Biomedical subjects
Publications and source records attributed to S Micali.
Laparoscopic procedures are performed using general anesthesia due to the perceived limitations of regional anesthesia in the upper abdomen and retroperitoneum. We present our initial experience with epidural anesthesia for retroperitoneal laparoscopic renal biopsy.
BACKGROUND AND PURPOSE: Telemedicine is the use of telecommunication technology to deliver healthcare. Telementoring has been developed to allow a surgeon at a remote site to offer guidance and assistance to a less-experienced surgeon. We report on our experience during laparoscopic urologic procedures with mentoring between Rome, Italy, and Baltimore, USA. MATERIAL AND METHODS: Over a period of 3 months, two laparoscopic left spermatic vein ligations, one retroperitoneal renal biopsy, one laparoscopic nephrectomy, and one percutaneous access to the kidney were telementored. Transperitoneal laparoscopic cases were performed with the use of AESOP, a robotic for remote manipulation of the endoscopic camera. A second robot, PAKY, was used to perform radiologically guided needle orientation and insertion for percutaneous renal access. In addition to controlling the robotic devices, the system provided real-time video display for either the laparoscope or an externally mounted camera located in the operating room, full duplex audio, telestration over live video, and access to electrocautery for tissue cutting or hemostasis. RESULTS: All procedures were accomplished with an uneventful postoperative course. One technical failure occurred because the robotic device was not properly positioned on the operating table. The round-trip delay of image transmission was less than 1 second. CONCLUSION: International telementoring is a feasible technique that can enhance surgeon education and decrease the likelihood of complications attributable to inexperience with new operative techniques.
PURPOSE: We report our experience with the retroperitoneal laparoscopic approach for treating pediatric patients and when the percutaneous needle approach is not possible due to uncontrolled hypertension, bleeding disorders, anti-clotting medications and anatomical abnormalities. MATERIALS AND METHODS: Retroperitoneal laparoscopic renal biopsy was performed in 20 patients 2 to 18 years old (mean age 9.7) during a 16-month period. At the same time 53 percutaneous needle biopsies and 1 open biopsy were performed. The child is in a flank position, and 2 trocars are used via a direct vision approach. The first trocar is 12 mm. in diameter and positioned on the posterior axillary line, and the second trocar is 5 mm. in diameter and is entered 4 cm. anteriorly. Gentle dissection is done to free the lower pole of the selected kidney, biopsy forceps are used to grasp the specimen under direct vision and the biopsy site is fulgurated using bipolar electrocautery. RESULTS: Biopsy was performed successfully in all cases except 1, which was converted to an open procedure. Mean operative time was 40 minutes, blood loss was minimal and mean hospital stay was 1.2 days postoperatively. No pain medication was required postoperatively, and all patients returned to their usual activities within 3 to 5 days. A minor intraoperative complication, which was a peritoneal tear with no postoperative sequelae, occurred in 1 case. CONCLUSIONS: The retroperitoneal laparoscopic technique is simple and safe, and does not require extensive laparoscopic experience. We believe that this approach is reliable, and has less morbidity and several advantages compared to open surgery. It should be selected as the first choice for treating pediatric patients when percutaneous needle renal biopsy is contraindicated.
BACKGROUND: Oliguria during laparoscopy is a well-documented phenomenon of unknown etiology. Experimental evidence suggests that renal perfusion is reduced during pneumoperitoneum. N-acetyl-beta-D-glucosaminidase (NAG), which is present in renal tubular cells, is released into the urine in response to tubular insults. In this study, urinary NAG was measured before and after procedures to assess for ischemic renal injury. METHODS: A total of 31 patients underwent laparoscopic procedures while 28 patients had conventional surgery. Urine was obtained first at the time of preoperative Foley catheter placement and later during the recovery room stay. NAG levels were measured and indexed to urinary creatinine. RESULTS: Operative time for the laparoscopy group was 105 min (range, 15-255); for the conventional group, it was 179 min (range, 75-385) (P < 0.05). No differences were noted between pre- and postoperative NAG levels or between the groups. There was no correlation between urinary NAG levels and operative time. CONCLUSION: Pneumoperitoneum is not associated with a change in the urinary concentration of NAG. This finding suggests that there is no significant renal tubular injury associated with laparoscopic surgery.
BACKGROUND: The role of extracorporeal shockwave lithotripsy (SWL) for ureteral calculi is still being debated. We evaluated our results in a large series to clarify the role of this modality. PATIENTS AND METHODS: A total of 478 patients with solitary ureteral stones were treated by in situ piezoelectric extracorporeal shockwave lithotripsy (SWL) using a Wolf Piezolith 2300 ultrasound-guided lithotripter. Two hundred fifty stones (52.3%) were located in the upper ureter and 228 (47.7%) in the distal ureter. Seventy of the upper ureteral stones were located in the ureteropelvic junction and 180 in the lumbar ureter. The diameter of the stones ranged from 5 to 30 mm. Four hundred sixty-seven patients were followed up for a mean of 4 months. RESULTS: Four hundred forty patients (94.2%) were stone free after in situ SWL alone. Complete removal of all stone fragments was achieved in 95.4% of the 216 patients with calculi of 5 to 10 mm in diameter, in 94.3% of the 229 with stones of 11 to 20 mm, and in 81.8% of the 22 with calculi of 21 to 30 mm. In situ treatment completely removed 61 of 69 ureteropelvic junction stones (88.4%), 166 of 175 lumbar stones (94.8%), and 213 of 223 distal ureteral stones (95.5%). In situ treatment failed in 27 stones (5.8%). After 4 months, 12 stone fragments and 15 unfragmented stones persisted despite retreatments and required endoscopic procedures. The mean number of sessions and shockwaves per patient was 1.8 and 4884, respectively. Morbidity was low. Renal colic in 57 patients (11.9%) was managed successfully by analgesics. In 36 patients, stone fragments obstructed the ureter; in 28 of these 36 (78%), the obstruction was resolved and the patients were stone free after in situ retreatments alone. All these results were achieved on an outpatient basis without sedation or local or general anesthesia. CONCLUSION: Piezoelectric SWL is an effective and noninvasive method for eliminating ureteral stones. Second-generation ultrasound-guided lithotripters are not yet obsolete.
Traditional practice has dictated that intra-abdominal pressure during laparoscopy be kept at or below 15 mm Hg to minimize the risk of cardiovascular and pulmonary complications. This study was undertaken to determine if maintaining an intra-abdominal pressure of 20 mm Hg could be utilized safely during genitourinary laparoscopy. We reviewed the intraoperative records of 76 consecutive patients undergoing various endoscopic urologic procedures at an intra-abdominal pressure of 20 mm Hg to assess physiologic changes and complications. The records were examined for operating time, minute ventilation (MV), end-tidal CO2 (ETCO2), and peak inspiratory pressure (PIP), which were compared with the preinsufflation values. Also, in the first 39 patients, initial insufflation volumes were recorded at 15 mm Hg and then again when pressure was raised to 20 mm Hg. The mean operating time was 186 +/- 90 min. There was an average 22% increase in the sufflated volume when the pressure was elevated from 15 to 20 mm Hg. To maintain a suitable ETCO2, the anesthesiologist needed to increase the MV an average of 2.9 +/- 2.0 L/min. Increases in ETCO2 (average 4.5 +/- 4.6 mm Hg) and PIP (6.9 +/- 3.6 mm Hg) were noted. In two cases, the intra-abdominal pressure had to be decreased from 20 to 15 mm Hg because of inability to maintain an acceptable ETCO2. Subcutaneous emphysema was noted in three patients, which resolved spontaneously within 24 hr. In one patient, asymptomatic pneumomediastinum was noted after a 6-hr procedure. Intra-abdominal insufflation can be safely maintained at 20 mm Hg in most patients. This higher pressure improves maintenance of the pneumoperitoneum.
OBJECTIVES: In the immediate postoperative period after percutaneous stone removal, body temperature elevations are common. Pyrexia after a percutaneous nephrolithotomy (PCNL) generates concern because of the possibility of urinary extravasation and bacteremia. We reviewed our experience with PCNL to determine the clinical significance of a postoperative fever before discharge from the hospital. METHODS: Between July 1994 and December 1996, 63 patients underwent 69 PCNLs. Each had documented negative urine cultures preoperatively and received prophylactic antibiotics at the time of surgery. For each case, clinical and operative charts were reviewed to determine stone composition, fever during hospital stay, postoperative bacteriologic cultures, postoperative white blood cell count (WBC), and clinical course. RESULTS: Complete data were available for 66 procedures. Eight patients (12%) had at least one body temperature reading between 38.0 and 38.5 degrees C. Eleven patients (16.7%) had at least one temperature greater than 38.5 degrees C. Each patient with a temperature greater than 38.5 degrees C was hemodynamically stable with negative blood and urine cultures. No patient with a fever between 38.0 and 38.5 degrees C was cultured. Stone analysis did not demonstrate any association between postoperative fever and stone composition (including 22 struvite stones). Postoperative WBC also did not predict pyrexia. Fever alone did not prolong hospital stay. CONCLUSIONS: In patients with negative urine cultures who are prophylaxed with immediate preoperative antibiotics and maintained on postoperative antibiotics, pyrexia after PCNL does not require an immediate bacteriologic evaluation in those who are hemodynamically stable.
BACKGROUND: Renal biopsy continues to be a pivotal tool and frequently indispensable diagnostic procedure in the clinical assessment of proteinuria and or unexplained renal disease. Laparoscopic renal biopsy has recently been reported as an alternative to open renal biopsy. METHODS: Thirty-two patients who had proteinuria and/or renal insufficiency underwent laparoscopic renal biopsy at our center. The indications for biopsy included failed percutaneous biopsy (N = 3), morbid obesity (14), solitary kidney (5), chronic anticoagulation/coagulopathy (6), religious consideration (refusal of potential blood transfusion) (2), multiple bilateral renal cysts and body habitus (1 case each). The kidney was approached via a laparoscopic retroperitoneal route (retroperitoneoscopy) using a two port technique. The lower pole of the kidney was localized using blunt dissection, laparoscopic cup biopsies were performed, and hemostasis was achieved using standard techniques. RESULTS: All biopsies were successfully completed laparoscopically with sufficient tissue obtained for histopathological diagnosis in all cases. Mean estimated blood loss was 25.9 ml (range 5 to 100). None of the patients required parenteral narcotics during the perioperative period. Operative time ranged from 0.8 to 3.0 hours (mean 1.5). Mean hospital stay was 1.7 days (range 0 to 7). Sixteen patients were treated as outpatients. Patients returned to normal activity at a mean of 1.7 weeks (range 0.3 to 3.0) postoperatively. In one patient, the spleen was inadvertently biopsied without consequence. An additional patient developed a postoperative 300 cc perinephric hematoma that resolved without the need for intervention. One postoperative mortality occurred on postoperative day seven secondary to a perforated peptic ulcer in a patient undergoing high-dose steroid therapy for lupus nephritis. CONCLUSION: Laparoscopic renal biopsy is a safe, reliable, minimally invasive alternative to open renal biopsy for patients in whom a closed percutaneous approach is either a relative or absolute contraindication, which can be performed on an outpatient basis.
This study evaluated the incidence and factors involved in the occurrence of gas embolism after laparoscopic injuries. A 5-MHz transesophageal echocardiographic (TEE) probe was placed in 11 anesthetized pigs and used to examine the right cardiac chambers and pulmonary artery. A calibrated carbon dioxide analyzer continuously measured end-tidal carbon dioxide (ETCO2). The ventilatory settings were adjusted to achieve a baseline ETCO2 between 25 and 28 mm Hg. A blinded dose-response curve for TEE and ETCO2 measurements were created by injecting 0.0007 to 1.5 mL/kg of CO2 gas intravenously. Venotomies (N = 22) were created laparoscopically in the inferior vena cava (IVC) of the study animals. All TEE images were videotaped and correlated with laparoscopic events. Embolic episodes were classified by comparison with images recorded during the bolus studies. A variety of methods for obtaining hemostasis and repairing the venotomies were evaluated and their effects on gas embolism were studied. No emboli were noted when the venotomies were bleeding freely, the hole was directly occluded, or the proximal IVC was compressed. Marked embolism was seen with distal IVC occlusion or when there had been significant blood loss. In this situation, manipulation of the hole and higher intraperitoneal pressures led to higher degrees of embolization. No emboli were seen in an open control group except after significant bleeding. The TEE is the most sensitive method of detecting gas emboli; however, the majority of episodes are not clinically significant. Embolism of CO2 occurs when central venous pressure is decreased by blood loss or distal compression. When significant venous bleeding occurs, intravascular volume should be maintained and the bleeding site should be directly occluded.
Laparoscopic partial nephrectomy (LPN) remains a technically challenging procedure largely because of the lack of methods for obtaining consistent parenchymal hemostasis. The objective of this study was to determine if the extent of resection influences the ability of the harmonic scalpel to achieve hemostasis and to define the cases in which the harmonic scalpel is appropriate for LPN. Thirty LPNs were performed in a 25-kg domestic pig model. The blunt blade of the laparoscopic harmonic scalpel (LaparoSonic Coagulating Shears; Ethicon Endo-Surgery, Cincinnati, OH) at power level 5 was used to divide the parenchyma. Control of the renal hilar vessels was not obtained. Three standardized types of resections were performed: I = peripheral wedge biopsy; II = upper- or lower-pole nephrectomy; and III = heminephrectomy. Bleeding was graded on a scale from 0 to 4: 0 = no hemostasis; 1 = steady bleeding; 2 = moderate bleeding; 3 = parenchymal oozing; and 4 = dry. Hemostasis grades of 2 or less were clinically significant bleeding necessitating supplemental coagulation. The mean hemostasis scores showed a significant (P < 0.02) trend toward inadequate hemostasis with increasing extent of resection: 3.3 for Type I, 3.0 for Type II, and 2.4 for Type III. The percent of kidneys with grade 2 bleeding or worse was 9% for Type I surgery, 25% for Type II, and 57% for Type III. Successful hemostasis with the harmonic scalpel correlates with the extent of parenchymal resection in the porcine model. Most wedge excisions can be done with the harmonic scalpel alone, whereas larger resections necessitate supplemental coagulation. On the basis of this study, heminephrectomies with the harmonic scalpel are not recommended because of the high incidence of significant hemorrhage.
PURPOSE: We retrospectively evaluated the records of 21 patients a mean of 46.1 years old with ureteral stones that had been impacted for greater than 2 months to determine predisposing factors for stricture formation. MATERIALS AND METHODS: Between January 1993 and September 1996, 21 patients were referred for ureteral stones that had remained unchanged in location for at least 2 months. In 11 patients previous attempts at stone removal had failed. Each patient underwent successful stone extraction by retrograde or percutaneous antegrade ureteroscopy, or laparoscopic or open ureterolithotomy. Outcome was determined by reviewing the clinical records and radiographic studies, including excretory urography and nephrostography. RESULTS: Average duration of stone impaction before definitive treatment was 8.8 months (range 2 to 48) and mean stone size was 10.3 mm. (range 1 to 30). All stones were calcium based. There were 3 proximal, 8 mid and 10 distal ureteral calculi. At a mean followup of 7 months ureteral strictures developed in 5 patients (24%) at the previous stone site. Mean duration of stone impaction was 11 months (range 5 to 17) in patients with stricture versus 8.2 months (range 2 to 48) in those with no stricture. Four of the 5 strictures occurred in patients who had had iatrogenic ureteral perforation during previous unsuccessful attempts at stone removal. CONCLUSIONS: Ureteral stone impaction more than 2 months in duration is associated with a 24% incidence of stricture formation. Ureteral perforation at the site of the stone was identified as the primary risk factor for stricture formation in these cases.
Since ten years laparoscopic techniques have been employed as alternatives of many established open procedures in gynecologic, abdominal and finally urologic surgery. Laparoscopic techniques show significant advantages compared to open surgery, such as less hospitalization, reduced need of analgesic drugs, quick return to daily activities and far a better cosmetic results. Laparoscopic surgery has been advocated for urologic, uro-gynecologic and andrologic diseases. Since 1983 one-day surgery was proposed for only a few gynecologic and abdominal procedures and only recently for laparoscopic renal biopsy and abdominal testis evaluation. In these preliminary experiences the conditions for a correct management of laparoscopic one-day surgery have been clearly pointed out: 1. correct surgical indication; 2. through knowledge of surgical technique; 3. duration of the procedure less than 90 minutes; 4. correct anesthesia. Technique of anesthesia must be adapted to the surgical procedure required, its duration and the physical features of the patient. General anesthesia is usually preferred for either longer and more complex procedures or when a higher abdominal insufflation pressure is needed. Spinal or local anesthesia are preferred for simpler procedures or when only one trocar is required. At date only few urologic procedures seem to be suitable to one-day laparoscopic surgery. 1) Varicocele: although laparoscopic varicocelectomy in one-day surgery has never been reported previously, it can be performed in a short time, only 3 trocars are needed and insufflation pressure can be maintained within 15 mm Hg. 2) Renal biopsy and marsupialization of renal cysts. These are usually managed percutaneously but in some particular indications procedures under direct vision should be preferable. Both are short-lasting and only superficial general anesthesia is required; as surgical access is retroperitoneal only two trocars are sufficient; at date only renal biopsies have previously been reported. 3) Diagnostic procedures on abdominal testis. The procedure is brief only superficial general anesthesia is needed and only one trocar is required. Conclusions. One-day laparoscopic surgery will require in the future a more and more strict cooperation between urologists and anesthetists in order to tailor the correct anesthesiological and laparoscopic technique to the procedure required and the features of the patient.
OBJECTIVES: Retroperitoneoscopic renal biopsy can be technically challenging in extremely obese patients because of loss of surgical landmarks and difficulty in identifying the kidney within retroperitoneal adipose tissue. We present our experience with retroperitoneoscopic renal biopsy in extremely obese patients and describe our surgical technique. METHODS: We performed retroperitoneoscopic renal biopsies on 8 extremely obese patients (body mass index greater than 40). Mean patient weight was 144.3 kg. Three patients presented with acute renal failure and 5 presented with nephrotic range proteinuria. Retroperitoneoscopic renal biopsy was indicated based on extreme obesity alone in 3 patients, 2 patients had failed previous attempts at percutaneous biopsy, 1 patient had a solitary kidney, 1 patient required chronic anticoagulation, and 1 patient was a Jehovah's Witness. Intraoperative ultrasonography and an anatomic approach facilitated the dissection and identification of the kidney. RESULTS: All eight retroperitoneoscopic renal biopsies were completed successfully without complication and all patients were discharged within 24 hours of the procedure. Sufficient tissue for pathologic diagnosis was obtained in all cases. Mean operating room time was 153 minutes and mean estimated blood loss was 71 mL. The patients returned to normal activity at a mean of 1.8 weeks. CONCLUSIONS: With the use of intraoperative ultrasonography and a systematic, anatomic approach, retroperitoneoscopic renal biopsy can be successfully completed in extremely obese patients. This procedure can be reliably performed on an outpatient basis with minimal morbidity and should be considered a viable alternative to open renal biopsy.
PURPOSE: The functional results and complications of 2 different ureteroileal anastomoses were evaluated in patients with bladder cancer undergoing radical cystectomy and orthotopic ileal bladder substitution. MATERIALS AND METHODS: Between 1989 and 1995, 102 patients underwent creation of a low pressure neobladder. In the first 50 cases the ureteroileal anastomosis was created with a split-cuff nipple technique as an additional antireflux mechanism. In the next 52 cases the ureteroileal anastomoses were constructed via the direct end-to-side technique counting on the antireflux protection of the afferent tubular limb. RESULTS: Stenosis occurred in 7 of the 100 ureters (6 patients) treated with the split-cuff nipple technique and 7 of 104 treated with a direct end-to-side anastomosis. This complication occurred more commonly in the left ureter (11 of 14 patients). Reflux was noted at cystography in 10 cases with the split-cuff nipple method and 12 with end-to-side anastomoses, and was symptomatic in only 3 patients. Four ureteral strictures were treated successfully with primary open repair. Percutaneous dilation and stenting were performed for 8 ureteral strictures: 2 cases were successful, 3 failed and 3 are unresolved. CONCLUSIONS: We observed no differences between the antireflux split-cuff and end-to-side anastomoses with regard to stricture formation or ureteral reflux. Therefore, we do not believe that there is a need to create antireflux ureteral anastomoses due to the tubular afferent ileal segment and given that the reflux is asymptomatic in most patients. Strictures may be treated with percutaneous balloon dilation and stenting but open repair appeared to be more effective.
PURPOSE: We assessed the efficacy of laparoscopy in the treatment of renal and ureteral stones. MATERIALS AND METHODS: Laparoscopic stone extraction was attempted in 11 men and 6 women 22 to 75 years old, including 6 with ureteral and 11 with renal calculi. Of the renal stones 9 were associated with a concomitant pathological condition requiring surgery. Four patients had multiple stones (2 to 93) and stone size ranged from 2 to 60 mm. (mean 15.6). RESULTS: Stones from 15 of 17 patients were removed successfully via laparoscopic techniques. Operative time ranged from 2.33 to 6.35 hours (mean 4.9). Prolonged operating times were associated with ancillary or failed procedures. Blood loss ranged from 20 to 350 ml. (mean 132.9), narcotic requirement from 0 to 100 mg. morphine (mean 26) and hospital stay from 1 to 15 days (mean 4.5). The 3 postoperative complications included prolonged ileus (2) and a retroperitoneal urinoma requiring secondary drainage. CONCLUSIONS: Laparoscopic stone removal is safe and feasible. Indications for this approach include urinary stones associated with an anatomical abnormality requiring urinary tract reconstruction and calculi for which other minimally invasive therapies failed.
With a varied presentation and a difficult preoperative diagnosis, schwannoma accounts for only a small percentage of retroperitoneal tumors. Moreover, malignant schwannoma of the adrenal gland, kidney and renal pelvis has previously been described. We report the first case of benign schwannoma causing obstruction by external compression of the ureteropelvic junction. A case report of a male patient who complained of a 3-month history of dull lumbar pain on the right side is reported. Using intravenous pyelogram, sonography and computed tomography a benign tumor of the retroperitoneum was suspected. Upon exploration, the suspected diagnosis of the tumor's retroperitoneal origin was confirmed. After the histological and immunohistochemical studies the diagnosis was verified. The diagnosis, treatment and histological features of benign schwannoma are discussed. A brief review of the literature is also included.
The repair of an enterocele has classically been via a transvaginal or open abdominal route. With the availability of minimally invasive procedures, we applied established laparoscopic techniques to enterocele repair. Three women with a history of hysterectomy had a symptomatic enterocele as well as a cystocele or rectocele. Each underwent a transperitoneal laparoscopic enterocele repair prior to a transvaginal rectocele or cystocele repair or laparoscopic colposuspension. Using three trocars and transvaginal digital manipulation, the enterocele was reduced and repaired utilizing a modified Moschocowitz technique. The cul-de-sac was obliterated by approximating the posterior vaginal fascia to the anterior wall of the rectum with a running suture. There was no operative morbidity. The average length of stay was 3.3 days. All patients were asymptomatic with no enterocele recurrence identified during a mean follow-up of 10.5 (range 7-15) months. Laparoscopic enterocele repair is a feasible surgical procedure with minimal morbidity. A larger series with longer follow-up is necessary before the efficacy and proper indications for this minimally invasive procedure are determined.
The success of balloon dissection techniques has given laparoscopic surgeons the option of a direct extraperitoneal approach to urologic disease. Unfortunately, these techniques are not without risks. We report on four cases of complications secondary to balloon dilation. In two instances, balloon misplacement caused dissection between muscle layers. This resulted in conversion to an open procedure in one instance and to a postoperative flank hernia in another. Balloon rupture with loose fragments occurred in two patients. In one of these cases, the peritoneum was lacerated, with balloon fragments displaced within the peritoneal cavity.