standard laparoscopy could be completed with a hand-assisted approach instead of being converted to an open operation. The surgeon's nondominant hand is placed in the abdomen through a small...

Hand Assisted Laparoscopic Radical Nephrectomy

In hand-assisted laparoscopic radical nephrectomy, a 7-8 cm incision is usually required to accommodate the surgeon's nondominant hand. TABLE 1 Operative Results of Transperitoneal Laparoscopy, Hand-Assisted Transperitoneal Laparoscopy, and Retroperitoneoscopy for Nephrectomy in Patients with Renal Cell Cancer TABLE 1 Operative Results of Transperitoneal Laparoscopy, Hand-Assisted Transperitoneal Laparoscopy, and Retroperitoneoscopy for Nephrectomy in Patients with Renal Cell Cancer...

Hand Assisted Techniques

Collins Knife Incision Ureteral Orifice

Hand-assisted laparoscopic nephroureterectomy has been advocated by some (19-22), because it provides the surgeon with tactile sensation and an incision adequate for intact specimen removal. Herein, we present two hand-assisted laparoscopic nephroureterectomy techniques. Gonzalez et al. described making a midline, periumbilical incision, which was used as the hand-assisted port (20). Prior to the dissection of the kidney, two large clips were placed on the proximal ureter to prevent any...

Hemostatic Aids And Impact Of Floseal

The specific technical challenge of laparoscopic partial nephrectomy lies in achieving a bloodless operative field for precise tumor excision and pelvicalyceal repair followed by renal hemostasis in a time-sensitive manner, with the least possible compromise of renal function. Achieving prompt and durable hemostasis is of paramount importance. Several techniques of parenchymal hemostasis during laparoscopic partial nephrectomy have been reported with varying success, including cauterization of...

High Intensity Focused Ultrasound

As an ultrasound wave propagates though biologic tissues, or any medium that is not ideally viscoelastic, it is progressively absorbed and the energy is converted to heat. If the ultrasound beam is brought to a tight focus at a selected depth within the body, the high energy density produced in this region results in temperatures exceeding the threshold level of protein denaturation. As a consequence coagulative necrosis occurs. The energy drops sharply outside the focal zone so that overlying...

Hilar Clamping Vs Nonclamping

Guilloneau et al. (119) compared 12 patients undergoing laparoscopic partial nephrec-tomy with renal hilar clamping versus 16 patients undergoing laparoscopic partial nephrectomy without hilar control. The non-clamping group experienced significantly greater blood loss (708 vs. 270 mL p 0.014) and longer operative time (3 vs. 2 hours p 0.004) compared to laparoscopic partial nephrectomy with hilar clamping. Postoperative serum creatinine levels were not significantly different (1.3 vs. 1.45 mg...

History Of Laparoscopy An Odyssey Of Innovations

Rays Tmj Disorder

Ordorica Division of Urology, University of South Florida, Tampa, Florida, U.S.A. Department of Urology, University of California Davis School of Medicine, Sacramento, California, U.S.A. Urologists once only peered into the new frontier of laparoscopy. Today we are now embracing it and thriving within it, bringing its benefits to our patients. Even as we witness its growth and realize its potential, it is instructive to peer into the past. The principal mark...

History Of Robotics

The term robot, taken from the Czech word robota, meaning forced labor, was coined by the Czech playwright Karel Capek in 1921 in his play Rossum's Universal Robots. Since then, man has had a fascination with the robot. The robot conjures up many, and often contradictory, images. The robot is at the same time a symbol of the future of technological advancement and limitless possibilities as well as the subservient machine performing menial, repetitive tasks. The robot alternatively liberates...

Howard Evans and Michael G Hobart

Division of Urology, Department of Surgery, University of Alberta, Alberta, Canada Complications Related to Retroperitoneal Step 5 Dissection and Ligation of the Despite skepticism, the technique of retroperitoneal laparoscopic radical nephrectomy evolved into a standardized approach, which resolved problems related to retroperitoneal landmark recognition.

Idiopathic Retroperitoneal Fibrosis

Idiopathic retroperitoneal fibrosis is a chronic inflammatory process that comes to uro-logic attention when extrinsic compression and encasement of the ureter by surrounding retroperitoneal tissues cause ureteral obstruction. The progressive nature of the inflammatory process can lead to flank pain and renal deterioration. Radiographic findings on intravenous pyelogram or retrograde pyelogram may include medial deviation of the involved ureter and the absence of intraluminal obstruction....

Imaging And Labeling With Nanostructured Materials

Body or organ imaging and labeling with nanostructure materials are also being used for adjuncts to uroradiological diagnosis. Recently, Harisinghani et al. (11) have demonstrated that highly lymphotropic super-paramagnetic nanoparticles, which gain access to lymph nodes by means of interstitial lymphatic fluid transport, allow the high-resolution magnetic resonance imaging of clinically occult lymph node metastases in patients with prostate cancer, which previously have not been detectable by...

Impact Of Warm Ischemia

Hemostasis remains a primarily task during laparoscopic partial nephrectomy. Temporary en bloc renal hilar clamping allows a bloodless field with enhanced visualization during tumor excision and renal repair. Supported by experimental and clinical data, several modalities of hilar control during laparoscopic partial nephrectomy have been advocated, including the clamping of the renal artery alone, both renal artery and vein, and intermittent occlusion (96-98). Advantages and disadvantages of...

Increased Intra Abdominal Pressure

Insufflation of gas elevates the intra-abdominal pressure. Increase in intra-abdominal pressure is the most prominent of the physiologic insults of laparoscopy and can have dramatic effects with only small changes. Increased intra-abdominal pressure compresses the splanchnic circulation (Fig. 1) (18), in both capillaries and capacitance vessels, and in both the venous and arterial systems (14,15,19-22). An intra-abdominal pressure of 20 mmHg or more diminishes blood flow to all abdominal and...

Indications

Retroperitoneoscopy has been used for a variety of renal and adrenal procedures (Table 1). In patients with morbid obesity or peritoneal scarring from prior transabdominal procedures, retroperitoneoscopy allows a superior and more direct approach to the renal hilum. The equipment usually required for retroperitoneoscopic surgery is summarized in Table 2. Laparoscopic radical nephrectomy (15) and adrenalectomy (16) can be performed efficiently and effectively by either the transperitoneal or the...

Indications And Contraindications

Contraindications to the laparoscopic approach are similar to those to open hernia repair (Table 1). The most important consideration is the surgeon's experience in performing a laparoscopic repair. The learning curve for a transabdominal preperitoneal or totally extraperitoneal repair has been documented to be around 50 cases (7). The laparoscopic transabdominal preperitoneal approach requires general anesthesia for adequate abdominal relaxation and insufflation. Although there have TABLE 1...

Indications Of Laparoscopic Radical Prostatectomy

The indications for the radical laparoscopic prostatectomy are the same as that for the open procedures including treatment of men with localized prostate carcinoma and a life expectancy of 10 years or more. TABLE 1 History and Technical Modifications of Laparoscopic Radical Prostatectomy Schuessler et al. (1) Kavoussi et al. (4) The first reported case underwent laparoscopic radical prostatectomy Laparoscopic approach to seminal vesicles for its diseases and perineal radical prostatectomy with...

Informed Consent Legalese

The jargon utilized by the legal system can be overwhelming. Some basic definitions are warranted for review (141). A plaintiff is the person who alleges malpractice. The defendant is the laparoscopic urologic surgeon, an assistant, and possibly the hospital where the surgery was performed. A complication is some difficulty, problem, or change in the patient's health that is unintended. Negligence is the failure to exercise the degree of care considered reasonable under the circumstances,...

Informed Patient Consent

To obtain informed consent, the physician must have disclosed adequately all facts about the nature of the treatment, the risks involved, the available alternatives and risks, These investigators found that the greatest percentage of claims arose from the categories of inpatient, adult, and surgical procedures, and that endourological procedures resulted in the greatest incidence of surgical claims. This was in contrast to an earlier report in 1977, which had shown vasectomy to be the most...

Innervation and Lymphatic Drainage

The abdominal wall is composed of nine layers. From outward in they are (i) skin, (ii) subcutaneous tissue, (iii) superficial fascia (Scarpa's fascia), (iv) external abdominal oblique muscle, (v) internal abdominal oblique muscle, (vi) transversus abdominis muscle, (vii) transversalis fascia, (viii) extraperitoneal adipose tissue, and (ix) peritoneum. The muscular abdominal wall is composed of three flat muscles (external oblique muscle, internal oblique, and transversus abdominis) and one...