Trocar and Hand Port Configuration

We have used the following hand incision and trocar configurations successfully in over 500 cases with little modification. Numerous factors must be considered when determining the optimal positioning of trocars and the hand incision. These factors include The surgeon's wrist should have free range of motion and the fingertips should comfortably reach the renal hilum (the most important part of the dissection). If emergent conversion is required, an incision should be made in a location that...

Computed Tomography

With the increase in cross-sectional imaging studies, computed tomography has become a more reliable modality for diagnosing renal cysts and differentiating them from other renal lesions such as a solid neoplasm. FIGURE 1 Renal ultrasound of a patient with multiple simple renal cysts. Note the sonolucent nature of cysts displaying through transmission with thin walls, absence of nodules, septations, or calcifications. The advantage of laparoscopic decortication of symptomatic renal cysts....

References

Effect of laparoscopy on immune function. Br J Surg 2001 88 1296-1306. 2. Kuhry E, Jeekel J, Bonjer HJ. Effect of laparoscopy on the immune system. Semin Laparosc Surg 2004 11 37-44. 3. Rimington P, Dasgupta P. Laparoscopic and robotic radical cystectomy. BJU Int 2004 93 460-461. 4. Endres JC, Salky BA. Laparoscopy in AIDS. Gastrointest Endosc Clin N Am 1998 8 975-990. 5. Brostoff J, Scadding GK, Male D, Roitt IM. Clinical immunology. Chapter 1 1.1-1.7. London Mosby, 1991....

Index

Adhesions, 381 cavity, hand incision, 789 extraperitoneal drain, 7 fascia, anterior, 971 hysterectomy, 411 surgery, 242, 971 preparation for, 188 viscera, inspection of, 5 wall, 432 anatomy, 432 injury, risk of, 1036 layers, 68, 435 lifting method, 813, 818 metastases, 817 neuralgias, body mass index, 930-931 parietal peritoneum of, 433 relaxation, 456 vasculature, by transillumination, 1036 Abdominal wall lift (AWL), 813, 818 cardiovascular and respiratory effects, 976 mechanical, 976...

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...

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...

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...

Anderson Hynes Dismembered Pyeloplasty

Anderson-Hynes dismembered pyeloplasty is preferred when pelvic reduction may be necessary, a renal calculus is present, or a crossing vessel is encountered (Fig. 3). A dismembered pyeloplasty may have superior efficacy compared with the other nondismembered techniques. In the largest head-to-head comparison of laparoscopic dismembered (n 25) and nondismembered pyeloplasties (n 15), Klingler et al. showed superior efficacy for dismembered (96 ) versus nondismembered (73.3 ) pyeloplasty. Once...

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...

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...

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...

Coagulation

Pregnancy is considered a hypercoagulable state increasing the risk of thromboembolic phenomena due to increased venous stasis, vessel wall injury, and changes in the coagulation cascade. The effects of estrogen cause increased synthesis of clotting factors, particularly factors VII, VIII, X, and XII (28). Intra-abdominal vascular stasis secondary to inferior vena cava compression from the uterus also increases the risk of deep venous thrombosis during pregnancy with an incidence of...

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...

Complications

Few studies differentiate between major and minor complications. The complication rates range from 0 to greater than 20 (Table 4) (5,33,38,57). Major complications seen with laparoscopic Burch include bladder injury, ureteral damage or kinking, abscess or seroma formation in the space of Retzius, failed procedure requiring additional surgery, de novo detrusor instability, new onset intrinsic sphincter deficiency, urinary retention, voiding dysfunction, and a possible increase in posterior...

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...

Delayed Complications

There is a growing amount of literature on the risk of postoperative laparoscopic hernia formation following trocar removal (95-99). The standard custom has been to close the fascia in all trocar sites 10 mm in diameter or above. The literature would suggest that although the risk of port site herniation is uncommon below the 10 mm cutoff it is by no means certain. In fact, children and obese patients are significantly at risk of herniation from the 5 mm trocars and smaller (100). The estimated...

Diagnosis

Adrenal lesions historically were diagnosed secondary to clinical manifestations of endocrinopathies. However, widespread use of abdominal ultrasound, computed tomography scanning, and magnetic resonance imaging has led to the not infrequent finding of the incidental adrenal mass. Figures 1 and 2 show typical examples of adrenal lesions diagnosed on computed tomography and magnetic resonance imaging. The differential diagnosis of an incidental adrenal mass is extensive and includes the benign...

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...

Expansion of Laparoscopic Approach

Pain, extended hospitalization, time away from work, and long-term disability are barriers to potential donors. The laparoscopic approach provides potential donors with a minimally invasive alternative to open donor nephrectomy. Laparoscopic donor nephrectomy has definitely decreased hospitalization. The average hospital stay for 2339 standard transperitoneal donors reported has been 2.9 days. There is a clear difference between the United States and the rest of the world, where pressure for...

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...

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...

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...

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....

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

Laparoscopic simple nephrectomy is indicated in benign renal diseases where complete loss of the renal unit has occurred or is desired. Such conditions include but are not limited to Obstructive or reflux nephropathy, Chronic inflammatory infection conditions including xanthogranulomatous and tuberculosis pyelonephritis (these are technically challenging), Posttransplantation hypertension. Simple nephrectomy is most commonly performed for symptomatic (pain, hypertension, and infections) and...

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,...

Introduction

Renal transplantation is the ideal solution to end-stage renal disease. It has had a major impact on the survival and quality of life of those suffering from kidney failure, affording these patients an independent lifestyle free from dialysis and its significant morbidity. Unfortunately, the annual supply of renal allografts has continued to fall short of the increasing number of patients seeking renal transplantation. Live donor nephrectomy has long been viewed as an underused alternative in...

Kidney Therapeutic Cloning and Stem Cells

Approximately 70,000 people in the United States are on a transplant wait list due to renal disease. The two currently available options for such patients are dialysis and renal allotransplantation. Both options are life-sustaining, but both are associated with significant morbidity and mortality. Dialysis is often poorly tolerated, and transplantation is burdened with severe donor shortages as well as the complications that accompany immuno-suppression. This has motivated researchers to...

Laparoscopic Prostatectomy

Radical prostatectomy is the most common therapy for patients with prostate cancer and accounts for approximately half of the 1.7 billion cost of prostate cancer treatment (30). In evaluating the cost of radical retropubic prostatectomy as compared to laparo-scopic and robot-assisted prostatectomy, we found that radical retropubic prostatectomy was the least expensive approach with a cost advantage of 487 and 1726 over laparoscopic radical prostatectomy and robot-assisted prostatectomy,...

Laparoscopic Pyeloplasty In Children

The small caliber of a child's ureter makes pyeloplasty a difficult procedure. For this reason, dismembered pyeloplasty is not ideal in children younger than six months and should be avoided. However, this technique remains the preferred method for treating ureteropelvic junction obstruction in older children and the open dismembered pyelo-plasty is the gold standard. Children's body habitus requires smaller instrumentation and fine 6.0 sutures for the ureteropelvic junction reconstruction. The...

Laparoscopic Technique

The patient is placed in the supine position on the operative table, prepped and draped in a standard sterile fashion. A Foley catheter is placed along with a nasogastric tube to Percutaneous needle aspiration has been described as an initial attempt to manage symptomatic lymphoceles. However, high recurrence rates are reported ranging from 42 to 100 (17-19). Small lymphoceles (< 100 mL) lying near the renal hilum, or lateroposterior, lateroinferior, or inferomedial lymphoceles are the most...

New Innovations In Laparoscopic Prostate Surgery

As the technique of laparoscopic radical prostatectomy has become standardized and widespread, several centers have begun to use these techniques for salvage laparo-scopic radical prostatectomy, and to perform sural nerve grafting during laparoscopic radical prostatectomy. In an early experience from France, Vallancien et al. (58) reported on laparoscopic radical prostatectomy performed as salvage therapy for seven patients. All had previously undergone radiotherapy (external beam radiation in...

Nonaccessrelated Bowel Injuries

Bishoff et al. performed a retrospective review of bowel injuries during urologic laparoscopy in 915 cases at two institutions and reported an overall incidence of 0.8 non-access-related bowel injuries (6). The authors reported bowel perforation in two patients (0.2 ) and serosal injury of the intestine or stomach in six patients (0.6 ). Intraoperatively recognized bowel injuries occurred in six patients three during staging pelvic lymph node dissection, two during pyeloplasty, and one during...

Operative Factors

Operative time is also a risk factor for rhabdomyolysis and peripheral nerve injury, making it a greater concern in laparoscopy, which can subject the patient to prolonged periods on the operating table. Rhabdomyolysis has been reported in as little as 4.5 hours in the full flank position (5), and similar times are reported for the lithotomy position. In peripheral neuropathies caused by nerve compression or stretching, risk of nerve injury increases as operative time increases. Prolonged...

Operative Technique

The laparoscopic surgical approach to the seminal vesicles was first described by Kavoussi and Clayman in 1993 as a method for freeing up the seminal vesicles at the time of laparoscopic pelvic lymph node dissection immediately prior to a perineal prostatectomy (37). This transabdominal laparoscopic approach has subsequently become one of the initial steps of laparoscopic radical prostatectomy (38). Pneumoperitoneum is obtained with a Veress needle or via an open technique. Either a 10-12 mm...

Other Intracorporeal Suturing Techniques

Laparoscopic Suturing Device

An enormous effort has been placed upon developing innovative methods of intracor-poreal suturing to obviate the difficulties we have spent so much time outlining above FIGURE 31 Useful needle configurations for intracorporeal urologic reconstruction. 1. swage, 2. point, and 3. body. (A) 3 8 curve, (B) ski configuration, and (C) S shaped needle. FIGURE32 Brightly colored sutures that fluoresce in xenon lighting. (Left) Multiple square knot simple sutures ready for conversion to suspension...

Patient Outcome

With carefully planned strategies, advanced urologic laparoscopy in a community setting can yield results comparable to major academic centers (9). The importance of balancing the complexity of procedures with the experience of the surgeon cannot be overemphasized. Operative time, an important factor in the private practice setting (10), has become very reasonable (Table 4). In many cases, the operative time matches that expected for the equivalent open procedure. As shown in Figure 1,...

Patient Preparation

The patient is put in deflected supine position with the arms at the sides and the legs adducted. Additionally, a 30-degree Trendelenburg decline supported with inflatable balloon pillow was placed under the patient's buttocks, which displaces the bowel cephalad by gravity. The abdomen is shaved from the costal margins to the pubic bone. A rectal balloon catheter is placed and inflated with 70 cm3. Before trocar placement, a 16-French Foley catheter is inserted under sterile conditions and...

Patient Selection Indications And Contraindications Indications

As shown in Table 1, the indications for laparoscopic adrenalectomy can be categorized as 2. Suspicious malignant lesions of small size, and 3. Nonfunctioning benign lesions that are either symptomatic or have the potential to become symptomatic. The resection of aldosteronomas was one of the initial indications for laparoscopic adrenalectomy. These lesions are often small and the patient's body habitus favorable therefore, they are particularly suited to the laparoscopic approach....

Pelvic Inflammatory Disease

Pelvic inflammatory disease should always be considered in the differential diagnosis of acute febrile abdominal pain. Infections of the uterus, tubes, and ovaries may cause infertility and can cause life-threatening sepsis in a significant number of women. The most frequent acute infection in reproductive age, nonpregnant women is pelvic inflammatory disease. It is an enormous public health problem. In 1998, direct costs were estimated to be around 1.9 billion (11). Chlamydia is the most...

Peripheral Neuropathies

Injuries to peripheral nerves have several etiologies. It is commonly accepted that stretch, compression, generalized ischemia, or any combination thereof contribute to postoperative sensory or motor deficits. Compression can be from direct contact with a surface from positioning or it may be indirect as the nerve is stretched over a bony prominence. All of these factors ultimately result in ischemia or mechanical damage that lead to structural and or functional derangement of the affected...

Pheochromocytoma

Pheochromocytomas can be challenging tumors to treat because of the unique manifestations of chronic and acute catecholamine excess. In general, catecholamine excess results in hypertension, tachycardia, and a host of clinical manifestations. Laboratory diagnosis is made by elevated levels of catecholamines in the blood and urine. Radiographic diagnosis is achieved with either computed tomography scan or magnetic resonance imaging. Magnetic resonance imaging classically demonstrates a bright...

Platelets

Platelet transfusions are indicated for patients suffering from or at significant risk of bleeding owing to thrombocytopenia and or platelet dysfunction. Basic guidelines for platelet transfusion are outlined in Table 1. In general, platelets should not be transfused prophylactically in the absence of microvascular bleeding, a low platelet count in TABLE 1 Suggested Transfusion Guidelines for Platelets Recent (within 24 hours) platelet count 10,000 mm3 (for prophylaxis) Recent (within 24 hours)...

Postoperative Complications

Complications such as ileus, fever, urinary tract infection, urinary retention, atelectasis, pneumonia, cellulitis, renal insufficiency, neuromuscular injury, incisional hernia, transfusion, recurrence of cyst, persistence of pain, deep venous thrombosis, and pulmonary embolism can occur following laparoscopic renal cyst ablation. Two postoperative complications that are worthy of special mention are perinephric hematoma and urinoma. To reduce the occurrence of postoperative bleeding and...

Postoperative Imaging

Surgicel Mri

As laparoscopic techniques are newer than open ones, guidelines for postoperative imaging are less well established. Patients are seen at four to six weeks after open partial nephrectomy for routine follow-up and have a physical examination, a serum creatinine level check, and an excretory urogram (37). Imaging with computed tomography or ultrasound is performed earlier in any patient who has clinical signs or symptoms of abscess, hematoma, urinary leak, or fistula. Generally, a computed...

Preoperative Upper Tract Drainage

Patients with a grossly dilated collecting system are best served by a minimum four-week period of drainage prior to nephrectomy. Occasionally this is necessary to check function following relief of obstruction, before recommending ablative surgery over reconstruction, but it is certainly of benefit from a technical point of view because a tense, grossly dilated pelvis may otherwise overlap the renal vessels and make their identification and control more difficult. A stay suture inserted...

Prevention

It is always preferable to have no complications. This is rarely ever entirely possible, but there are many factors that can be controlled and deserve mentioning here. First and foremost, the inexperienced or unskilled laparoscopic surgeon is more likely to have significant complications (133). Gaining experience and skill is mandatory. This is best done in a supervised well-controlled environment. Second, the instruments and equipment should be thoroughly familiar with the surgeon (71). Dull...

Prostate Biopsy

An image-guided robot system has been developed and employed for transperineal prostate biopsies. The surgeon selects the biopsy site using transrectal ultrasound images and the robot obtains the sample from that location with a precision of 1 to 2 mm in needle position. This procedure was found to be quicker, more precise than the conventional Two alternative robotic projects enabling automated harvesting of prostate biopsy samples have been recently developed. Certain urologic procedures are...

Prostate Surgery

During laparoscopic radical prostatectomy, precise intraoperative identification of the neu-rovascular bundle, the prostate apex, and location of cancer nodule may potentially enhance postoperative functional outcomes and surgical margin status. Transrectal ultra-sonography is currently one of the most precise imaging modalities for the prostate. Ukimura and Gill investigated the technical feasibility and utility of intraoperative realtime transrectal ultrasonography guidance during...

Prostate Sparing Laparoscopic Radical Cystectomy

Prostate- and seminal-sparing cystectomy may be an option in young patients whose preservation of urinary continence and sexual potency are fundamental (26). In carefully selected patients, this procedure was proposed in open surgically resulting in more than 90 of patients being potent, while nearly all are totally continent, with no additional oncologic risk. In 2003, Guazzoni et al. reported the initial three cases of laparoscopic nerve- and seminal-sparing cystectomy with extracorporeally...

R Sherburne Figenshau Md Urology Mail

New York State Department of Health Memorandum H-18, June 12, 1992. 2. Kahan SE, Goldman HB, Marengo S, Resnick MI. Urological medical malpractice. J Urol 2001 165 1638-1642. 3. Koontz WW, Russel JB. Thought on the prevention of urologic liability claims. Trans Am Assoc Genitourin Surg 1977 68 33. 4. Corcaran M. What is negligence BJU Int 2000 86 280-285. 5. Garmisa SP. Informed consent. Chicago Daily Law Bulletin, May 14, 2004. 6. Tammelleo AD. Are hospitals required to obtain patients'...

Results Fertility

Varicocele repair has been proven to improve semen parameters in 50 to 80 of men and surgical methods successfully eliminate > 90 of the varicoceles (16,34,35,43). Pregnancy rates following laparoscopic varix ligation (26-46 ) are similar to those reported following open repair (49,50). The american urological association's Best Practice Guidelines identified only two well-designed, randomized, prospective controlled studies of men with palpable varicoceles, abnormal semen quality, and normal...

Retroperitoneoscopic Live Donor Nephrectomy

The retroperitoneal approach to laparoscopic live donor nephrectomies initially evolved as an alternative technique to address concern with the low rates of right-sided laparoscopic donor nephrectomy in most series, an apparent reflection of the increased degree of technical difficulty harvesting the right kidney by the transperitoneal approach. As such, most reported series of retroperitoneoscopic donor nephrectomy involve the right kidney (42-45), although a small series of successful...

Right Transperitoneal Laparoscopic Technique

For a right-sided transperitoneal laparoscopic renal cyst ablation, trocar configuration is the mirror image of that used for a left-sided technique (i.e., the second 10 12-mm trocar is placed lateral to the right rectus muscle with all other trocars remaining the same). The ascending colon is reflected medially and for cysts located near the hilum, reflection of the duodenum may be required. A combination of blunt and sharp dissection of the attachments between the duodenum and kidney (Kocher...

Running Suture Technique For Vesicourethral Anastomosis

Hoznek et al. started their own laparoscopic experience with prostatectomy about six months later than the Montsouris group. One will notice that these authors moved very early to a running suture to deal with the urethrovesical anastomosis. This attitude aimed at sparing the time devoted to knots on interrupted stitches as well as to avoid any intraluminal knotting (5). The patient is positioned in dorsal decubitus, with the legs slightly spread to allow intraoperative rectal examination. Five...

Single Knot Method For The Laparoscopic Running Urethrovesical Anastomosis

This protocol was developed in Brussels in December 2000, after a continuing cohort of 85 patients operated in 20 months, of whom 75 underwent an interrupted suture tied extracorporeally for the very first, then intracorporeally according to the Montsouris technique, and 10 patients had a running suture for the anastomosis. Since 2000, about 265 consecutive patients have been treated with this modified running suture consisting of one single intracorporeal knot (9-11). After laparoscopic...

Splenectomy

Laparoscopic splenectomy has been shown to be advantageous when compared to open splenectomy and is comparable to open splenectomy in terms of safety and efficacy in nonpregnant patients (110). Some authors advocate laparoscopic splenectomy as the procedure of choice for hematological conditions in nonpregnant patients (111). Autoimmune throm-bocytopenic purpura is the most common autoimmune disorder encountered in the pregnant patient (112). ITP appears during pregnancy with an incidence of...

Step 5 Apical Dissection of the Prostate

Incision of venous complex is performed following additional bipolar coagulation and then incising tangentially to avoid incision of the anterior surface of the prostate. An avascular plane of dissection separating the urethra from the venous complex must be found underneath the venous complex. This plane allows complete identification of the prostate limits and urethra. Some authors prefer introducing a metal bougie into the urethra to facilitate the apical dissection and improve tactile...

Symptoms

The vast majority of renal cysts are asymptomatic and ordinarily do not require treatment. Renal cysts that grow and obstruct portions of the collecting system, compress normal renal parenchyma, stretch the renal capsule, or spontaneously hemorrhage can cause symptoms. These symptoms include flank or abdominal pain, hematuria, hypertension, infection, or obstructive uropathy (2). In cases of extremely large and or multiple cysts, such as in patients with autosomal dominant polycystic kidney...

Endometriosis

Endometriosis is the presence of functioning endometrial tissue outside of the endometrium and myometrium. The clinical syndrome involves cyclic pelvic pain that begins just before menses and lasts throughout the days of menstrual flow, noncyclic chronic pelvic pain, and dyspareunia. It is associated with inflammation, immune system abnormalities (28), and neoangiogenesis often causing infertility, scarring of the fallopian tubes, dysmenorrhea, dyschezia, and dyspareunia. The prevalence of...

Ureteral Reconstruction

Ricostruzione Uretere

The ureter has been opened, repaired, or reconstructed predominately utilizing sutured techniques (39). Nezhat probably was the first to report a clinical application of intracor-poreal-sutured reconstruction of a ureter obstructed by endometriosis. Excision of the involved segment and ureteroureterostomy was performed over 7 French catheter with four interrupted 4-0 absorbable sutures. A CO2 laser was utilized for the bloodless dissection prior to reconstruction with an estimated surgical time...

Transurethral Resection of Prostate

Robotic surgical systems used for soft-tissue operations, such as those performed in urology, require very sophisticated robotic responsiveness and computer control to adapt to the deformability and mobility of the organs. Procedures performed on fixed bony structures or within the skull have the advantage of having relatively fixed points of reference to aid in robot registration. In 1988, Davies demonstrated the feasibility of the robotic transurethral resection of the prostate using the PUMA...

Virtual Reality

Jaron Lanier introduced the term virtual reality in 1989, but the concept that computers would have enough power to interface with a human's sensory perceptions formed the basis of Ivan Sutherland's doctoral thesis from Massachusetts Institute of Technology in 1963. As with most things in the computer world, the first head-mounted display became a reality and a young entrepreneur, Morton Heiling, tried to sell Sensorama, a simulated computerized motorcycle ride through a virtual city....

Virtual Reality Training for Laparoscopic Skills

The explosion of laparoscopic procedures in urology today led by such pioneers as Gill, Clayman, Guilloaneau, and Kavoussi are being associated with clear health benefits to Urology patients when compared to the open techniques. As laparoscopic approaches are validated as the standard of care, the dissemination, acquisition and certification of laparoscopic skills presents itself as a huge challenge. The American College of Surgeons recommends the granting of clinical privileges based upon...

Effects on Acute Phase Response and Cytokines

The acute-phase response and cytokines are important components of immunological function. Decreased production of cytokines reflecting a reduced inflammatory reaction after laparoscopy might be considered beneficial during the postoperative period. C-reactive protein is the most widely studied acute-phase response protein following surgery. C-reactive protein levels usually rise 4 to 12 hours after surgery, peak at 24 to 72 hours and thereafter remain raised for about two weeks (12). Other...

Technical Modifications for the Management of Complex Renal Cysts

The laparoscopic approach to ablating simple renal cysts is relatively straightforward however for complex renal cystic lesions, there are technical modifications worthy of mention. Although for peripelvic cysts both transperitoneal and retroperitoneal laparoscopic techniques are feasible, the transperitoneal approach provides optimum exposure of the renal hilum, a larger working space, and is therefore the approach of choice. Excision of Gerota's fascia and perirenal fat overlying the...

Videolaparoscopyassisted Implantation Of Continuous Ambulatory Peritoneal Dialysis Catheter 5162

Historically, this procedure has been performed under general anesthetic because a pneumoperitoneum with CO2 gas is not well tolerated by patients. Subsequently, this procedure has been modified by Giannattasio et al. and Crabtree and Fishman and can now be performed under local anesthesia with nitrous oxide gas and intravenous sedation. Currently videolaparoscopy is used more due to many benefits such as lower risk of trauma, short recovery time, short hospital stay, and small surgical scar...

Recurrences

Hernia recurrence remains the most reported and widely scrutinized aspect of hernior-rhaphy. There are numerous causes of recurrences during laparoscopic hernia repair, with the majority being technical failures (Table 4). The most common causes of hernia recurrence are incomplete dissection and inadequate size of the mesh coverage (12,13). When performing a laparoscopic hernia repairs, it is imperative that all potential defect sites as well as cord lipomas be investigated. Failure to identify...

Considerations For Orchidopexy

It has been shown that undescended testicles at birth and throughout the first year of life have normal histology, and that includes a normal population of germ cells. Huff et al. showed that beyond age of 18 months, both light microscopy and electron microscopy showed the development of abnormal histologic changes (15). This was one factor that dictated timing of orchidopexy. Anesthesia risks also dictated timing of orchidopexy however, infants aged four to six months have been shown now, with...

Cancer Outcomes

A major concern of morcellation is cancer recurrence and port site metastasis. Recent data do not suggest that specimen morcellation for renal cell carcinoma compromises onco-logic efficacy. Several centers performing laparoscopic radical nephrectomy combined with piecemeal specimen retrieval have reported excellent long-term outcomes, comparable to open radical nephrectomy (Table 2) (1,2,32,33). The process of morcellation, when performed appropriately, after laparoscopic nephrectomy improved...

Controversy About The Role Of Laparoscopy For Malignancy

Although the role of laparoscopy for benign adrenal disease is currently defined, laparoscopic excision of malignant renal tumors of the adrenal gland remains controversial. The concern about laparoscopy for adrenal malignancy stems from seven individual case reports published in the last several years (Table 2) (26-32). These single case reports challenge the adequacy of adrenal resection for adrenal glands with a primary adrenal malignancy or solitary metastatic site. In each case report, the...

Peritoneal Dialysis Catheter Removal

Peritoneal dialysis catheter removal can also be safely performed without significant discomfort under local anesthesia. Here too, an operating room is not needed because the procedure can be performed in a procedure room using standard precautions for infection control. Briefly, the local anesthetic is infiltrated at the site of the primary incision and the subcutaneous tissue. Dissection is then carried down to the subcutaneous tissue and the subcutaneous tunnel harboring the catheter is...

The History Of Laparoscopic Radical Prostatectomy

The goals of laparoscopic radical prostatectomy, as in retropubic radical prostatectomy, are lifelong oncologic control of localized prostate carcinoma while maintaining continence and potency functions with minimizing of operative morbidity that contribute to a global quality of life. Transperitoneal laparoscopic radical prostatectomy with ascending approach was first performed by Schuessler et al. (1) and presented in 1992. However, the technical difficulties did not allow widespread...

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...

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

Transperitoneal Subcostal Incision Toldt

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

Gerota Fascia Located

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...

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...

Laparoscopic Evaluation

Feminization Testicular Shrinkage

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...

Etiopathogenesis

Chyluria may be classified as parasitic or nonparasitic (Table 2). Various theories have been suggested to explain the cause of chyluria. Prout postulated the theory of secretion of fat from blood through the kidney (9). Mollenbroch (1670) suggested abnormal connection between lymphatic and urinary system (10). Ackerman (1863) gave the obstructive theory and suggested that the obstruction of lymphatics anywhere between intestinal lacteals and the thoracic duct may give rise to chyluria (3). The...

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

Lateral Prostectomy

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...