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Biomedical subjects

Mihir M Desai

Publications and source records attributed to Mihir M Desai.

At least 19 recordsLinked to original sources
PubMed2006

Long-term efficacy of holmium laser endoureterotomy for benign ureteral strictures.

OBJECTIVES: To determine the long-term clinical and radiographic success of holmium laser endoureterotomy for nonobliterative benign ureteral strictures. METHODS: A total of 19 patients (12 women and 7 men, mean age 47.5 years) underwent holmium laser endoureterotomy for iatrogenic ureteral strictures (seven proximal, seven mid, and five distal) using semirigid ureteroscopy and a 360-microm fiber at 1 J and 10 Hz. RESULTS: Success was strictly defined as both relief of symptoms and radiographic resolution of obstruction by intravenous pyelography or diuretic renography, or both. With a median follow-up of 3.0 years, success was achieved in 13 (68.4%) of 19 patients. CONCLUSIONS: Our results have shown that holmium laser endoureterotomy is associated with a long-term success rate equivalent to, or better than, other currently available minimally invasive treatment options. Also, failure was uniformly evident within the first 3 months after treatment.

Adult↗
PubMed2006

Probe-ablative nephron-sparing surgery: cryoablation versus radiofrequency ablation.

Over the past decade, a number of probe ablative therapies have emerged for the treatment of patients with localized renal tumors. Cryoablation and radiofrequency ablation (RFA) have been studied in the greatest detail. We present the results of 164 laparoscopic cryoablations and 82 percutaneous RFAs performed in our institution and compare them retrospectively in terms of complications, impact on renal function, follow-up imaging, and oncologic outcomes. Comparison of cryotherapy versus RFA revealed that mean tumor size was similar (2.56 cm vs 2.51 cm); however, the cryoablation group had a greater number of anteriorly located tumors (39% vs 10%), as well as fewer central tumors (6% vs 37%) and fewer solitary kidneys (24% vs 49%). Mean thermal treatment time was 19.3 minutes versus 32.2 minutes in the cryoablation and RFA groups, respectively. Radiologic evidence of tumor recurrence or persistence of disease was noted in 3 patients (1.8%) who underwent cryoablation and in 9 (11.1%) who were treated with RFA. All of have been successfully treated with repeat ablation/nephrectomy, or they are currently under observation. Complication rates were minimal in both groups; no significant impact on mean serum creatinine levels was noted. Cancer-specific survival following cryotherapy was 98% at a median follow-up of 3 years and 100% for RFA at 1-year median follow-up. Cryoablation and RFA are developmental nephron-sparing options. Early results are encouraging for both forms of probe ablation in terms of early oncologic control, preservation of renal function, and low complication rates. Longer-term oncologic data are necessary so that the true value of these treatment modalities can be determined.

Adult↗
PubMed2006

Repair of adult ureteropelvic junction obstruction in the solitary kidney: effect on renal function.

OBJECTIVES: To evaluate the effect of pyeloplasty for the treatment of ureteropelvic junction (UPJ) obstruction on adult renal function in the setting of a solitary kidney. METHODS: Since 1989, 312 patients have undergone operative intervention for UPJ obstruction. Of these, 13 patients (5 men and 8 women), aged 17 to 76 years (median 44.5), had a solitary kidney and were available for postoperative surveillance. Treatment consisted of endopyelotomy (n = 3), laparoscopic dismembered pyeloplasty (n = 3), and open dismembered pyeloplasty (n = 9). Two patients underwent two separate interventions for UPJ obstruction repair. Success was defined as symptomatic relief and radiographic resolution at the latest follow-up visit. In all patients, serum creatinine, estimated glomerular filtration rate, and weight were measured preoperatively, postoperatively, and at all follow-up examinations. Statistical analysis was performed to analyze group differences using the Wilcoxon signed-rank test. RESULTS: The median follow-up was 22 months (range 2 to 96). Three patients experienced a treatment failure and were excluded from the analysis. At the latest follow-up visit, the postoperative serum creatinine had improved by a median of 0.6 mg/dL (range -0.2 to 6.3; P <0.0001), and postoperative estimated glomerular filtration rate had improved by a median of 24.4 mL/min (range -13.9 to 66; P <0.0001). No statistically significant difference in renal function was observed between the patients' first and last follow-up visits. CONCLUSIONS: Operative intervention for the treatment of adult UPJ obstruction may result in symptomatic relief and, perhaps more importantly, renal functional improvement. These findings are important for effectively counseling patients and considering indications for intervention.

Adolescent↗
PubMed2006

Case report: simultaneous laparoscopic management of bilateral ureteropelvic junction obstruction in a horseshoe kidney.

A 42-year-old man presented with a horseshoe kidney with a nonfunctioning left moiety and bilateral ureteropelvic junction obstruction. Concomitant laparoscopic left nephrectomy and right pyeloplasty was performed. The total operative time was 5.7 hours, with a blood loss of <350 mL. There were no complications, and the hospital stay was 3 days. This appears to be the first such case reported.

Adult↗
PubMed2006

Percutaneous nephrolithotomy requiring multiple tracts: comparison of morbidity with single-tract procedures.

PURPOSE: To compare the morbidity of percutaneous nephrolithotomy (PCNL) requiring multiple percutaneous tracts with that of procedures requiring a single tract for calculus clearance. PATIENTS AND METHODS: Data from 20 patients undergoing PCNL through two or more percutaneous renal tracts over a 1-year period were compared with a contemporary cohort of 20 patients undergoing PCNL requiring a single tract. The mean stone size was 2157 mm(2) v 423 mm(2) (P < 0.0001), the baseline serum creatinine concentration was 1.67 mg/dL v 1.13 mg/dL (P < 0.05), and the baseline hemoglobin concentration was 11.8 g/dL v 13.4 g/dL (P < 0.05) in the multiple- and single-tract groups, respectively. RESULTS: All single-tract and 95% of multiple-tract patients were rendered stone free. The mean drop in hemoglobin was similar in the two groups (2.3 g/dL for single tract v 2.1 g/dL for multiple tracts; P = 0.55). Complications occurred in two patients in each group. Four multiple-tract patients required blood transfusion. The need for transfusion correlated with lower preoperative hemoglobin and higher preoperative serum creatinine. There was a significant rise in serum creatinine (1.67 mg/dL to 1.91 mg/dL; P < 0.05) and drop in creatinine clearance (76.9 mL/min to 67.2 mL/min; P < 0.05) in the multiple-tract group; this was more pronounced in patients with existing renal insufficiency. No significant change in renal function was seen in the single-tract group. CONCLUSIONS: Monotherapy with PCNL utilizing multiple percutaneous tracts is highly effective in the treatment of staghorn and other large-volume renal calculi. Blood loss and complication rates with such an aggressive approach are comparable to those of PCNL incorporating a single percutaneous tract for more straightforward calculi.

Adult↗
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

Outpatient laparoscopic pyeloplasty.

OBJECTIVES: To assess the feasibility of ambulatory laparoscopic pyeloplasty. Laparoscopic pyeloplasty aims to reproduce the excellent functional outcomes of open pyeloplasty while diminishing procedural morbidity. METHODS: Six patients fulfilled specific inclusion criteria for outpatient laparoscopic pyeloplasty: informed consent, body mass index of 40 kg/m2 or less, primary ureteropelvic junction obstruction, uncomplicated laparoscopic surgery completed by 12:00 pm, and postoperative pain control by oral analgesics. All patients had a double-J ureteral stent placed cystoscopically before laparoscopic access. No drains were placed postoperatively. RESULTS: All 6 patients successfully underwent laparoscopic dismembered pyeloplasty (3 left, 3 right) using the retroperitoneal (n = 5) or transperitoneal (n = 1) approach. The average patient age was 22 years. The mean surgical time was 223 minutes (range 165 to 270), the mean blood loss was 82 mL (range 10 to 250), and the mean postoperative hospital stay was 359 minutes (range 226 to 424). Postoperative analgesia comprised a mean of 6 mg morphine sulfate and 32 mg of ketorolac. No complications or readmissions occurred postoperatively. Intravenous urography and Lasix technetium-99m mercaptoacetyltriglycine renal scans documented resolution of obstruction. With long-term follow-up (mean 38.4 months), no recurrences have developed. CONCLUSIONS: We report our initial series of ambulatory laparoscopic pyeloplasty. In this well-selected patient population, outpatient pyeloplasty was feasible and safe.

Adolescent↗
PubMed2005

Laparoscopic partial nephrectomy versus laparoscopic cryoablation for the small renal tumor.

We sought to compare perioperative and short-term outcomes of laparoscopic partial nephrectomy versus laparoscopic cryoablation in patients with peripheral small renal tumors. Prospectively accrued data of patients with a small renal tumor (< or = 3 cm) undergoing laparoscopic partial nephrectomy (group 1, n = 153) or laparoscopic cryoablation (group 2, n = 78) were compared retrospectively. Patients undergoing laparoscopic partial nephrectomy were younger (mean age, 60.6 vs 65.6 years; P = 0.005), healthier (American Society of Anesthesiologists class 3/4 present in 46% vs 75%; P = 0.001), had a lower baseline serum creatinine (90.1 vs 106.0 micromol/L [1.02 vs 1.2 mg/dL]; P = 0.01), a larger tumor size (2.3 vs 2.1 cm; P = 0.02), and fewer cases of solitary kidneys (5% vs 23%; P = 0.000). Laparoscopic partial nephrectomy was associated with greater blood loss (211 vs 101 mL; P = 0.000) and a higher incidence of delayed complications after hospital discharge (16.3% vs 2.2%; P = 0.01) compared with cryoablation. Both groups were comparable with regard to operative time (P = 0.77), intraoperative complications (P = 0.1), postoperative complications (P = 0.55), hospital stay (P = 0.13), convalescence (P = 0.96), and postoperative serum creatinine (112.2 vs 123.7 micromol/L [1.27 vs 1.4 mg/dL]; P = 0.31). Local recurrence was detected over a mean follow-up time of 5.8 months in group 1 (0.6%) and 24.6 months in group 2 (3%). Although the technical simplicity, decreased blood loss, and somewhat lower complication rate are attractive features of renal cryotherapy, this must be balanced against the current lack of long-term follow-up data that are needed to confirm the oncologic adequacy of this developmental procedure. Laparoscopic partial nephrectomy, albeit a technically advanced procedure, duplicates established open principles and has therefore evolved to become our current minimally invasive nephron-sparing procedure of choice in the majority of patients with a small renal tumor.

Adolescent↗
PubMed2005

Dismembered percutaneous endopyeloplasty: a new procedure.

PURPOSE: We recently described a novel technique of percutaneous non-dismembered endopyeloplasty (Fenger type). Herein, we extend this transrenal technique further and report percutaneous dismembered endopyeloplasty (Anderson-Hynes type). MATERIALS AND METHODS: In five pigs with unilateral ureteropelvic junction (UPJ) obstruction created 3 to 6 weeks earlier, percutaneous dismembered endopyeloplasty was performed. Percutaneous transrenal access to the UPJ was obtained, and the UPJ was completely dismembered from within the renal pelvis through the solitary percutaneous tract. The dismembered proximal ureter was circumferentially mobilized, and in two animals, the UPJ segment was completely excised and removed. A spatulated end-to-end endopyeloplasty anastomosis (Anderson-Hynes) was created transrenally with 5 to 10 interrupted sutures using a novel nephroscopic suturing device (Sew-Right SR-5; LSI Solutions, Rochester, NY). In two animals, the entire percutaneous procedure was performed with CO2 insufflation instead of fluid irrigation. RESULTS: The technique was developed in three pigs. Subsequently, two pigs were treated and sacrificed at 2 and 5 weeks. All UPJs were dismembered successfully, and a precisely sutured mucosa-to-mucosa anastomosis was created. Intraoperative bleeding was negligible, and the operative time ranged from 3 to 5 hours, with the majority of the time dedicated to transrenal retroperitoneal dissection of the scarred, fibrotic UPJ. Carbon dioxide insufflation was efficacious because it minimized fluid extravasation and tissue edema and additionally enhanced visibility. Postoperative pyelograms revealed an adequately funneled UPJ, with good flow into the distal ureter. The two survival animals had minimal apparent morbidity from the procedure, and retrograde pyelograms at euthanasia revealed a patent anastomosis without extravasation. A 6F catheter easily crossed the reconstructed UPJ at autopsy in all animals. CONCLUSIONS: Dismembered percutaneous Anderson-Hynes endopyeloplasty is technically feasible and is promising. Further technical experience and additional functional outcome analysis in the survival model are necessary. With the technique described herein, we introduce the concept of percutaneous intrarenal reconstructive surgery (PIRS), wherein advanced intrarenal and retroperitoneal dissection with reconstruction can be performed endourologically, further broadening the horizons of conventional percutaneous techniques.

Anastomosis, Surgical↗
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

Renal cryoablation: outcome at 3 years.

PURPOSE: We report intermediate term oncological followup data on 56 patients undergoing laparoscopic renal cryoablation, of whom each completed a 3-year followup. MATERIALS AND METHODS: Since September 1997, 56 patients undergoing laparoscopic renal cryoablation have completed a followup of 3 years each. The postoperative followup protocol comprised serial magnetic resonance imaging (MRI) at 1 day, months 1, 3, 6, 12, 18 and 24, and yearly thereafter for 5 years. Computerized tomography guided needle biopsy of the cryolesion was performed 6 months postoperatively and repeated if MRI findings were abnormal. Followup data were obtained prospectively. RESULTS: For a mean renal tumor size of 2.3 cm mean intraoperative size of the created cryolesion was 3.6 cm. Sequential mean cryolesion size on MRI on postoperative 1 day, and at 3 and 6 months, and 1, 2 and 3 years was 3.7, 2.8, 2.3, 1.7, 1.2 and 0.9 cm, representing a 26%, 39%, 56%, 69% and 75% percent reduction in cryolesion size at 3 and 6 months, and 1, 2 and 3 years, respectively. At 3 years 17 cryolesions (38%) had completely disappeared on MRI. Postoperative needle biopsy identified locally persistent/recurrent renal tumor in 2 patients. In the 51 patients undergoing cryotherapy for a unilateral, sporadic renal tumor 3-year cancer specific survival was 98%. There was no open conversion, kidney loss, urinary fistula, dialysis requirement, or perirenal or port site recurrence in any patients. CONCLUSIONS: Three-year outcomes following renal cryoablation are encouraging. Longer term (5-year) data are necessary to determine the proper place of renal cryotherapy among minimally invasive, nephron sparing options.

Adult↗
PubMed2005

Laparoscopic partial nephrectomy for cystic masses.

PURPOSE: Although laparoscopic partial nephrectomy (LPN) has emerged as an effective treatment option in select patients with a solid renal tumor, scant data are available on cystic renal tumors. We report our experience with LPN in 50 patients with a cystic renal lesion. MATERIALS AND METHODS: Of 284 patients undergoing LPN at our institution since August 1999 preoperative computerized tomography identified a suspicious cystic lesion in 50 (17.6%) (group 1). Data were retrospectively compared with those on 50 matched, consecutive patients undergoing LPN for a solid renal mass (group 2). All patients with Bosniak II/IIF cysts were advised to undergo watchful waiting. Surgery was offered if the cyst changed in character or if that was the patient preference. RESULTS: Median tumor size was 3 cm in group 1 and 2.6 cm in group 2 (p = 0.07). Groups 1 and 2 were comparable in regard to perioperative parameters. In patients with Bosniak II (9), IIF (4), III (12) and IV (21) cysts final histopathology revealed renal cell carcinoma in 22%, 25%, 50% and 90%, respectively. All 100 patients had a negative surgical margin. No patient in group 1 had intraoperative puncture/spillage of the cystic tumor. In group 1 during a mean followup of 14 months (range 1 month to 3 years) 1 patient had retroperitoneal recurrence at 1 year despite negative surgical margins during initial LPN. CONCLUSIONS: Surgical outcomes of LPN for suspicious cystic masses are similar to those of LPN for solid tumors. However, extreme caution and refined laparoscopic technique must be exercised to avoid cyst rupture and local spillage.

Aged↗
PubMed2005

Prospective, randomized comparison of transperitoneal versus retroperitoneal laparoscopic adrenalectomy.

PURPOSE: We report a prospective, randomized comparison of transperitoneal laparoscopic adrenalectomy (TLA) vs retroperitoneal laparoscopic adrenalectomy (RLA) for adrenal lesions with long-term followup. MATERIALS AND METHODS: Between December 1997 and November 1999, 57 consecutive eligible patients with surgical adrenal disease were prospectively randomized to undergo TLA (25) or RLA (32). Study exclusion criteria were patient age greater than 80 years, body mass index greater than 40, bilateral adrenalectomy and significant prior abdominal surgery in the quadrant of interest. Mean followup was 5.96 years in the 2 groups. RESULTS: The groups were matched in regard to patient age (p = 0.84), body mass index (p = 0.43), American Society of Anesthesiologists class (p = 0.81) and laterality (p = 0.12). Median adrenal mass size was 2.7 cm (range 1 to 9) in the TLA group and 2.6 cm (range 0.5 to 6) in the RLA group (p = 0.83). TLA was comparable to RLA in terms of operative time (130 vs 126.5 minutes, p = 0.64), estimated blood loss (p = 0.92), specimen weight (p = 0.81), analgesic requirements (p = 0.25), hospital stay (p = 0.56) and the complication rate (p = 0.58). One case per group was electively converted to open surgery. Pathology data on the intact extracted specimens were similar between the groups. Averaged convalescence was 4.7 weeks in the TLA group and 2.3 weeks in the RLA group (p = 0.02). During a mean followup of 6 years 2 patients in the TLA group had a late complication (port site hernia). Mortality occurred in 5 patients, including 1 with TLA and 4 with RLA, during the 6-year followup. CONCLUSIONS: For most benign adrenal lesions requiring surgery laparoscopic adrenalectomy can be performed safely and effectively by the transperitoneal or the retroperitoneal approach.

Adrenal Gland Neoplasms↗
PubMed2005

Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: patient selection and perioperative outcomes.

PURPOSE: We compared the results of transperitoneal (T) and retroperitoneal (R) approaches to laparoscopic partial nephrectomy (LPN) in regard to perioperative outcomes and technical considerations, thereby, identifying patient selection guidelines for each approach. MATERIALS AND METHODS: The choice of approach was dictated primarily by tumor location, that is TLPN for anterior or lateral lesions and RLPN for posterior or posterolateral lesions. The approaches differed primarily by the hilar control technique. During TLPN en bloc hilar control was achieved with a Satinsky clamp, while during RLPN individual vessel control was obtained with bulldog clamps. RESULTS: In a 3-year period 100 TLPNs and 63 RLPNs were performed for renal tumor. Of posterior tumors 77% were managed by RLPN, whereas 97% of anterior tumors were managed by TLPN. TLPN was associated with significantly larger tumors (3.2 vs 2.5 cm, p <0.001), more caliceal suture repairs (79% vs 57%, p = 0.004), longer ischemia time (31 vs 28 minutes, p = 0.04), longer operative time (3.5 vs 2.9 hours, p <0.001) and longer hospital stay (2.9 vs 2.2 days, p <0.01) than RLPN. Blood loss, perioperative complications, postoperative serum creatinine, analgesic requirements and histological outcomes were comparable between the groups. CONCLUSIONS: We perform TLPN for all anterior or lateral tumors as well as for large or deeply infiltrating posterior tumors that require substantive resection (heminephrectomy). The limited retroperitoneal space makes RLPN technically more challenging but provides superior access to posterior and particularly posteromedial lesions. When feasible, we prefer to perform laparoscopic partial nephrectomy by the transperitoneal approach because of its larger working area and superior instrument angles for intracorporeal renal reconstruction.

Adolescent↗