Laparoscopic live donor nephrectomy: current status.
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Child↗
Biomedical subjects
Sam B Bhayani
Publications and source records attributed to Sam B Bhayani.
Three-Dimensional (3D) Vision: Does It Improve Laparoscopic Skills? An Assessment of a 3D Head-Mounted Visualization System.
Laparoscopic urologic procedures have become increasingly popular, but their widespread use has been limited by training issues. The use of 3-dimensional (3D) vision might aid in training and performance of laparoscopic tasks. The purpose of this study was to evaluate a 3D visual system used by novice laparoscopists. In this prospective, randomized study, 24 novice laparos-copists were evaluated on a validated and standardized laparoscopic task using both 2-dimensional (2D) and 3D visualization systems. The task was performed more rapidly with 3D visualization (108 vs. 127 seconds, P < .05). On subjective evaluations, participants believed the task was easier with the 3D system, and participants preferred the 3D system to the 2D system by a 2:1 margin. 3D visualization improves the learning curve for laparoscopic surgery. Surgeons should consider 3D systems when learning complex laparoscopic surgeries. Further evaluation of operative times and complications is needed in clinical studies.
Journal Article↗
Taking the side of transperitoneal access for surgery in upper urinary tract.
Laparoscopic surgery has become a preferred treatment option for the management of upper urinary tract pathology. Large series of complex urologic operations have been published, with favorable outcomes. Although the early experience with urologic laparoscopy consisted almost exclusively of transperitoneal procedures, some surgeons prefer the retroperitoneal approach. The debate of retroperitoneal versus transperitoneal laparoscopy for upper tract pathology is complex because comparative and randomized studies are lacking. In contrast to the retroperitoneal approach, transperitoneal laparoscopic procedures allow for a larger working space, adequate maneuverability, and the presence of familiar anatomic landmarks. This article highlights our experiences and approaches to major laparoscopic upper urinary tract surgery for benign and malignant conditions. A summary of the published literature as it pertains to the transperitoneal approach also is presented.
Humans↗
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↗
Evaluation of water jet morcellation as an alternative to hand morcellation of renal tissue ablation during laparoscopic nephrectomy: an in vitro study.
OBJECTIVES: To evaluate the feasibility and safety of morcellation with a new prototype device that uses high-pressure water flow as a cutting/ablating tool and compare it with standard manual morcellation. METHODS: Ten porcine kidneys were morcellated with the new water jet device and ten with conventional manual morcellation. Morcellation in all cases was performed in commercially available entrapment bags. The two groups were evaluated for morcellation time, fragment size, and perforation rates (macroscopic and microscopic). RESULTS: The kidney size in both groups was similar. Morcellation was significantly (P <0.0001) faster in the water jet morcellator group than in the hand morcellation group (5.6 versus 11.9 minutes). The macroscopic evaluation after filling the entrapment bags with normal saline revealed 4 (40%) and 2 (20%) pinhole perforations in the water jet and hand morcellation groups, respectively. The microscopic evaluation revealed an 80% perforation rate in the water jet group and a 20% rate in the hand morcellator group. The size of the resulting fragments in the water jet group was not available, because the morcellated kidney was transformed in a semiliquid form. Therefore, cytology evaluation of the tissue was not possible. CONCLUSIONS: Water jet technology can be used to morcellate renal porcine tissue effectively. It is faster, but the problems of safety and histologic evaluation must be solved before this promising technology can be used in a clinical setting.
Animals↗
Laparoscopic sacral colpoperineopexy for treatment of perineal body descent and vaginal vault prolapse.
Perineal body descent has been linked to pudendal nerve injury and anorectal disorders, including constipation, rectal pain, and fecal incontinence. Open sacral colpoperineopexy has been described for the treatment of perineal descent. We present a technique for laparoscopic sacral colpoperineopexy and highlight this approach with accompanying video segments.
Aged↗
Nerve-sparing laparoscopic radical prostatectomy: replicating the open surgical technique.
OBJECTIVES: To present a detailed demonstration of a nerve-sparing laparoscopic radical prostatectomy (LRP) technique that replicates anatomic nerve-sparing radical retropubic prostatectomy (RRP). Techniques for neurovascular bundle preservation during open RRP have undergone several decades of careful refinement. Identifying pre-existing anatomic planes and the avoidance of thermal injury near the nerves are principles considered paramount during nerve-sparing RRP. During LRP and robotic-assisted radical prostatectomy, the use of cautery for hemostasis during nerve dissection is common despite its unknown effects on cavernous nerve function. METHODS: We describe a combined antegrade and retrograde laparoscopic approach to neurovascular bundle dissection. The technique is demonstrated in the accompanying video segments. The use of specialized laparoscopic instrumentation, including a fine-tipped right-angle clamp and curved dissector, is discussed. The principles of meticulous tissue handling and avoidance of electrocautery are stressed. The preliminary outcomes are presented using data obtained using an abridged version of the International Index of Erectile Function and the Expanded Prostate Cancer Index Composite questionnaires. RESULTS: To date, our technique has been applied to LRP in more than 177 patients. Blood loss has been minimal (less than 300 mL), and intraoperative anatomic nerve preservation appeared excellent. On the basis of our early experience, 76% of patients engaging in sexual intercourse preoperatively who underwent bilateral nerve preservation (n = 21) reported the ability to engage in sexual intercourse 1 year after LRP. CONCLUSIONS: Our nerve-sparing LRP technique replicates established open surgical principles of anatomic nerve-sparing RRP. The techniques described here minimize the potential for cavernous nerve damage from electrical energy or heat. Early functional outcomes appear comparable to the results obtained with open RRP performed at our institution.
Adenocarcinoma↗
Laparoscopic partial nephrectomy in patients with neoplasia in a solitary kidney.
OBJECTIVES: To assess the renal function and describe our operative experience with laparoscopic partial nephrectomy (LPN) in patients with solitary kidneys. METHODS: The medical records were analyzed to find patients with a solitary kidney and renal neoplasms who underwent LPN. Demographic, operative, pathologic, and follow-up data were obtained. RESULTS: Four patients were identified with solitary kidneys who had undergone LPN. The mean operative time was 251 minutes, mean warm ischemic time 15 minutes, mean estimated blood loss 395 mL, and mean hospitalization stay 3 days. The mean preoperative creatinine was 1.5 mg/dL and the mean peak creatinine 2.0 mg/dL. All patients returned to their baseline creatinine levels in the follow-up period. The final pathologic finding was Stage pT1 in 1, pT3a in 2, and angiomyolipoma in 1 patient. All surgical margins were negative. No cancer recurrence developed in the patients, with a mean follow-up of 17 months (range 3 to 35). CONCLUSIONS: LPN in patients with a solitary kidney is feasible and a reasonable treatment alternative to open partial nephrectomy.
Blood Loss, Surgical↗
Laparoscopic-assisted nephrectomy with inferior vena cava tumor thrombectomy: preliminary results.
OBJECTIVES: To evaluate the feasibility and outcome of laparoscopic-assisted radical nephrectomy and inferior vena cava (IVC) tumor thrombectomy in patients with renal cell carcinoma and level I IVC tumor thrombus. METHODS: The clinical, operative, and pathologic data were retrospectively obtained from patients undergoing the above-mentioned procedure for renal tumors involving the IVC. This approach involved laparoscopic dissection of the kidney and renal vasculature/IVC. After renal artery ligation, an 8 to 12-cm incision was made from the tip of the 11th rib extending anteriorly toward the midline. Through this incision, a Satinsky vascular clamp was placed on the IVC in such a way as to include all the caval thrombus. The tumor thrombus was removed en bloc with the kidney and the cavotomy repaired with a running suture. RESULTS: Four obese patients underwent transperitoneal laparoscopic-assisted right nephrectomy with inferior vena cava (IVC) thrombectomy. The mean tumor size was 9 cm (range 6 to 13), with the thrombus extending 2 cm into the IVC in all cases. Patients had a mean body mass index of 32.8 (range 30.5 to 37.2) and a mean American Society of Anesthesiologists score of 2.8 (range 2 to 3). The mean operative time was 248 minutes (range 225 to 274). The mean estimated blood loss was 517 mL (range 250 to 900). No intraoperative or postoperative complications occurred. The mean hospital stay was 6.2 days (range 4 to 11, median 5). CONCLUSIONS: Laparoscopic-assisted nephrectomy and IVC thrombectomy is a difficult but feasible procedure. This approach allows a smaller incision than a typical open approach. Additional studies are needed to examine the advantages of this approach over a pure open approach.
Aged↗
Pancreatic injuries during laparoscopic urologic surgery.
OBJECTIVES: To review our experience with pancreatic injury (PI) associated with urologic laparoscopy. PI associated with urologic laparoscopy is uncommon. METHODS: From January 1999 to April 2004, 890 laparoscopic operations for upper urinary tract pathologic findings were performed, of which 574 were left-sided procedures. We reviewed the medical records for recognized intraoperative or postoperatively documented PI and recorded the patient demographic data and intraoperative and postoperative management. RESULTS: Four PIs were identified, all associated with left-sided procedures. The overall rate of PI was 0.44%. Two injuries occurred during left radical nephrectomy (2.1%) and two during left adrenalectomy (8.6%). The mean tumor size was 6 +/- 3.4 cm. The diagnosis was made intraoperatively in 1 patient, postoperative midepigastric pain with elevated serum amylase levels was the clinical presentation in 2 patients, and the incidental finding of pancreatic tissue in the final pathologic specimen confirmed the injury in the fourth patient. A prolonged pancreatic fistula developed only in 1 case. Three patients were treated conservatively and computed tomography-guided drainage of a pancreatic collection was required in one. The mean hospital stay was 18 days (range 4 to 57). CONCLUSIONS: PI is uncommon but can result in significant morbidity. Intraoperative detection and repair can minimize sequelae. Management with conservative measures and percutaneous drainage is usually successful, although a prolonged postoperative course can be expected.
Humans↗
Use of a specialized prostatic urethral sound to facilitate nerve-sparing laparoscopic radical prostatectomy.
Urethral sounds have historically been used to aid in prostatic excision. We describe a specialized prototype urethral sound (Prostagrip; LSI solutions, Rochester, NY) that is able to grasp and rotate the prostate to expose the neurovascular bundles during laparoscopic radical prostatectomy.
Humans↗
Re: Editorial: Laparoscopy and urologic oncology--I now pronounce you man and wife.
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Humans↗
Making ends meet: a cost comparison of laparoscopic and open radical retropubic prostatectomy.
PURPOSE: We compared the perioperative costs of laparoscopic radical prostatectomy (LRP) and open radical retropubic prostatectomy (RRP) at a metropolitan hospital by developing a detailed computer model. MATERIALS AND METHODS: Our predictive model incorporates institutional cost centers for operative time, operating room consumables, professional fees, hospital room and board, oral analgesics, autologous blood banking, blood transfusion and cystography. Versions with and without pelvic lymphadenectomy (PLND) were evaluated using 1 and 2-way sensitivity analyses. Operative times, lengths of stay and transfusion rates were derived from published series. We also reviewed individual hospital charges for 172 consecutive prostatectomy cases for comparison and validation of model predictions. RESULTS: The model predicted cost premiums for LRP of 14.4% (without PLND) and 17.5% (with PLND). The actual hospital charge premium for LRP and PLND was 18.4%, which differed from the predicted cost premium by less than 1%. The most significant cost centers in order of importance were operative time, length of stay and consumables. To achieve cost equivalence with RRP, operative times would need to average 159 minutes (LRP and PLND) and 174 minutes (LRP alone) holding other factors constant. Cost equivalence could not be achieved by shortening hospital stay alone unless LRP were performed as an outpatient procedure. CONCLUSIONS: Our model predicts the perioperative costs of LRP to be greater than RRP by a factor of less than 1.2x. If disposable instruments and trocars are eliminated, and patients undergoing LRP and PLND are discharged on postoperative day 2, cost equivalence with RRP and PLND can be achieved with operative times of 3.4 hours.
Computer Simulation↗
Tumor capacitance: electrical measurements of renal neoplasia.
PURPOSE: Studies have demonstrated that biological tissues possess unique electrical properties. We evaluate the electrical properties of renal tumors using a specialized probe with the capability of measuring intra-tissue capacitance in an ex vivo model of fresh surgically excised tissue. MATERIALS AND METHODS: An electrical monitoring device was used to measure tissue capacitance at a frequency of 1 MHz on 34 ex vivo kidney specimens freshly obtained after surgical excision. Tissue capacitance was promptly measured in the excised tumor as well as surrounding normal parenchyma and fat. Dielectric permittivity in each tissue was calculated using the measured capacitance data. These data were compared and correlated to pathological findings. RESULTS: The final pathology on the 34 specimens revealed 28 renal cell carcinomas (RCC), 3 oncocytomas and 3 angiomyolipomas. In patients with RCC dielectric permittivity of tumor tissue was 1.43 +/- 0.39 times greater than that of surrounding normal parenchyma (p < 0.001). The average tumor-to-normal tissue dielectric permittivity ratio for RCC was significantly greater than that for angiomyolipoma (1.43 +/- 0.39 vs 0.73 +/- 0.77, p < 0.05) but similar to that for oncocytoma (1.43 +/- 0.39 vs 1.63 +/- 0.77, p = 0.39). CONCLUSIONS: Tissue capacitance measurements may be used to differentiate renal tumor from surrounding normal tissue. In vivo studies will ultimately determine the clinical use of this technology in localizing renal neoplasms and differentiating between malignant and benign tissues.
Adenoma, Oxyphilic↗
Necessity of ureteral catheter during laparoscopic partial nephrectomy.
PURPOSE: Laparoscopic partial nephrectomy (LPN) is a relatively recently introduced method of treating renal tumors and, as such, surgical technique is evolving. In open series urinary fistula formation represents a common postoperative complication. In the laparoscopic approach investigators have advocated the placement of a ureteral catheter with retrograde dye injection to visualize caliceal entry to aid in closure. In this study we assessed the necessity of ureteral catheter placement during LPN in decreasing urinary leakage. MATERIALS AND METHODS: From February 1998 until November 2002 laparoscopic partial nephrectomy was performed in 103 patients with renal tumors. The patients were assessed retrospectively and divided into 2 groups according to placement (group 1) or no placement (group 2) of an external ureteral catheter. Group 1 included 54 patients (mean age +/- SD 57.4 +/- 13.4 years) and group 2 included 49 patients (mean age +/- SD 57.5 +/- 10.9). Intraoperative and postoperative parameters including blood loss, operative time, ischemia time, mass size, complications and hospital stay were reviewed and compared between the 2 groups. RESULTS: There were no differences between the 2 groups in mean estimated blood loss (group 1, 394.7 cc vs group 2, 291.5 cc, p = 0.07), postoperative serum creatinine (group 1, 0.95 mg/dl vs group 2, 0.89 mg/dl, p = 0.12), requirement for pain medication (group 1, 8.9 mg vs group 2, 4.9 mg morphine equivalents, p = 0.12), hospital stay (group 1, 3.1 vs group 2, 2.9, p = 0.29) and warm ischemia time (group 1, 28 minutes vs group 2, 26.5 minutes, p = 0.18). Mean total operative time was significantly longer for group 1 compared to group 2 (191.1 vs 149.4 minutes, respectively, p = 0.001). Postoperative urinary leakage requiring prolonged drainage occurred in 1 patient in group 1 and 1 in group 2. In both cases caliceal entry was identified and sutured. CONCLUSIONS: With experience caliceal entry can be identified without the need for a ureteral catheter in patients undergoing LPN for a tumor less than 4.5 cm. Urinary fistula may occur despite caliceal entry and repair. A ureteral catheter may not decrease urinary fistula in patients undergoing LPN.
Adult↗
Management of secondary ureteropelvic junction obstruction after failed primary laparoscopic pyeloplasty.
PURPOSE: Laparoscopic pyeloplasty has been established as a minimally invasive alternative to open pyeloplasty. However, little is known about the treatment of patients in whom this technique fails. We present our experience with treating ureteropelvic junction obstruction after failed primary laparoscopic pyeloplasty. MATERIALS AND METHODS: From August 1993 to September of 2003, 227 patients underwent laparoscopic pyeloplasty for primary ureteropelvic junction obstruction. Of these patients 10 (4.4%), including 6 females and 4 males 24 to 62 years old (mean age 42.1), underwent secondary treatment after laparoscopic pyeloplasty failed. The type of secondary intervention varied by anatomical factors, and patient and surgeon preference. Success was defined as symptomatic relief and improved radiographic imaging at latest followup. RESULTS: Secondary interventions were repeat laparoscopic pyeloplasty in 1 patient, retrograde endoscopic balloon dilation in 2 and endopyelotomy in 7 (laser, cold knife and cutting balloon endopyelotomy in 3, 2, and 2, respectively). No postoperative complications were seen. Patients were followed for a mean of 25.5 months (range 3 to 96) after the second procedure. Seven of 10 secondary interventions (70%) were successful with no obstruction on followup imaging. Three of 10 interventions (30%) failed, namely 1 laparoscopic pyeloplasty, 1 endoscopic balloon dilation and 1 laser endopyelotomy. Failure of the second procedure occurred at a mean of 9.3 months. CONCLUSIONS: When given the choice, most patients select endoscopic management after failed primary laparoscopic pyeloplasty due to its minimally invasive nature and low complication rate. Success rates are 70% with repeat intervention. Some patients require a third intervention.
Adult↗
Vena caval transection during retroperitoneoscopic nephrectomy: report of the complication and review of the literature.
PURPOSE: Major vascular injuries are uncommon but serious complications of laparoscopic surgery. Early recognition and conversion to an open procedure may be required to avoid further complications. We report 2 cases in which the vena cava was transected during retroperitoneoscopic nephrectomy, and review the literature. MATERIALS AND METHODS: All urological laparoscopic cases from 1993 to 2002 at 2 institutions were reviewed to identify major vessel transection. Two cases of inadvertent transection of the vena cava were identified. Medical records were reviewed for clinical and pathological information to identify factors leading to this complication. A MEDLINE search was performed to identify similar reports in the literature. RESULTS: Two patients at 2 institutions were identified with vena caval transection during retroperitoneoscopic nephrectomy. In both cases the vena cava was misidentified as a renal vein. The injury was recognized immediately in both cases and an open repair was performed by vascular surgery. Both patients recovered with no sequelae. In both cases a rotated camera on an angled laparoscope in addition to the relative lack of retroperitoneal landmarks may have contributed to a loss of orientation within the operative field. A similar report of an aortic transection was also found in the literature. CONCLUSIONS: Disorientation of the operating surgeon within the surgical field secondary to rotation of the camera lens and lack of retroperitoneal landmarks may contribute to vena caval transection during retroperitoneoscopic nephrectomy. This injury has not been found in transperitoneal nephrectomy, likely because more intra-abdominal landmarks exist, aiding in maintenance of orientation. Prompt intraoperative recognition and repair of the transection results in a favorable outcome.
Adult↗
Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome.
PURPOSE: Laparoscopic partial nephrectomy (LPN) has emerged as a viable alternative to open surgery for renal tumors less than 4 cm. We present oncological followup of patients treated with laparoscopic nephron sparing surgery at our institution. MATERIALS AND METHODS: Between September 1996 and December 2001, 48 patients who underwent LPN for clinically localized tumors were found to have pathologically proven renal cell carcinoma. Medical and operative records were reviewed for clinical characteristics, pathological findings and followup information. RESULTS: Mean patient age was 59.7 years (range 32 to 81) and mean followup was 37.7 months (range 22 to 84). Mean tumor size was 2.4 cm (range 1.0 to 4.0). Final pathological stage was pT1 in 42 patients (87.5%) and pT3a in 6 (12.5%). Histology revealed clear cell in 32 patients (66.7%), papillary in 10 (20.8%), chromophobe in 3 (6.3%), collecting duct in 1 (2.1%) and unclassified in 2 (4.2%). Intraoperative frozen section biopsies revealed negative margins in all cases. Final surgical margins were positive in 1 patient (2.1%). Followup evaluation consisting of physical examination and yearly cross-sectional imaging, which revealed no recurrences in 46 of 48 patients (95.8%). One patient with von Hippel-Lindau disease was found to have local recurrence 18 months after LPN and observation was elected. The second patient had recurrence in the same kidney away from the original tumor site approximately 4 years later. CONCLUSIONS: LPN is an effective treatment modality for clinically localized renal cell carcinoma. Oncological outcomes at a mean followup of 3 years are promising, although the durability of oncological outcomes must be determined.
Adult↗