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Jamil Rehman

Publications and source records attributed to Jamil Rehman.

At least 19 recordsLinked to original sources
PubMed2006

High body mass index in muscular patients and flank position are risk factors for rhabdomyolysis: case report after laparoscopic live-donor nephrectomy.

BACKGROUND AND PURPOSE: Rhabdomyolysis is well known after traumatic crush injuries or ischemia involving muscles. Postoperatively, it most likely is secondary to surgical positioning and patient muscle mass. We report a case after laparoscopic live-donor nephrectomy. CASE REPORT: A muscular 35-year-old man underwent elective left laparoscopic live-donor nephrectomy in a 70 degrees flank position with four ports. He was in the right-side lying position with hip flexion (flank position) for approximately 4 hours. A kidney bridge had been placed between the iliac crest and the rib cage. Postoperatively, the patient had light-pinkish urine and low urine output. There was marked induration of the buttocks and significant pedal and scrotal edema. With judicious use of alkalinization and diuretics, the patient did not require dialysis, and renal function returned to base level by postoperative day 20. The recipient of the kidney had a normal postoperative course. CONCLUSION: Rhabdomyolysis is a syndrome of muscle necrosis and release of intracellular components into the circulation. Acute renal failure secondary to myoglobinuria is a common complication. We currently use little flexion of the table during donor nephrectomy and bring the table to a neutral position immediately after kidney retrieval. Postoperatively, one needs a high index of suspicion for rhabdomyolysis to avoid or at least promptly recognize this rare but potentially serious condition after any operation lasting >or=4 hours.

Acute Kidney Injury↗
PubMed2005

Impact of a double-pigtail stent on ureteral peristalsis in the porcine model: initial studies using a novel implantable magnetic sensor.

BACKGROUND AND PURPOSE: The effect of stents on ureteral peristalsis in vivo is not entirely clear. We sought to develop a minimally invasive method for its study. MATERIALS AND METHODS: In female domestic pigs, electrical potentials from the ureter were measured by bipolar steel-wire electromyography electrodes delivered laparoscopically. Mechanical movement was measured by giant magneto resistive sensors mounted on custom-made aluminum strips. After baseline values were obtained, the animals were randomized to receive silicone or polyurethane stents, and ureteral peristalsis was measured for 8 hours acutely and for 4 hours 1 week later. RESULTS: Implantation of the devices took an average of 30 minutes. A consistent correlation was found between laparoscopically observed peristaltic waves and the peristalsis detected by the two measuring devices. The devices themselves did not affect peristalsis. Stent insertion increased peristaltic activity initially but later reduced or stopped it. There was no difference in the effects of the two types of stents. CONCLUSIONS: The new technique permits close monitoring of ureteral peristalsis in vivo. Smaller stents appear to have less immediate effect than larger ones, but all type of stents tested eventually caused aperistalsis.

Animals↗
PubMed2005

Extraperitoneal laparoscopic prostatectomy (adenomectomy) for obstructing benign prostatic hyperplasia: transvesical and transcapsular (Millin) techniques.

PURPOSE: We describe extraperitoneal laparoscopic resection of large prostatic adenomas (<100 g) as an alternative to open simple prostatectomy by both the transcapsular or Millin and the transvesical approaches. PATIENTS AND METHODS: We have performed more than 20 laparoscopic prostatectomies (adenomectomies) for benign prostatic hyperplasia (BPH) for glands >100 g. The initial two cases, with follow-up longer than 1 year, are included in this report. Using an extraperitoneal approach, enucleation of the obstructing prostatic lobes was performed with the aid of a Harmonic Scalpel and laparoscopic claw forceps. Hemostatic sutures were placed at 5 and 7 o'clock. The urethrovesical junction (transvesical) or capsulotomy (Millin) were closed in an interrupted fashion using intracorporeal sutures. RESULTS: Both procedures were successful. The total operative time was 180 minutes for first the case and 120 minutes for the second. The adenoma removed was approximately 138 g in the first case and 102 g in the second case. The estimated blood loss was <50 mL and <200 mL, respectively. The postoperative courses were unremarkable. Analgesic requirements were minimal, and the patient was discharged on postoperative day 2 and 3, respectively. A follow-up examination at 1, 3, 6, and 12 months showed that the flow rate is >20 mL and the postvoiding residual volume 0, with normal continence and sexual potency in both men. CONCLUSIONS: Extraperitoneal laparoscopic simple prostatectomy is a simple straightforward technique. Minimal bleeding, a reduced transfusion rate, shorter hospitalization, and faster recovery are additional advantages. This minimally invasive technique is a reasonable alternative to open simple prostatectomy for large glands with reduced morbidity.

Adenoma↗
PubMed2005

Instrumentation for laparoscopic renal surgery--Padron Endoscopic Exposing Retractor (PEER) and Endoholder: point of technique.

During laparoscopic surgery, as in open surgery, exposure is critical. However, this can be difficult during laparoscopy due to limited haptic feedback and the loss of 3-dimensional visualization. Excessive force may be inadvertently applied by assistants when anatomic structures are retracted; similarly, the retractors may be unknowingly moved because the limited field of view with the laparoscope precludes constant visualization of the retracting instrument. To overcome these problems, we have been using a 5- or 10-mm PEER retractor in combination with an articulating arm instrument holder (Endoholder) to aid laparoscopic renal surgery. The adjustable spring-loaded articulating instrument holder (Endoholder) consists of 4 components, including table attachment, a base rod, flexible extension arm, and precision clamp. The clamp accommodates variously sized instruments, and the flexible extension arm rotates 360 degrees to aid in positioning. The instrument holder is clamped to the table via the base rod over a sterile drape. A PEER Retractor, Roto-lok ratchet (5- or 10-mm diameter and 32-cm length) is placed intracorporeally to retract and position the kidney for hilar, upper, and lower pole dissection. The PEER retractor's handle is secured in place using the precision clamp of the instrument holder. The articulating instrument holder and PEER retractor are used for our renal, adrenal, and ureteral laparoscopic procedures. Placement of the retractor through a 5- or 10-mm port and deployment can be done quickly. Adequate and stable positioning of the retractor provides excellent and secure visualization of the operative field. These instruments have been used in more than 200 cases without any complication except 1 minor liver laceration. The articulating instrument holder with the PEER retractor is a very useful aid during laparoscopic renal surgery. This instrument reduces the chances of inadvertent injury to viscera by the assistant while maintaining an excellent anatomic view throughout the procedure. This will have a significant impact on the advancement of laparoscopy and its acceptance by every urologist.

Adrenalectomy↗
PubMed2005

Case and management of incidentalomas in patients with Von Hippel-Lindau disease.

Adrenal incidentalomas, those adrenal masses discovered on imaging studies undertaken for other indications, represent an evaluation and management conundrum. Evaluating every incidentaloma for functional status and/or resecting all incidentalomas would not be cost-effective because the vast majority of incidentalomas are benign, non-functioning adenomas. Current management strategies focus on size, functionality and imaging characteristics. These strategies do not take into account individual patient characteristics, for example, comorbid hereditary syndromes. In this article we report a case of a pheochromocytoma presenting as a small incidentaloma in a patient with Von Hippel-Lindau disease. We review the current literature describing the appropriate evaluation and management of adrenal incidentalomas and investigate the nuances of evaluation of these masses in patients with Von Hippel-Lindau disease.

Adrenal Gland Neoplasms↗
PubMed2004

Needle-based ablation of renal parenchyma using microwave, cryoablation, impedance- and temperature-based monopolar and bipolar radiofrequency, and liquid and gel chemoablation: laboratory studies and review of the literature.

BACKGROUND AND PURPOSE: Small renal tumors are often serendipitously detected during the screening of patients for renal or other disease entities. Rather than perform a radical or partial nephrectomy for these diminutive lesions, several centers have begun to explore a variety of ablative energy sources that could be applied directly via a percutaneously placed needle-like probe. To evaluate the utility of such treatment for small renal tumors/masses, we compared the feasibility, regularity (consistency in size and shape), and reproducibility of necrosis produced in normal porcine kidneys by different modes of tissue ablation: microwaves, cold impedance-based and temperature-based radiofrequency (RF) energy (monopolar and bipolar), and chemical. Chemoablation was accomplished using ethanol gel, hypertonic saline gel, and acetic acid gel either alone or with simultaneous application of monopolar or bipolar RF energy. MATERIALS AND METHODS: A total of 107 renal lesions were created laparoscopically in 33 domestic pigs. Microwave thermoablation (N=12) was done using a Targis T3 (Urologix) 10F antenna. Cryoablation (N=16) was done using a single 1.5-mm probe or three 17F microprobes (17F SeedNet system; Galil Medical) (N=10 single probe and N=6 three probes); a double freeze cycle with a passive thaw was employed under ultrasound guidance. Dry RF lesions were created using custom-made 18-gauge single-needle monopolar probe with two or three exposed metal tips (GelTx) (N=12) or a single-needle bipolar probe (N=6) at 50 W of 510 kHz RF energy for 5 minutes. In addition, a multitine RF probe (RITA Medical Systems) was used in one set of studies (N=6). Both impedance- and temperature-based RF were evaluated. Chemoablation was performed with 95% ethanol (4 mL), 24% hypertonic saline (4 mL), and 50% acetic acid (4 mL) as single injections. In addition, chemoablation was tested with monopolar and bipolar RF (wet RF). Tissues were harvested 1 week after ablation for light microscopy. RESULTS: In 11 of the 15 ablation techniques, there was complete necrosis in all lesions; however, three ethanol gel lesions had skip areas, three hypertonic saline gel lesions showed no necrosis or injury, and one monopolar RF and one bipolar RF lesion showed skip areas. In contrast to impedance-based RF, heat-based RF (RITA) caused complete necrosis without skip areas. All cryolesions resulted in complete tissue necrosis, and cryotherapy was the only modality for which lesion size could be effectively monitored using ultrasound imaging. CONCLUSIONS: Cryoablation and thermotherapy produce well-delineated, completely necrotic renal lesions. The single-probe monopolar and bipolar RF produce limited areas of tissue necrosis; however, both are enhanced by using hypertonic saline, acetic acid, or ethanol gel. Hypertonic saline gel with RF consistently provided the largest lesions. Ethanol and hypertonic saline gels tested alone failed to produce consistent cellular necrosis at 1 week. In contrast, RITA using the Starburst XL probe produced consistent necrosis, while impedance-based RF left skip areas of viable tissue. Renal cryotherapy under ultrasound surveillance produced hypoechoic lesions, which could be reasonably monitored, while all other modalities yielded hyperechoic lesions the margins of which could not be properly monitored with ultrasound imaging.

Acetic Acid↗
PubMed2004

Laparoscopic radical prostatectomy: Washington University initial experience and prospective evaluation of quality of life.

BACKGROUND AND PURPOSE: The laparoscopic approach to radical prostatectomy offers an alternative to the open surgical procedure with less morbidity. We prospectively collected data including a validated quality-of-life questionnaires on our first 38 laparoscopic radical prostatectomies (LRPs). The first 10 patients (group 1), second 10 patients (group II), and the most recent 18 patients (group III) were examined separately to study the learning curve for this procedure. In addition, we determined the pattern of recovery of urinary continence, potency, and quality of life. PATIENTS AND METHODS: Between July 1999 and July 2002, 38 consecutive transperitoneal laparoscopic radical prostatectomies were performed for clinically localized prostate carcinoma. Patients completed quality-of-life questionnaires (Rand 36 Health Survey) before surgery as well as at 1, 3, 6, and 12 months and every 6 months thereafter. The patients were also interviewed by an individual not directly involved in patient care. RESULTS: One patient (the second in our experience) was converted to the open approach because of failure to progress. The average operating time for the whole series was 423 +/- 137.6 minutes (range 215-825 minutes), the last 10 procedures taking 305 +/- 63 minutes (range 215-420 minutes). Complications consisted of one case each of intraoperative bladder injury, transient superficial peroneal nerve palsy, pulmonary embolism, and bladder neck obstruction. The bladder injury was closed laparoscopically without further complication. Bladder neck obstruction was secondary to a bladder wall fold that was treated with transurethral resection 14 months after surgery with good results. Four patients in group 1 had minor anastomotic leaks, while only one patient after that had a leak (group III). Four patients required transfusion, two intraoperatively and two postoperatively. In group III, the urethral catheter remained in place for an average of 8 days (range 6-10 days). With a mean follow-up of 22.8 months (range 9-43 months), 84.8% of the patients had perfect urinary control. Postoperatively, 9 patients (27%) were fully continent on removal of the Foley catheter. At 1, 3, 6, and 9 months postoperatively, diurnal urinary control was reported by 30.3%, 48%, 72.7%, and 84.8% of the patients, respectively. One patient needed an artificial urinary sphincter. Among the incontinent patients, 24.2% had urinary urgency, and one third of these patients reported urge incontinence. CONCLUSIONS: Laparoscopic prostatectomy is a reproducible technique with a steep learning curve. Operating times and the incidence of anastomotic leaks and urinary incontinence decrease significantly after the initial 10 patients.

Erectile Dysfunction↗
PubMed2004

Smooth-muscle regeneration after electrosurgical endopyelotomy in a porcine model as confirmed by electron microscopy.

BACKGROUND AND PURPOSE: Endopyelotomy is the preferred treatment for ureteropelvic junction (UPJ) obstruction because of its short operating time, limited morbidity, fast recovery, and reasonable efficacy. We used tissue and immunohistochemistry staining and electron microscopy to look at the muscle regeneration following an endopyelotomy incision in a porcine model. MATERIALS AND METHODS: Bilateral electrosurgical endopyelotomy was performed in six domestic pigs with placement of 7F 20-cm Percuflex double-J stents for up to 4 weeks, and urinary tracts were harvested at 3 or 5 months. Specimen evaluation included tissue staining with hematoxylin-eosin, Masson's trichrome, and Verhoeff's iodine and Van Gieson solution; histochemical staining for smooth-muscle actin, desmin and myosin staining, and electron microscopy. Each specimen was assigned a "healing" score of 0 (normal) 1 (slight changes), 2 (mild changes), or 3 (severe changes). The fibrosis score was based on six factors: muscle layer fibrosis, lamina propria fibrosis, amount of granulation tissue present, new deposits of collagen, fibrosis in the periureteral fat, and presence of myofibroblasts. The muscles were characterized with immunohistochemistry and electron microscopy. RESULTS: At both 3 and 5 months, the urothelium was healed, and the lamina propria was healed with focal loss. By 3 months, smooth-muscle bundles bridged the defect, and by 5 months, the whole defect was covered. Smooth muscle cells were evident by electron microscopy by 3 months, and actin and myosin could be detected by immunohistochemistry. Desmin-positive cells accounted for 50% of the population at 3 months and 40% at 5 months. The regenerated smooth-muscle bundles were oriented in different directions and intermingled with fibrous tissue. They could be distinguished easily from normal ureter under the microscope. CONCLUSION: Verifiable, functional smooth-muscle bundles bridge the endopyelotomy defect by 3 months, as confirmed by immunohistochemistry staining and electron microscopy.

Animals↗
PubMed2004

Prospective comparison of the immunological and stress response following laparoscopic and open surgery for localized renal cell carcinoma.

PURPOSE: We prospectively compared the systemic immune and stress response of patients who underwent laparoscopic total nephrectomy (LRN) (14) and open nephrectomy (ON) (10) for renal cell carcinoma. The ON group comprised open radical (4), open total (2) and open partial (4) nephrectomy cases. MATERIALS AND METHODS: Only patients with no history of cancer or autoimmune disease and American Society of Anesthesiologists score 2 or less who were not using immunosuppressive drugs were selected. Peripheral venous blood was collected preoperatively and intraoperatively, and 24 hours, 2 weeks, 4 weeks and 3 months postoperatively. Blood was analyzed for stress markers (adrenalin, noradrenalin and cortisol), inflammatory response markers (C-reactive protein, white blood count and leukocyte count), lymphocytic response markers (CD3, CD4 and CD8), cytokines interleukin-2 and 4, interferon-alpha and tumor necrosis factor-alpha), HLA-DR expression and the proliferative response to mitogen stimulation using concanavalin A, phytohemagglutinin 10, and pokeweed mitogen. RESULTS: Mean tumor size +/- SD for ON and LRN was 5.6 +/- 2.4 and 4.5 +/- 1.6 cm, respectively (p = 0.21). The trends with time for all measured postoperative parameters were similar in the 2 groups. Inflammatory and stress response markers were statistically similar for in the groups at all time points. A significant difference between the groups was noted for the percentage of CD4+ and CD8+ lymphocytes. However, this difference was present preoperatively and there was no significant absolute change in these 2 parameters. The cytokine response and HLA-DR expression were similar in the 2 groups at all time points. Likewise, the lymphocytic stimulation index for concanavalin A, phytohemagglutinin and pokeweed mitogen were statistically similar for LRN and ON at all time points. CONCLUSIONS: The immunological and stress response after LRN and ON for renal cell carcinoma is similar. The few differences observed in measured parameters likely reflect preoperative differences in baseline and/or the contributory effect of anesthesia.

Carcinoma, Renal Cell↗
PubMed2004

Laparoscopic mid sagittal hemicystectomy and bladder reconstruction with small intestinal submucosa and reimplantation of ureter into small intestinal submucosa: 1-year followup.

PURPOSE: We evaluated the long-term results of laparoscopic hemicystectomy and bladder replacement with small intestinal submucosa (SIS) with ureteral reimplantation into the SIS material. MATERIALS AND METHODS: A total of 12 minipigs underwent laparoscopic hemicystectomy. Six pigs underwent bladder reconstruction with SIS and ipsilateral ureteral reimplantation. The remaining 6 control pigs underwent hemicystectomy and primary bladder closure with ipsilateral nephroureterectomy. Preoperative and followup evaluations included blood chemistry, radiography and urodynamic evaluations. The 6, 3, 6 and 9-week, and 12-month followup evaluations included biopsies. At 1 year the animals were sacrificed. Histopathological and contractility studies, and reverse transcriptase-polymerase chain reaction for growth factors and basement membrane components were performed. RESULTS: Bladder capacity and bladder compliance were similar in the 2 groups at all time points. One pig per group died, that is a control at the 9-month evaluation due to an anesthetic complication and an SIS pig 7 months after bladder reconstruction due to spontaneous bladder rupture at the anastomotic site. In the SIS group 4 of 5 surviving pigs had unobstructed reimplanted ureters without evidence of hydroureteronephrosis, while 1 had high grade obstruction at the reimplantation site. Histopathology study after 1 year revealed muscle at the graft periphery and center but it consisted of small fused bundles with significant fibrosis. Nerves were present at the graft periphery and center but they were decreased in number. CONCLUSIONS: Laparoscopic SIS bladder reconstruction and ureteral reimplantation into the SIS after hemicystectomy are technically feasible. However, compared to primary bladder closure no advantage in bladder capacity or compliance was documented.

Animals↗
PubMed2003

Combined percutaneous and retrograde approach to staghorn calculi with application of the ureteral access sheath to facilitate percutaneous nephrolithotomy.

PURPOSE: We describe our technique and clinical experience with application of the ureteral access sheath for single access ablation of staghorn and partial staghorn calculi. MATERIALS AND METHODS: We retrospectively reviewed our experience with 9 patients who underwent percutaneous nephrolithotomy for staghorn (6) or partial staghorn (3) renal calculi using a combined antegrade and retrograde approach. Patient data, operative parameters, efficacy of stone ablation and convalescence parameters were reviewed. RESULTS: Mean operative time for the primary procedure was 3.1 hours with a mean estimated blood loss of 290 ml. Postoperatively, the mean analgesic requirement was 33.2 mg. MSO(4) equivalents. Hospital stay was 3.2 days. There were no major and 4 minor (44%) complications. No patient required transfusion. Complete stone clearance was achieved in 7 of the 9 cases (78%) using a single percutaneous nephrostomy tract. CONCLUSIONS: Our preliminary clinical experience using the ureteral access sheath during percutaneous nephrolithotomy for simultaneous antegrade and retrograde stone treatment has been favorable. A large renal stone burden can be successfully managed with a single percutaneous access and limited blood loss.

Humans↗
PubMed2003

Characterization of intrapelvic pressure during ureteropyeloscopy with ureteral access sheaths.

OBJECTIVES: To evaluate the impact of the ureteral access sheath on intrarenal pressures during flexible ureteroscopy in light of the recent resurgence in their use. As such, using human cadaveric kidneys, we studied changes in intrarenal pressure in response to continuous irrigation at different pressures with and without access sheaths of various sizes and lengths. METHODS: This study was performed using seven cadaveric kidneys. In three kidneys the study was done in situ with a 7.5F flexible ureteroscope (URS) passed by itself and then passed through a 10/12F sheath (35 and 55 cm in length), whereas, in four kidneys, due to narrowing of the intramural ureter, the study was done ex vivo using the unsheathed URS and then passing the 7.5F flexible URS via the 10/12F, 12/14F, and 14/16F sheaths (all 35 cm in length). A 10F Cope loop pyelostomy was placed to measure intrapelvic renal pressure. Three sets of 3-minute readings (ie, flow and intrarenal pressure) were taken with the tip of the URS at the distal ureter, middle ureter, and renal pelvis (just above the ureteropelvic junction); the entire process was done at three different irrigant pressure settings: 50, 100, and 200 cm H(2)O. Irrigant flow and intrarenal pressures were measured at all three settings using the URS passed without a sheath and then with the URS passed through the various sheaths positioned at the distal ureter, middle ureter, and renal pelvis. RESULTS: With all of the sheaths, intrapelvic pressure remained low (less than 30 cm H(2)O), and there was a 35% to 80% increase in irrigant flow versus the control unsheathed URS. With the sheath in place, the majority of the irrigant drained alongside the URS and out the sheath. Flow and pressure with the 12/14F sheath were equivalent to the 14/16F sheath. CONCLUSIONS: The 12/14F access sheath provides for maximum flow of irrigant while maintaining a low intrarenal pelvic pressure. Even with an irrigation pressure of 200 cm H(2)O, renal pelvic pressure remained below 20 cm H(2)O.

Equipment Design↗
PubMed2003

Hemostatic laparoscopic partial nephrectomy assisted by a water-cooled, high-density, monopolar device without renal vascular control.

OBJECTIVES: To evaluate the feasibility of laparoscopic partial nephrectomy assisted by a water-cooled, high-density, monopolar device (TissueLink Floating Ball). METHODS: Transperitoneal laparoscopic partial nephrectomy was performed without vascular control for four renal tumors in 3 patients. A flexible ultrasound probe was used to confirm tumor location and depth. Gerota's fascia was opened distant from the tumor site. Renal fat was dissected from the renal parenchyma except for the fat overlying the tumor. The tumor resection area was marked 1 cm outside the boundaries of the tumor. After application of the TissueLink Floating Ball at the planned surgical margin, the tumor was resected with cold laparoscopic scissors. Bleeding from the vessels of the divided renal parenchyma was controlled with the Floating Ball if necessary. The specimen was sent for frozen section to confirm margin status. RESULTS: Mean estimated blood loss per tumor was 275 mL. The dissection extended to the collecting system in 2 of 4 cases. In 1 patient, a minor postoperative urine leak resolved spontaneously. CONCLUSIONS: Use of the TissueLink Floating Ball facilitated resection of small renal tumors without renal vascular control. Although further study is necessary, water-cooled, high-density monopolar energy may have a role in laparoscopic partial nephrectomy.

Aged↗
PubMed2003

Tissue chemoablation.

PURPOSE: To provide an overview of the state of the art of tissue chemoablation in animal and human organs and cancers. We also describe our experience with the feasibility, predictability, and reproducibility of necrosis produced by needle chemoablative therapies including ethanol, hypertonic saline, and acetic acid solutions as well as gels in a porcine renal model. MATERIALS AND METHODS: A MEDLINE search was performed for articles on animal and human tissue chemoablation published since 1965. In addition, at Washington University, experimental chemoablation was performed in pigs with 95% ethanol (4 mL), 24% hypertonic saline (4 mL), or 50% acetic acid (4 mL) solutions as well as in gel form. RESULTS: There is extensive literature on the use of chemoablation for liver metastases; recently, chemoablation of the prostate has become an area of research. Human studies have been limited to patients who are not surgical candidates or to investigational procedures performed prior to definitive prostatic surgery. Animal studies of renal chemoablation as a sole therapy have produced mixed results. In our studies, only acetic acid provided complete necrosis. CONCLUSIONS: To date, ethanol chemoablation has been shown to be feasible and reproducible only for metastatic hepatic carcinoma. In urology, chemoablation is still very much in the investigational stage for both the prostate and the kidney. A significant drawback is that even in the gel form, the spread of the chemoablative substance through the tissue is irregular and unpredictable. In the future, chemoablation may become a more effective modality by combining it with radiofrequency or other energy sources.

Acetic Acid↗
PubMed2003

Laparoscopic cyst decortication in autosomal dominant polycystic kidney disease: impact on pain, hypertension, and renal function.

BACKGROUND AND PURPOSE: In patients with autosomal dominant polycystic kidney disease (ADPKD), laparoscopic cyst decortication (LCD) has been proposed as a means to relieve chronic cyst-related pain. We present our 7-year experience with LCD for ADPKD with regard to pain relief, hypertension, and renal function. PATIENTS AND METHODS: Between August 1994 and February 2001, 29 ADPKD patients with chronic pain (N=29), hypertension (N=21), and renal insufficiency (N=10) underwent 35 LCD procedures. Every detectable cyst within 2 mm of the renal surface was treated. Pain relief was assessed using a pain analog scale; relative pain relief (RPR) equaled (preoperative pain score) - (postoperative pain score)/(preoperative pain score). Hypertension was evaluated using the antihypertensive therapeutic index (ATI): [(dose of blood pressure medication 1/max dose 1) + (dose med 2/max dose 2) + etc.] x 10. Renal function was assessed using the Cockcroft and Gault formula for creatinine clearance. RESULTS: The mean operating room time was 4.9 hours (range 2.6-6.6 hours) with no conversions to open surgery. An average of 220 cysts (range 4-692) were treated per patient. The mean follow-up was 32.3 months (range 6-72 months). The RPR was 58%, 47%, and 63% at 12, 24, and 36 months, respectively. At 12, 24, and 36 months, 73%, 52%, and 81% of patients, respectively, noted >50% improvement in their pain compared with the preoperative situation. Five patients became normotensive, and patients improved their ATI by an average of 49% (range 11%-93%). However, six patients had worsening hypertension, with an ATI increase averaging 53% (range 11%-122%), and one patient who was not hypertensive preoperatively has since developed hypertension. The creatinine clearance changed +4%, +7%, and -2% at 12, 24, and 36 months, respectively. Only one patient had a >20% increase in creatinine clearance. The only patients with a >20% decrease in creatinine clearance were those who had a creatinine clearance <30 mg/dL preoperatively (average decrease 34% [range 20%-51%]). CONCLUSIONS: For ADPKD patients with debilitating pain, extensive LCD can provide durable relief. In the majority of patients with pain and hypertension, a marked improvement in blood pressure also occurs. Cyst decortication was not associated with worsening renal function; indeed, renal function remained largely unchanged over the 3-year follow-up period.

Adult↗
PubMed2003

Evaluation of a vessel sealing system, bipolar electrosurgery, harmonic scalpel, titanium clips, endoscopic gastrointestinal anastomosis vascular staples and sutures for arterial and venous ligation in a porcine model.

PURPOSE: We assessed the usefulness of the LigaSure (Valleylab, Boulder, Colorado) vessel sealing system for vascular control during laparoscopic surgery and compared it with other available hemostatic modalities. MATERIALS AND METHODS: A total of 31 domestic pigs were divided into 5 groups. In groups 1 and 2 the vessel sealing system was compared with titanium clips and Endo-GIA (United States Surgical, Stamford, Connecticut) staples. In group 3 the vessel sealing system was compared with standard Klepinger (Karl Storz, Culver City, California) bipolar forceps. In group 4 the harmonic scalpel and Trimax (United States Surgical) bipolar forceps were compared. In group 5 in vivo laparoscopic application of the vessel sealing system was evaluated. RESULTS: The 5 mm. laparoscopic vessel sealing system sealed arteries up to 6 mm. and veins up to 12 mm. in diameter at supraphysiological bursting pressure. We evaluated 13 arteries with a diameter of 6 mm. or less at a mean bursting pressure of 662 mm. Hg (range 363 to 1,985) and 11 veins with a diameter of 12 mm. or less with a mean bursting pressure of 233 mm. Hg (range 63 to 440). Collateral tissue damage extended 1 to 3 mm. from the application site. Standard bipolar energy with Klepinger and Trimax forceps was less reliable and in some cases vessel sealing could not be accurately assessed before vessel division. Collateral tissue injury was 1 to 6 mm. The harmonic scalpel did not reliably seal vessels larger than 3 mm. but resulted in the least acute collateral tissue injury of 0 to 1 mm. CONCLUSIONS: In the porcine model the LigaSure system is a viable option for laparoscopic management of arteries up to 6 mm. and veins up to 12 mm. in diameter.

Anastomosis, Surgical↗
PubMed2003

Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction.

PURPOSE: Laparoscopic pyeloplasty has become a viable option for the treatment of select patients with primary ureteropelvic junction obstruction with success rates similar to those of open surgery. However, little has been written on the application of this technique for secondary ureteropelvic junction obstruction. We report the largest series of secondary ureteropelvic junction obstruction managed by laparoscopic pyeloplasty. MATERIALS AND METHODS: Between March 1994 and March 2001, 36 patients underwent laparoscopic transperitoneal pyeloplasty for secondary ureteropelvic junction obstruction. The patients had undergone an average of 1.3 ureteropelvic junction procedures (range 1 to 4) prior to presentation, including cutting balloon retrograde endopyelotomy in 28, antegrade endoscopic endopyelotomy in 7, retrograde endoscopic endopyelotomy in 4, retrograde balloon dilation in 4 and open pyeloplasty in 3. A preoperative diagnosis of recurrent obstruction was confirmed by renal scan in 31 cases, retrograde pyelography in 2 and computerized tomography in 3. Of the 31 patients who underwent spiral computerized tomography angiogram 87% had crossing vessels. Laparoscopic repair comprised dismembered pyeloplasty in 31 cases, Fengerplasty in 3 and flap repair in 2. Postoperative renal scan or excretory urography objective followup was available for all patients at a mean of 10 months (range 3 to 40). Postoperative subjective patient well-being was assessed using an analog pain scale at a mean followup of 21.8 months (range 3 to 85). RESULTS: Average operative time was 6.2 hours (range 2.7 to 10). Average hospital stay was 2.9 days (range 1 to 7). One intraoperative complication occurred, that is bleeding necessitating conversion to an open procedure. Postoperative complications occurred in 8 cases, including anastomotic leakage in 4, and urinary tract infection, pneumonia, atelectasis, fever, bilateral upper extremity weakness and stone formation 2 months postoperatively in 1 each. On excretory urography, furosemide renal scan or the Whitaker test 32 of 36 patients (89%) had a widely patent ureteropelvic junction. Two patients (5.5%) had equivocal radiographic studies but were asymptomatic. In 2 patients the ureteropelvic junction was obstructed by renal scan. One patient had an indwelling stent for renal function deterioration and 1 was asymptomatic. Hence, 34 of the 36 patients (94%) had a reasonable objective response. Overall a 50% or greater decrease in pain was seen in 32 of 36 patients (89%). In the 4 patients with a less than 50% decrease in pain objective renal scans showed an open ureteropelvic junction. As such, the overall success rate of a greater than 50% decrease in pain, a patent ureteropelvic junction and stable or improved function of the affected renal unit was 83% (30 of 36 patients). CONCLUSIONS: For secondary ureteropelvic junction obstruction, laparoscopic pyeloplasty can be performed safely with a success rate comparable to that of standard open pyeloplasty. The patient benefits of laparoscopic ureteropelvic junction repair of secondary ureteropelvic junction obstruction are similar to the benefits of laparoscopic repair of primary ureteropelvic junction obstruction.

Adolescent↗