The detection of incidental adrenal masses has increased substantially with the advent and widespread use of high-resolution cross-sectional imaging techniques such as CT and MRI. The work-up and treatment of these incidentally found adrenal masses continue to be a clinical challenge for radiologists, endocrinologists, and adrenal surgeons. The approach to the evaluation of most of these adrenal masses depends on the radiologic appearance of the lesion, and whether the patient has a known underlying malignancy. The aim of this article is to review imaging features of pathologic abnormalities of the adrenal gland. Recent advances in noninvasive imaging methods that attempt to differentiate benign from malignant lesions also are addressed.

Adrenal Gland Diseases↗

PubMed2006

Feasibility of laparoscopic approach in management of xanthogranulomatous pyelonephritis.

OBJECTIVES: To report the feasibility of the laparoscopic approach for management of xanthogranulomatous pyelonephritis (XGP). METHODS: From 2002 to 2005, 11 patients underwent laparoscopic (n = 7) or hand-assisted laparoscopic (n = 4) nephrectomy by a single surgeon for pathologically confirmed XGP. The preoperative presentation, operative details, postoperative recovery, and complications were recorded. RESULTS: A total of 5 men and 6 women were included in this study, and the mean patient age was 51 years (range 28 to 78). All cases began with the laparoscopic approach (6 left and 5 right). Four cases were converted to the hand-assisted technique because of the difficulty in progression, but no case required conversion to open nephrectomy. The mean operative time was 157 minutes (range 101 to 201), with a mean estimated blood loss of 217 mL (range 50 to 440). No intraoperative complications occurred. The mean hospital duration was 2.4 days (range 1.5 to 4). Four patients had postoperative complications, including two with an ileus, one with a persistent fever requiring intravenous antibiotics, and one with a renal fossa abscess requiring percutaneous drainage. All specimens were pathologically confirmed to be XGP. CONCLUSIONS: Laparoscopic nephrectomy for XGP is complicated and more technically demanding than the laparoscopic nephrectomy for noninfectious etiologies. Consideration should be made for using a hand port should the laparoscopic procedure fail to progress in a satisfactory manner. In experienced hands, the laparoscopic approach presents a reasonable surgical option for the treatment of XGP. For the novice laparoscopist, however, the open approach should remain the modality of choice.

Adult↗

PubMed2005

Laparoscopic adrenalectomy for pheochromocytoma.

Laparoscopic adrenalectomy has become the standard technique for the surgical removal of the adrenal gland for functional adrenal tumors including aldosteronoma, glucocorticoid, and androgen/estrogen-producing adenomas. Many laparoscopic surgeons also think that for small to moderately sized pheochromocytomas, the laparoscopic approach is as safe and effective as the open technique. Several physiologic considerations specific to pheochromocytoma must be addressed before and during surgery regardless of the operative approach. The advantages of laparoscopic adrenalectomy over open adrenalectomy remain the same for pheochromocytomas as for other pathologic conditions of the adrenal gland. These include a shorter length of stay, a decrease in postoperative pain, a shorter time to return to preoperative activity level, and improved cosmesis.

Adrenal Gland Neoplasms↗

PubMed2005

Impact of delay to nephroureterectomy for patients undergoing ureteroscopic biopsy and laser tumor ablation of upper tract transitional cell carcinoma.

OBJECTIVES: To investigate whether a delay in nephroureterectomy for patients with transitional cell carcinoma of the upper urinary tract owing to ureteroscopic biopsy and/or laser tumor ablation affects postoperative disease status. METHODS: Of 155 patients diagnosed with upper tract transitional cell carcinoma at our institution from 1993 to 2003, 121 underwent nephroureterectomy. We compared the postoperative disease status of patients who underwent nephroureterectomy on the basis of positive cytology findings and filling defect on contrast imaging (no ureteroscopy; n = 34) to patients who underwent nephroureterectomy after ureteroscopic biopsy (n = 75) and patients who underwent nephroureterectomy after ureteroscopic biopsy and laser tumor ablation (n = 12). RESULTS: At a mean follow-up of 38.7 months, 29 (85.3%) of 34 patients who underwent nephroureterectomy on the basis of contrast imaging and urinary cytology alone were disease free compared with 61 (81.3%) of 75 patients who underwent ureteroscopic biopsy before nephroureterectomy (P = 0.18). The mean time from biopsy to nephroureterectomy for these 75 patients was 28 days, and the mean follow-up after nephroureterectomy was 40.1 months. Finally, 10 (83.3%) of 12 patients who underwent ureteroscopic biopsy and laser tumor ablation before nephroureterectomy were disease free at a mean follow-up of 37.2 months. The mean time from ureteroscopic biopsy to nephroureterectomy in this group was 196 days. No significant difference was found in the postoperative disease status between patients undergoing nephroureterectomy after ablation and those who proceeded to nephroureterectomy after endoscopic biopsy or those who did not undergo ureteroscopy before nephroureterectomy (P = 0.16). CONCLUSIONS: Ureteroscopy with biopsy and/or tumor ablation before nephroureterectomy did not adversely affect the postoperative disease status.

Aged↗

PubMed2005

Robot-assisted laparoscopic dismembered pyeloplasty: a combined experience.

BACKGROUND AND PURPOSE: The need for advanced laparoscopic skills limits the implementation of laparoscopic pyeloplasty to centers with extensive experience. The introduction of robotic technology into the field of minimally invasive surgery has facilitated complex surgical dissection and genitourinary reconstruction. We report our experience with robot-assisted laparoscopic pyeloplasty using the daVinci Surgical System at three New York City medical centers. PATIENTS AND METHODS: A retrospective review of all robot-assisted laparoscopic Anderson-Hynes dismembered pyeloplasty cases in 18 female and 17 male patients between April 2001 and January 2004 was performed. The average patient age was 39.0 years (range 15-69 years). All patients had symptoms or radiographic evidence of ureteropelvic junction (UPJ) obstruction. Robotic assistance with the daVinci Surgical System was employed after preparation of the UPJ with a standard laparoscopic approach. RESULTS: The mean operative time and suturing time was 216.4 +/- 52.9 minutes and 63.0 +/- 14.2 minutes, respectively. The average estimated blood loss was minimal at 73.9 +/- 58.3 mL. The mean length of hospitalization was 69.4 hours (range 28-310 hours). The average use of intravenous morphine was 28.4 mg (range 0-162 mg). There were no intraoperative complications or open conversions. A mean follow-up of 7.9 months revealed a success rate of 94%, with two patients requiring further treatment. CONCLUSIONS: This combined multi-institutional series reveals that robot-assisted pyeloplasty with the daVinci Surgical System is safe and reproducible. These intermediate results appear comparable to those of open and laparoscopic pyeloplasty repairs.

Adolescent↗

PubMed2005

Laparoscopic vs open partial nephrectomy in consecutive patients: the Cornell experience.

OBJECTIVE: To compare a contemporary series of laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) at one institution, to evaluate the size and types of tumour in each group and the early outcome after each procedure, as LPN is replacing open radical nephrectomy as the standard of care for uncomplicated renal tumours but partial nephrectomy remains significantly more difficult laparoscopically, especially if the goal is to duplicate the open surgical technique. PATIENTS AND METHODS: We retrospectively analysed the records of all patients who underwent partial nephrectomy at our institution from January 2000 to April 2004, identifying 66 who had LPN and compared them with 59 who had OPN (mean age at LPN and OPN, 62.1 and 64.2 years, respectively; 70% men in each group). Variables analysed included operative time, blood loss, creatinine levels before and after partial nephrectomy, time to resuming clear liquids and regular diet, length of stay, tumour size, tumour pathological type and complications. Groups were compared using Student's t-test, with P < 0.05 taken to indicate significance. RESULTS: Of those having LPN, 59% had right-sided tumours, vs 53% in the OPN group; the respective mean tumour size was 2.2 and 3.4 cm, the mean operative duration 144 and 239 min (both P < 0.001), and the mean estimated blood loss 236 and 363 mL (P = 0.09). Seven patients in the OPN group had obligatory partial nephrectomy for either a solitary kidney (two) or azotaemia (five). No patient in the LPN group required an obligatory partial nephrectomy. Serum creatinine levels were measured before and 1 and 2 days after surgery, and were 88, 88 and 97 micromol/L for the LPN group, and 97, 106 and 106 micromol/L for the OPN group. Clear fluids were started a mean of 41 h after surgery, a regular diet resumed 76 h after and discharge was 129 h after surgery in the OPN group; the respective values for the LPN group were 24 h (P = 0.01), 49 h (P = 0.2) and 82 h (P < 0.001). Complications were similar in both groups but the pathological subtypes differed. CONCLUSIONS: LPN offers early functional advantages over OPN in terms of earlier resumption of diet and slightly earlier discharge. However, the two groups of patients were clearly not evenly matched for size nor pathological subtypes, with larger, malignant subtypes more predominant in the OPN group. These results suggest that while LPN is a safe, effective treatment for small renal tumours, obligatory partial nephrectomy or large tumours continue to be performed using open techniques with good results.

Female↗

PubMed2004

Right laparoscopic live donor nephrectomy: a single institution experience.

BACKGROUND: Laparoscopic live donor nephrectomy (LLDN) is increasingly used by transplantation centers worldwide. As in open live donor nephrectomy, the left kidney is preferred for LLDN; however, not all potential donors have anatomy conducive to left nephrectomy. The purpose of our study, therefore, was to report on a large, single-institution experience with right LLDN performed using a hand-assisted, transperitoneal approach. METHODS: We performed a retrospective review of 40 consecutive patients who underwent transperitoneal right hand-assisted LLDN at our institution. Information on donor age, relation to recipient, and indication for right-sided donation was collected. Surgical demographics included operative time, warm ischemia time, and estimated blood loss. Recipients were followed for graft loss and for long-term renal allograft function. RESULTS: The indications for right-sided donor nephrectomy were a difference in split renal function of greater than 10%, multiple left renal vessels, and right renal cysts. The mean surgical time in our series was 115.8 min, with a mean estimated blood loss of 85.7 mL and a warm ischemia time of 116.0 seconds. Surgical and postoperative complications were limited. Mean serum creatinine levels in the recipients were 1.6 mg/dL on day 7, 1.4 mg/dL on day 30, and 1.4 mg/dL at 1 year after transplantation. CONCLUSIONS: Right LLDN using a hand-assisted, transperitoneal technique was performed with minimal morbidity and favorable graft function. We believe that offering hand-assisted LLDN to patients with an indication for right-sided donation can safely and effectively increase the pool of donor organs available to patients with end-stage renal disease.

Adult↗

PubMed2004

The advantages of hand-assisted laparoscopy.

The technical challenges of performing laparoscopic renal surgery require fellowship training and are associated with a steep learning curve. For the established urologist in practice, fellowship training is not a reality. As a result of these obstacles, in the late 1990s, laparoscopic renal surgery was entering the domain of the general surgeons who had a large number of laparoscopic procedures at their disposal to develop laparoscopic skills. Hand-assisted laparoscopic renal surgery is a hybrid procedure combining the most salient features of open renal surgery and laparoscopic renal surgery. By allowing the surgeons to place their non-dominant hand into the abdominal cavity, palpation and spatial orientation became possible, lessening the learning curve for laparoscopic surgery. Moreover, hand-assisted laparoscopic surgery could be applied to a variety of renal surgeries, extirpative and reconstructive, with results similar to those already achieved by standard laparoscopy. Throughout the past 5 years, hand-assisted laparoscopy has allowed urologists to incorporate laparoscopic renal surgery into their practices to the benefit of their patients and of their specialty. This review article offers a historical review of the development of hand-assisted laparoscopy and describes the procedures commonly performed today using this technique.

Cystectomy↗

PubMed2004

Hand-assisted laparoscopic nephroureterectomy for upper urinary-tract transitional-cell carcinoma.

Hand-assisted laparoscopic nephroureterectomy with laparoscopic, cystoscopic, or open management of the distal ureter and bladder cuff allow anyone from the novice to the advanced laparoscopic surgeon to perform en-bloc resection of the kidney, ureter, and bladder cuff without compromising oncologic principles. Patients receive significant benefits in the form of less pain, shorter hospital stay, and rapid convalescence. As more urologic surgeons develop skills with this procedure, a more critical analysis of early and long-term results will be possible. As operative times decrease, hand-assisted laparoscopic nephroureterectomy may become the procedure of choice for upper-tract transitional-cell carcinoma. The techniques and early results are described.

Carcinoma, Transitional Cell↗

PubMed2004

Abnormal selective cytology results predict recurrence of upper-tract transitional-cell carcinoma treated with ureteroscopic laser ablation.

BACKGROUND AND PURPOSE: Endoscopic management of transitional-cell carcinoma (TCC) of the upper urinary tract remains associated with a significant rate of recurrence. We evaluated the impact of selective upper-tract cytology findings on tumor recurrence and renal salvage rate after ureteroscopic laser tumor ablation. PATIENTS AND METHODS: From 1993 though 2003, 38 patients with upper-tract TCC underwent ureteroscopic laser tumor ablation. Cytology specimens were collected from the upper urinary tract prior to ablation. "Abnormal cytology" was defined as the presence of malignant or atypical cells. Patients with abnormal cytology results were compared with patients with those having negative findings for tumor recurrence and renal salvage rates using the X (2) test. RESULTS: Of the 38 patients, 26 (68.4%) experienced at least one recurrence at a mean follow-up of 37.2 months. Pretreatment upper-tract cytology results were available in 34 of these patients: 17 (50%) were negative, and 17 were abnormal. Sixteen of the patients (94.1%) with abnormal cytology results had tumor recurrence after ablation, compared with 8 of the 17 (47.1%) with negative cytology findings (P = 0.0026). Twelve patients (31.5%) underwent nephroureterectomy during follow-up: 8 of the 17 (47.1%) with abnormal cytology, and 4 of the 17 (23.5%) with negative cytology (P = 0.15). CONCLUSION: Abnormal selective cytology results were associated with a significantly higher rate of tumor recurrence and a trend toward increased renal loss in patients with upper-tract TCC treated with ureteroscopic ablation. These findings suggest a prognostic value for upper-tract cytology analysis in patients undergoing endoscopic therapy.

Adult↗

PubMed2003

Transabdominal laparoscopic adrenalectomy.

Laparoscopic adrenalectomy has become the standard technique for the surgical removal of the adrenal gland at many centers worldwide. Functional adrenal tumors such as aldosteronoma, glucocorticoid, androgen/estrogen-producing adenomas, and small-to-moderate sized solitary pheochromocytomas are amenable to removal via a laparoscopic approach. The advantages of laparoscopic adrenalectomy over open adrenalectomy are well documented and include a shorter hospital stay, a decrease in postoperative pain, shorter interval between surgery and return to preoperative activity level, and improved cosmesis. Various laparoscopic approaches to the adrenal gland have been described. Among these are the lateral transabdominal, anterior transabdominal, lateral retroperitoneal, and posterior retroperitoneal approaches. Each of these methods has specific advantages and disadvantages. This article reviews the transperitoneal approach to laparoscopic adrenalectomy, and discusses indications, operative technique, and a survey of the available literature.

Adrenalectomy↗

PubMed2003

Adrenal-preserving minimally invasive surgery: the role of laparoscopic partial adrenalectomy, cryosurgery, and radiofrequency ablation of the adrenal gland.

Adrenalectomy has become the standard of care for the management of hormonally active adrenal masses. Various surgical therapies have been proposed to excise completely or destroy these adrenal lesions, which may be benign or malignant. New minimally invasive, adrenal-sparing procedures have recently been introduced, among them laparoscopic partial adrenalectomy, cryosurgery, and radiofrequency ablation. These procedures focus on reducing patient morbidity and hastening postoperative recovery while preserving normal adrenal tissue. However, questions remain about the risks and benefits associated with routine application of minimally invasive therapies for adrenal-sparing surgery in terms of complete tumor extirpation. Clearly, more experience and longer follow-up is necessary to validate these procedures. Herein we describe the surgical techniques and early results of treatment with adrenal-sparing surgery.

Adrenal Gland Neoplasms↗

PubMed2003

Pleural injury during laparoscopic renal surgery: early recognition and management.

PURPOSE: Injury to the diaphragm is an uncommon yet recognized complication of several laparoscopic procedures, including laparoscopic renal surgery. As these procedures increase in popularity and use, laparoscopic surgeons should be aware of techniques for avoiding this complication as well as methods of identifying pleural injury and managing it appropriately. We report our experience with the detection and intraoperative management of pleural injury sustained during laparoscopic renal surgery and its subsequent treatment. MATERIALS AND METHODS: From July 1993 to April 2001 at 4 institutions 1,765 patients underwent laparoscopic renal surgery for benign and malignant disease as well as for live renal donation. We retrospectively reviewed the charts and interviewed the primary surgeons to determine the etiology of pleural injury, intraoperative detection and management, and possible future prevention. RESULTS: Pleural injury occurred in 10 cases (0.6%). In 2 cases injury involved inadvertent trocar placement through the pleural cavity. These cases were managed by intraoperative chest tube placement. In 8 cases the diaphragm was injured in iatrogenic fashion during kidney dissection, including during splenic mobilization in 2, liver mobilization in 2, ascending colon mobilization in 1, dissection of the upper renal pole in 2 and dissection of a large renal cyst off of the diaphragm in 1. In all patients injury was detected intraoperatively and repaired via laparoscopy. In 1 patient residual pneumothorax postoperatively necessitated tube thoracostomy. CONCLUSIONS: Pleural injury sustained during laparoscopic surgery is an uncommon but potentially serious complication of laparoscopic renal procedures. The experienced laparoscopic surgeon can identify and repair the injury intraoperatively, minimizing patient morbidity postoperatively.

Diaphragm↗

PubMed2003

Minimally invasive surgical management of ureteropelvic junction obstruction: laparoscopic and robot-assisted laparoscopic pyeloplasty.

Ureteropelvic junction (UPJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by an intrinsic or extrinsic obstruction in the area where the ureter joins the renal pelvis. The majority of cases are congenital in origin; however, acquired conditions at the level of the ureteropelvic junction may also present with symptoms and signs of obstruction. Until recently, open pyeloplasty and endoscopic techniques have been the main surgical options, with the intent of complete excision or incision of the obstruction. The introduction of laparoscopy and robot-assisted applications has allowed for minimally invasive reconstructive surgery that mirrors open surgical techniques. These techniques offer substantial benefits to patients by reducing morbidity, hastening postoperative recovery, and improving cosmetic outcome. During the last decade, laparoscopic pyeloplasty has garnered much interest. However, because of the technically challenging nature of this procedure, it is performed only at select medical centers by surgeons with advanced laparoscopic training. The recent introduction of robotics to the field of minimally invasive surgery may facilitate this procedure and allow for more widespread implementation by surgeons of varying skill levels. This review is limited primarily to the treatment of congenital or acquired UPJ obstruction via laparoscopic and robot-assisted laparoscopic pyeloplasty. Herein, we report the early results, ongoing evolution, and potential future role for these novel surgical procedures.

Humans↗