Biomedical subjects

Jihad H Kaouk

Publications and source records attributed to Jihad H Kaouk.

At least 19 recordsLinked to original sources

PubMed2005

Acute obstructive renal failure after laparoscopic cryoablation of multiple renal tumors in a solitary kidney.

A 67-year-old man with a solitary left kidney and baseline serum creatinine of 3.3 ng/mL (normal range 0.7 to 1.4) underwent laparoscopic cryoablation of two enhancing, solid renal tumors. Postoperatively, the case was complicated by a large blood clot in the renal collecting system causing obstruction and anuria. This complication of cryotherapy, never before reported to our knowledge, was treated successfully with a temporary ureteral stent. Follow-up magnetic resonance imaging at 3 months did not demonstrate any new lesions or enhancement of the treated renal masses. His serum creatinine at 3 months was 3.7 ng/mL.

Acute Disease↗

PubMed2005

Laparoscopic heminephrectomy for tumor.

OBJECTIVES: To present our experience with laparoscopic heminephrectomy. We defined heminephrectomy as excision of 30% or more of the renal parenchyma. Laparoscopic partial nephrectomy has typically been performed for smaller, exophytic tumors. With growing experience, we have performed more extensive resections for larger tumors, when indicated. METHODS: Since August 1999, we have performed laparoscopic partial nephrectomy in more than 300 patients. Of these, 41 patients were deemed to have undergone laparoscopic heminephrectomy (group 1). A contemporary group of 41 consecutive patients who underwent laparoscopic partial nephrectomy (less than 30% resection) were retrospectively identified for comparison (group 2). RESULTS: The preoperative patient demographics were similar, except for a greater body mass index (P = 0.02) in group 1. Group 1 had larger tumors (3.7 cm versus 2.3 cm, P <0.001) that were more commonly centrally located (41% versus 9.8%, P = 0.001) and more deeply infiltrating (P <0.001) compared with group 2. Group 1 underwent larger parenchymal resections (P <0.001) and routine pelvicaliceal suture repair (P = 0.002). The warm ischemia time was longer in group 1 (39 versus 33 minutes, P = 0.02); however, the amount of blood loss (150 versus 100 mL, P = 0.28) and total operative time (220 versus 190 minutes, P = 0.09) were comparable between the groups. The analgesic requirements, hospital stay, overall complications, and postoperative serum creatinine were comparable between the groups. Histopathologic examination showed that all 82 surgical margins were negative. CONCLUSIONS: Laparoscopic heminephrectomy is an advanced procedure that can be performed efficaciously with equivalent outcomes to those of less substantial resections. To our knowledge, experience with laparoscopic heminephrectomy has not been previously described.

Adult↗

PubMed2005

Improved hemostasis during laparoscopic partial nephrectomy using gelatin matrix thrombin sealant.

OBJECTIVES: To evaluate whether using a biologic hemostatic sealant facilitates hemostasis during laparoscopic partial nephrectomy. Secure and durable parenchymal hemostasis is a critical requirement during laparoscopic partial nephrectomy. METHODS: Since September 1999, laparoscopic partial nephrectomy has been performed in more than 300 patients by a single surgeon, duplicating open surgical principles. Recently, from patient 225 onward, we modified our technique by incorporating topical application of a gelatin matrix thrombin sealant (FloSeal) to cover the partial nephrectomy bed before sutured renorrhaphy over a Surgicel bolster. The impact of FloSeal on reducing hemorrhagic complications was evaluated by comparing two sequential groups of patients: group 1 consisted of 68 patients in whom FloSeal was not used (patients 156 to 224) and group 2 consisted of 63 patients in whom it was used (patients 225 to 288). RESULTS: Groups 1 (no FloSeal) and 2 (FloSeal) were comparable in tumor size, number of central tumors, and performance of pelvicaliceal suture repair (84% versus 92%; P = 0.16). Intraoperative variables were also comparable in terms of mean warm ischemia time (36.1 versus 37.2 minutes; P = 0.55), blood loss (150 versus 106 mL; P = 0.36), operative time, and hospital stay. However, the FloSeal group had significantly fewer overall complications (37% versus 16%; P = 0.008) and tended toward a lower rate of hemorrhagic complications (12% versus 3%), although this did not achieve statistical significance (P = 0.08). CONCLUSIONS: The results of this study have shown that adjunctive use of gelatin matrix thrombin sealant substantially enhances parenchymal hemostasis and has decreased our procedural and hemorrhagic complications to levels comparable with contemporary open partial nephrectomy series. This gelatin matrix-thrombin tissue sealant is now a routine part of laparoscopic partial nephrectomy at our institution.

Gelatin Sponge, Absorbable↗

PubMed2005

Prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy.

PURPOSE: We report on a prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy for renal tumor. MATERIALS AND METHODS: Between June 1999 and June 2001, 102 consecutive eligible patients with a computerized tomography identified renal tumor were prospectively randomized to undergo either a transperitoneal (group 1, 50 patients) or retroperitoneal (group 2, 52 patients) laparoscopic radical nephrectomy with intact specimen extraction. Exclusion criteria for the study included body mass index greater than 35 or a history of prior major abdominal surgery in the quadrant of interest. Both groups were matched regarding age (63 versus 65 years, p = 0.69), BMI (29 versus 28, p = 0.89), American Society of Anesthesiologists class (2.7 versus 2.8, p = 0.37), laterality (right side 46% versus 48%, p = 0.85) and mean tumor size (5.3 versus 5.0 cm, p = 0.73). RESULTS: All 102 procedures were technically successful without the need for open conversion. Compared to the transperitoneal approach, the retroperitoneal approach was associated with a shorter time to renal artery control (91 versus 34 minutes, p <0.0001), shorter time to renal vein control (98 versus 45 minutes, p <0.0001) and shorter total operative time (207 versus 150 minutes, p = 0.001). However, the transperitoneal and retroperitoneal approaches were similar in terms of estimated blood loss (180 versus 242 cc, p = 0.13), hospital stay (43 versus 45 hours, p = 0.55), intraoperative complications (10% versus 7.7%, p = 0.30), postoperative complications (20% versus 13.5%, p = 0.14) and postoperative analgesia requirements (27 versus 26 mg MSO4 equivalent p = 0.13). Pathology revealed renal cell carcinoma in 84% and 75% of cases, respectively, with no positive surgical margin in any case. CONCLUSIONS: Laparoscopic radical nephrectomy can be performed efficiently and effectively with the transperitoneal or the retroperitoneal approach. While renal hilar control and total operative time may be quicker with retroperitoneoscopy, the approaches are similar in terms of other patient outcomes evaluated.

Adult↗

PubMed2005

Complications of laparoscopic partial nephrectomy in 200 cases.

PURPOSE: We analyzed complications of the initial 200 cases treated with laparoscopic partial nephrectomy for a suspected renal tumor. MATERIALS AND METHODS: Since August 1999, 200 consecutive patients have undergone laparoscopic partial nephrectomy. Mean patient age was 61.6 years, mean body mass index was 29.9 and mean tumor size was 2.9 cm (range 1 to 10). There were 51 central tumors (25%) and 15 solitary kidneys (7.5%). A central tumor was defined as any tumor infiltrating up to the collecting system or renal sinus, during the excision of which entry into and repair of the collecting system was necessary. Mean estimated blood loss was 247 cc and mean operative time was 3.3 hours. Data on complications were obtained from a prospectively maintained computerized database and via telephone calls to patients and/or local referring physicians. RESULTS: A total of 66 patients (33%) had 1 or more complications, which were intraoperative in 11 (5.5%), postoperative in 24 (12%) and delayed in 31 (15.5%). Overall 30 patients (15%) had a non-urological complication and 36 (18%) had a urological complication, including hemorrhage in 19 (9.5%) and urine leakage in 9 (4.5%). Hemorrhage occurred intraoperatively in 7 cases (3.5%) and postoperatively in 4 (2%), while it was delayed in 8 (4%). Of patients with urine leakage none required reoperation, 6 (3%) required a Double-J stent (Medical Engineering Corp., New York, New York) only, 2 (1%) required a Double-J stent with computerized tomography guided drainage and 1 required no treatment. Open conversion was necessary in 2 patients (1%), reoperation was done in 4 (2%) and elective laparoscopic radical nephrectomy was performed in 1 (0.5%). CONCLUSIONS: Laparoscopic partial nephrectomy is an advanced procedure with potential for complications. It requires considerable experience with reconstructive laparoscopy.

Adolescent↗

PubMed2005

Laparoscopic retropubic simple prostatectomy.

PURPOSE: Open retropubic simple prostatectomy is occasionally performed for symptomatic, large volume benign prostatic hyperplasia. We describe the technique of laparoscopic simple retropubic prostatectomy. MATERIALS AND METHODS: Since August 2001 at our 2 institutions laparoscopic simple retropubic prostatectomy has been performed in 17 patients with symptomatic significant prostatomegaly on transrectal ultrasonography (60 gm or greater, mean 93). Essential aspects of our 5 port technique are transverse cystotomy just proximal to the prostatovesical junction, subcapsular plane development, prostatic adenomectomy, prostatic fossa trigonization and prostatic capsule suture repair. Demographic, perioperative and outcome data were recorded. RESULTS: Mean operative time was 156 minutes (range 85 to 380), blood loss was 516 ml (range 100 to 2,500), hospital stay was 48 hours (range 15 to 110), and Foley catheter duration was 6.3 days (range 3 to 7). Mean specimen weight on pathological examination was 72 gm (range 32 to 120). Five patients (29%) required blood transfusion. Complications occurred in 3 patients (19%), that is intraoperative hemorrhage, catheter clot obstruction and duodenal ulcer bleeding in 1 each. All patients reported complete continence during a followup period of 1 month to 2 years. Considerable improvement from baseline was noted in American Urological Association score (preoperative vs postoperative 24.5 vs 9.9) and the maximum urine flow rate (preoperative vs postoperative 7 vs 22.8 cc per minute). CONCLUSIONS: Laparoscopic simple retropubic prostatectomy for large benign prostate hyperplasia is feasible. Our initial experience is presented.

Adenocarcinoma↗

PubMed2005

The impact of warm ischaemia on renal function after laparoscopic partial nephrectomy.

UNLABELLED: Authors from Cleveland assessed the impact of warm ischaemia on renal function, using their large database of laparoscopic partial nephrectomies for tumour. While agreeing that renal hilar clamping is essential for precise excision of the tumour, and other elements of the operation, the authors indicate that warm ischaemia may potentially damage the kidney. However, they found that there were virtually no clinical sequelae from warm ischaemic of up to 30 min. They also found that advancing age and pre-existing renal damage increased the risk of postoperative renal damage. OBJECTIVE: To assess the effect of warm ischaemia on renal function after laparoscopic partial nephrectomy (LPN) for tumour, and to evaluate the influence of various risk factors on renal function. PATIENTS AND METHODS: Data were analysed from 179 patients undergoing LPN for renal tumour under warm ischaemic conditions, with clamping of the renal artery and vein. Renal function was primarily evaluated in two groups of patients: 15 with tumour in a solitary kidney, who were evaluated by serial serum creatinine measurements; and 12 with two functioning kidneys undergoing unilateral LPN, and evaluated by renal scintigraphy before and 1 month after LPN to quantify differential renal function. Also, in all 179 patients, mean serum creatinine data at baseline, 1 day after LPN, at hospital discharge, and at the last follow-up were provided as supportive evidence. Logistic regression analyses were used to assess the effect of various risk factors on renal function after LPN, i.e. patient age, baseline serum creatinine, tumour size, solitary kidney status, duration of warm ischaemia, pelvicalyceal suture repair, urine output and intravenous fluids during LPN. RESULTS: In the group of patients with a solitary kidney the mean warm ischaemia time was 29 min, kidney parenchyma excised 29%, and serum creatinine at baseline, discharge, the peak after LPN and at the last follow-up (mean 4.8 months) 1.3, 2.3, 2.8, and 1.8 mg/dL, respectively. One patient (6.6%) required temporary dialysis. In the second group, assessed by renal scintigraphy, the function of the operated kidney was reduced by a mean of 29%, commensurate with the amount of parenchyma excised. For all 179 patients, a combination of age > or = 70 years and a serum creatinine level after LPN of > or = 1.5 mg/dL correlated with a higher serum creatinine after LPN. On logistic regression, baseline serum creatinine and solitary kidney status were the only variables significant for serum creatinine status after LPN. CONCLUSIONS: The bloodless field provided by renal hilar clamping is important for precise tumour excision, pelvicalyceal suture repair and securing parenchymal haemostasis during LPN. However, renal hilar clamping causes warm ischaemia. These data indicate that the clinical sequelae of warm ischaemic renal injury of approximately 30 min are minimal. Advancing age and pre-existing azotaemia increase the risk of renal dysfunction after LPN, especially when the warm ischaemia exceeds 30 min.

Adult↗

PubMed2004

Right donor nephrectomy: a comparison of hand-assisted transperitoneal and retroperitoneal laparoscopic approaches.

BACKGROUND: We compare the anatomic and functional outcomes of right live-donor nephrectomy (LDN) using either a hand-assisted approach (HALDN) or a pure retroperitoneoscopic approach (RLDN) in two institutions. PATIENTS AND METHODS: Data were recorded prospectively in 59 patients undergoing right LDN using either hand-assisted (n=31) or pure retroperitoneoscopic (n=28) approaches. All HALDN cases were performed at the University of Cincinnati, and all RLDN cases were performed at the Cleveland Clinic Foundation. RESULTS: Demographics were similar with respect to age (41.1+/-11.5 vs. 44.5+/-8.5 years) and human leukocyte antigen mismatches (2.7+/-1.8 vs. 2.6+/-1.6). Operative times were longer for HALDN (3.4+/-0.7 vs. 3.0+/-0.7 hours, P <0.04), whereas warm ischemia time was shorter (3:55+/-1:47 vs. 4:55+/-0:55 minutes, P <0.001). Length of renal vein and artery were equivalent (2.4/3.4 vs. 2.3/3.2 cm, P =0.5). Complication rates were similar (10% vs. 7%, P =0.5), including conversion to open surgery (n=1), accessory upper pole artery transection (n=1), and swollen testicle (n=1) in the HALDN group, and a small parenchymal injury (n=1) and a capsular tear (n=1) in the RLDN group. Donor length of stay and convalescence were similar in both groups (43.5+/-14.1 vs. 45.7+/-25.3 hours, P =0.1; convalescence 23.5+/-5.3 vs. 20.2+/-4.1 days, P =0.5). One-week, 1-month, and 1-year serum creatinine levels were equivalent with both approaches. No grafts were lost in either group. CONCLUSIONS: This study confirms that the HALDN and RLDN techniques can provide kidney grafts with equivalent-length vessels and excellent function.

Adult↗

PubMed2004

Laparoscopic radical prostatectomy: a multi-institutional study of conversion to open surgery.

OBJECTIVES: To perform a multi-institutional review of the incidence and factors contributing to conversion from laparoscopic radical prostatectomy (LRP) to open radical retropubic prostatectomy (RRP) among eight surgeons. METHODS: The medical records from all patients undergoing LRP at seven institutions were reviewed to assess the incidence of open conversion to RRP. The clinical, operative, pathologic, and functional outcomes of patients who required conversion were compiled and analyzed. RESULTS: Of 670 operations, 13 (1.9%) were converted from LRP to RRP. The most common steps at which conversion occurred were the apical dissection (38%) and the posterior seminal vesicle dissection (31%). Failure to progress was the most common cause of conversion, followed by injury to adjacent structures and hypercarbia. Comorbidities associated with conversion were prior pelvic surgery and obesity (body mass index greater than 30). Six of the 13 conversions occurred in the surgeons' first 5 cases. Despite open conversion, patients were continent (no pads) (92%) and potent (44%) with at least 6 months of follow-up. CONCLUSIONS: Open conversion from LRP to RRP is an uncommon event, but is more likely to occur during a surgeon's early experience. Surgeons beginning their experience with LRP are advised to select their patients carefully to minimize the need for conversion to open surgery. Obese patients and those at risk of periprostatic adhesions should initially not be considered for LRP. Despite open conversion, the functional outcomes did not appear to be adversely affected.

Adenocarcinoma↗

PubMed2004

Retroperitoneoscopic radical nephrectomy in a super-obese patient (body mass index 77 kg/m2).

Although obesity was initially considered a relative contraindication for laparoscopy, the retroperitoneal approach has been reported to be safe and effective for such patients during renal and adrenal surgery. We report a case of successful retroperitoneoscopic radical nephrectomy in a super-obese patient (body mass index 77 kg/m2) with a 12-cm renal tumor. The operative time was 3 hours, and the estimated blood loss was 100 mL. The patient was discharged home 36 hours after surgery. No intraoperative or perioperative complications occurred. The pathologic examination revealed renal cell carcinoma, and all surgical margins were negative (pT2N0M0). The patient returned to normal activities 3 weeks postoperatively.

Body Mass Index↗

PubMed2004

Right retroperitoneal versus left transperitoneal laparoscopic live donor nephrectomy.

OBJECTIVES: To describe our preferred method of right laparoscopic live donor nephrectomy (LDN) using a retroperitoneoscopic approach to determine the indications for, and overall rate of, right LDN and to compare the donor and recipient early outcomes of right retroperitoneal LDN to those of left transperitoneal LDN in a consecutive single-institution series. METHODS: At our institution, LDN for allotransplantation was performed in 143 consecutive patients. The indications for right LDN (n = 29) included multiple left renal vessels (n = 18), early branching of the left renal artery (n = 1), left renal vein anomaly (n = 2), right renal arterial fibromuscular dysplasia (n = 2), right renal cyst (n = 3), mild right hydronephrosis with delay on renal scan (n = 1), or right nephrolithiasis (n = 2). RESULTS: Right LDN was performed in 29 (20.3%) of 143 patients using a retroperitoneal approach in all but the first case. Right retroperitoneal LDN was associated with decreased blood loss and operative time compared with left transperitoneal LDN. The hospital stay, analgesic use, and donor serum creatinine at discharge were similar in both groups. Despite a statistically significantly increased warm ischemia time and decreased renal vein length, right retroperitoneal LDN was associated with recipient functional outcomes at 5 and 30 days after transplant that were no different from those after left transperitoneal LDN. CONCLUSIONS: Right retroperitoneal laparoscopic LDN provides similar donor and recipient outcomes when compared with the left transperitoneal approach and obviates most of the technical challenges encountered with a right transperitoneal approach.

Adult↗

PubMed2004

Laparoscopic nephron-sparing surgery for two or more ipsilateral renal tumors.

OBJECTIVES: To review our experience with laparoscopic nephron-sparing surgery in the management of two or more synchronous, ipsilateral renal masses. Minimally invasive nephron-sparing procedures are increasingly used for the treatment of select patients with a single, small renal tumor. METHODS: Since 1998, we have performed laparoscopic nephron-sparing surgery in 288 consecutive patients, including laparoscopic partial nephrectomy (n = 200) and renal cryotherapy (n = 88). Of these, 13 patients (4.5%) were treated for synchronous ipsilateral renal masses. RESULTS: A total of 27 renal tumors were treated in 13 patients. The patients were divided into four groups on the basis of the treatment. Group 1 (n = 3) underwent en-bloc laparoscopic partial nephrectomy encompassing both tumors; group 2 (n = 2) underwent individual laparoscopic partial nephrectomy of discrete masses during the same procedure; group 3 (n = 2) had one mass treated with partial nephrectomy and the other mass treated with cryotherapy; and group 4 (n = 6) had all tumors treated with cryotherapy. All cases were completed successfully without conversion to open surgery or laparoscopic nephrectomy. The mean overall operative time was 4.3 hours, and the mean blood loss was 169 mL. No intraoperative complications occurred. Three patients had postoperative complications, none requiring re-exploration. One patient in group 4 developed de novo tumors in the treated kidney, located distant from the cryoablated sites. CONCLUSIONS: Laparoscopic partial nephrectomy is an emerging, efficacious laparoscopic treatment option for select patients. Laparoscopic cryotherapy is a useful alternative or adjunct to partial nephrectomy. The judicious combination of these complementary techniques further extends the scope of minimally invasive nephron-sparing surgery.

Angiomyolipoma↗

PubMed2004

Laparoscopic injury and repair of obturator nerve during radical prostatectomy.

A 61-year-old man with bilateral Gleason score 7 (3+4) clinical Stage T1c prostate cancer was treated with laparoscopic bilateral pelvic lymphadenectomy and radical prostatectomy. The left obturator nerve was inadvertently transected during left obturator lymph node dissection and repaired by laparoscopic reapproximation.

Adenocarcinoma↗

PubMed2004

Factors related to delayed graft function after laparoscopic live donor nephrectomy.

PURPOSE: Delayed graft function after live donor transplantation affects 5% to 10% of recipients regardless of procurement technique. This delay in function is associated with an increased risk of rejection and decreased graft survival. In the present study we critically assess allograft recovery to identify the risk factors related to delayed graft function. MATERIALS AND METHODS: We retrospectively reviewed donor and recipient medical records from 100 consecutive laparoscopic live donor nephrectomies from August 1997 to October 2001. Four criteria were used to classify delayed graft function: I) requirement of dialysis in postoperative week 1, II) creatinine 2.5 mg/dl or greater at postoperative day 5, III) time to half peak activity (mercaptoacetyltriglycine renal scan) at postoperative day 5 greater than 12.2 minutes (normal range 1 to 12.2) and IV) time to peak activity (mercaptoacetyltriglycine renal scan) at day 5 greater than 6.5 minutes (normal range 2.1 to 6.5). Patients could qualify for multiple outcome categories. Patients who did not match any of these criteria were classified as having normal renal function (outcome 0). RESULTS: The number of patients in the delayed graft function categories were 5 with outcome I, 14 with outcome II, 39 with outcome III and 24 with outcome IV. There were 23 patients represented in more than 1 category and 59 patients were classified as having normal function. Recipient age, donor/recipient gender relationship, unrelated highly mismatched donors and cold/total preservation time were identified as risk factors related to impaired early renal function recovery. None of the variables related to the laparoscopic technique itself represented risk factors for delayed graft function. CONCLUSIONS: Female donor kidneys into male recipients and highly HLA mismatched donors represent factors that may be controlled by donor selection when feasible. All attempts should be made to decrease cold ischemia time and, therefore, total preservation time. Prolonged carbon dioxide pneumoperitoneum, warm ischemia time, renal artery length or use of right kidney did not adversely affect the functional outcome of the allografts procured laparoscopically.

Adult↗

PubMed2004

Laparoscopic ureterocalicostomy: initial experience.

PURPOSE: Ureterocalicostomy is a reconstructive option in the rare patient with surgically failed or difficult ureteropelvic junction (UPJ) obstruction with fibrosis and significant hydronephrosis. We introduce the technique of laparoscopic ureterocalicostomy. MATERIALS AND METHODS: Laparoscopic ureterocalicostomy was performed in 2 patients, of whom 1 had UPJ obstruction and multiple secondary calculi in a dilated, dependent lower pole calix, and 1 had surgically failed UPJ obstruction with a scarred pelvis and significant hydronephrosis. Using a transperitoneal technique the UPJ was dismembered and suture ligated, the cut end of the ureter was spatulated, the attenuated lower pole renal parenchyma was amputated and mucosa-to-mucosa ureterocaliceal anastomosis was performed with running 4-zero absorbable suture over a stent. In the first case 32 renal calculi were also removed using a combination of laparoscopic nephroscopy and intraoperative ultrasonography. RESULTS: In cases 1 and 2 operative time was 5.2 and 2.5 hours, estimated blood loss was 200 and 75 cc, and hospital stay was 2 days, respectively. There were no intraoperative complications. The stent was removed at 8 and 5 weeks, respectively. Postoperative retrograde pyelogram and diuretic renal scan confirmed anastomotic patency and improved drainage in each patient. At 9 months patient 1 remains without flank symptoms and a second renal scan at 6 months showed further improvement in drainage. Patient 2, who continued to be symptomatic with flank discomfort despite objective improvement in drainage parameters, elected secondary nephrectomy at 6 months. CONCLUSIONS: Laparoscopic ureterocalicostomy is feasible and it effectively duplicates established open surgical principles. To our knowledge the initial experience in the literature is presented.

Adult↗

PubMed2004

Thoracic complications during urological laparoscopy.

PURPOSE: We documented thoracic related complications during urological laparoscopic surgery. MATERIALS AND METHODS: A total of 1129 patients underwent major urological laparoscopic procedures in a 5-year period. Operative reports and postoperative radiographic reports were retrospectively reviewed to identify patients with thoracic related medical and surgical sequelae. Of the patients 619 (55%) underwent at least 1 chest x-ray in the immediate or early postoperative period. In the remaining 510 patients (45%) there was no clinical indication to perform chest x-ray. RESULTS: Of 619 patients undergoing chest x-ray 438 (71%) were completely normal. Medical pulmonary complications, surgical thoracic complications and subclinical, incidentally detected gas collections in the chest were identified in 12.6%, 0.5% and 5.5% of patients, respectively. Medical complications in 12.6% of cases included pulmonary infiltrate/atelectasis in 9.7%, pleural effusion in 4.8% and pulmonary embolus in 0.3%. Surgical complications included symptomatic pneumothorax in 4 patients (0.35%), hemothorax in 1 (0.08%) and chylothorax in 1 (0.08%). Subclinical abnormal thoracic gas collections were radiographically noted in 34 of the 619 patients (5.5%) on chest x-ray, including pneumomediastinum in 19 (3.1%), pneumothorax in 10 (1.6%) and pneumopericardium in 5 (0.8%). Overall 36 of 40 (90%) thoracic surgical complications (3) and subclinical, incidentally detected gas collections (33) occurred during retroperitoneal laparoscopy. Re-intervention was necessary in 6 patients (0.5%), namely pulmonary embolus requiring vena caval filter placement in 3 (0.3%), pneumothorax requiring a chest tube in 2 (0.17%) and hemothorax requiring emergency open thoracotomy in 1 (0.08%). No patient underwent open conversion to complete the initial proposed operation. CONCLUSIONS: Due to its high solubility the expectant management of incidental CO2 pneumothorax, pneumopericardium and pneumomediastinum is recommended initially in the clinically stable patient. Inadvertent diaphragmatic entry can be satisfactorily repaired laparoscopically without open conversion. Although it is rare, surgical thoracic complications are potentially life threatening, requiring prompt identification and management.

Adult↗

PubMed2004

Real-time transrectal ultrasonography during laparoscopic radical prostatectomy.

PURPOSE: We describe the technical aspects of real-time transrectal ultrasound (TRUS) monitoring and guidance during laparoscopic radical prostatectomy (LRP). Furthermore, we describe the TRUS visualized anatomy of periprostatic structures during LRP. MATERIALS AND METHODS: In 25 consecutive patients undergoing transperitoneal LRP, baseline preoperative, real-time intraoperative and immediate postoperative TRUS evaluations were performed. To define periprostatic anatomy precisely TRUS measurements were obtained with specific reference to the neurovascular bundle (NVB), prostate apex, membranous urethra, bladder neck, rectal wall and any cancer nodule. Conventional gray scale, power Doppler, harmonic imaging and 3-dimensional ultrasound functions were used. RESULTS: Real-time TRUS navigation facilitated 3 technical aspects of LRP. 1) It identified the correct plane between the posterior bladder neck and prostate base, allowing quick laparoscopic identification of the vasa and seminal vesicles. 2) It identified the occasional, difficult to see distal protrusion of the prostate apex posterior to the membranous urethra, thus enhancing apical dissection with negative margins. 3) It provided visualization of any hypoechoic nodule abutting the prostate capsule, alerting the laparoscopic surgeon to perform wide dissection at that location. TRUS measured various anatomical parameters including i) the mean distance +/-SD between the NVB and the lateral edge of the prostate a) at apex (1.9 +/- 0.9 mm), b) base (2.5 +/- 0.8 mm) and c) tip of seminal vesicle (4.0 +/- 1.6 mm), ii) the dimensions of the NVB a) before (4.5 x 3.9 mm), b) after (4.2 x 3.6 mm) nerve sparing LRP and c) after nonnerve sparing LRP (0.9 x 0.9 mm), iii) arterial blood flow resistive index within NVB a) before (0.83 +/- 0.04), b) after (0.84 +/- 0.03) nerve sparing LRP and c) after nonnerve sparing LRP (0), iv) and the length of membranous urethra a) before (12.2 +/- 1.1 mm) and b) after (11.7 +/- 1.0 mm) surgery. Focal distortion of the prostate surface by an exophytic nodule was visualized on TRUS in 3 patients, necessitating ipsilateral nerve resection at LRP and contributing to negative surgical margins. CONCLUSIONS: This initial experience suggests that real-time intraoperative TRUS guidance may enhance anatomical performance of LRP. This improved understanding of periprostatic anatomy has the potential to improve functional and oncological outcomes. Such corroboration is awaited.

Humans↗

PubMed2004

Laparoscopic extended pelvic lymphadenectomy for bladder cancer: technique and initial outcomes.

PURPOSE: We describe the technique and our evolving outcomes of laparoscopic extended pelvic lymphadenectomy for bladder cancer. MATERIALS AND METHODS: Since 1999 laparoscopic radical cystectomy with pelvic lymphadenectomy and intracorporeal urinary diversion has been performed in 22 patients. The initial 11 patients underwent limited dissection (group 1) and the subsequent 11 consecutive patients underwent extended lymphadenectomy (group 2). Our split-and-roll technique of laparoscopic extended pelvic lymphadenectomy has evolved to achieve lymphatic tissue clearance by bilaterally skeletonizing the genitofemoral nerve, external iliac artery, external iliac vein, obturator nerve, hypogastric artery, common iliac artery and pubic bone. RESULTS: Extended lymphadenectomy added 1.5 hours of operative time. The median number of nodes retrieved was 3 and 21 in groups 1 and 2, respectively (p = 0.001). Three patients per group were found to have positive nodal disease. In 1 patient undergoing extended dissection injury to a deep pelvic vein was managed by intracorporeal suturing and resulted in 200 ml blood loss. Two other patients had deep venous thrombosis. At a mean followup of 11 months (range 2 to 43) there were no port site recurrences. CONCLUSIONS: Laparoscopic extended pelvic lymphadenectomy for bladder cancer can be performed with anatomical boundaries and nodal yields commensurate with those of current recommendations for open surgery.

Adenocarcinoma↗