Impact of laparoscopic nephrectomy on donor preoperative decision-making and postoperative quality of life and psychosocial outcomes.
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Adolescent↗
Biomedical subjects
William K Johnston
Publications and source records attributed to William K Johnston.
200 consecutive hand assisted laparoscopic donor nephrectomies: evolution of operative technique and outcomes.
PURPOSE: Despite the popularity of hand assisted laparoscopic donor nephrectomy published experience is less than that with standard laparoscopic donor nephrectomy and few critical assessments of operative maneuvers have been described. MATERIALS AND METHODS: We describe the impact of changes in operative technique made by a single surgeon during 200 hand assisted laparoscopic donor nephrectomies. RESULTS: With a mean operative time of 229 minutes and hospital stay of 1.9 days the rates of conversion to open surgery, intraoperative complications and major postoperative complications were 1%, 1.5% and 6%, respectively. Lasting changes in technique were dissection of a ureteral/gonadal packet, bipolar cautery use on gonadal/adrenal/lumbar veins and resting the kidney before removal. The incidence of ureteral complications decreased from 8% to 5.1% with dissection of the ureter in conjunction with the gonadal vein rather than isolating it. Warm ischemia time decreased from a mean of 186 to 143 seconds with bipolar electrocautery instead of clips to control gonadal/adrenal/lumbar veins. After starting to rest the kidney before removal the incidence of primary graft nonfunction and delayed function decreased from 6.7% to 0% and 30% to 11.8%, respectively, with a corresponding improvement in 2-year graft survival from 83% to 95%. CONCLUSIONS: This large series of hand assisted donor laparoscopic nephrectomies with a mean followup approaching 3 years demonstrates that the procedure is safe for the donor and procures a good specimen. Decreases in ureteral complications, warm ischemia time and graft dysfunction might be attributable to specific changes in our operative technique.
Adult↗
Acute integrity of closure for partial nephrectomy: comparison of 7 agents in a hypertensive porcine model.
PURPOSE: We assessed the acute effectiveness of closure after partial nephrectomy of 7 techniques in a large hypertensive porcine model using shallow and deep resections to approximate clinical situations. MATERIALS AND METHODS: Open surgical partial nephrectomy with hilar clamping was performed in pigs weighing 150 to 200 lbs, including small-a quarter length and a quarter width of kidney, medium-a third length and a third width of kidney, and into the renal sinus and up to the collecting system, and large-lower pole heminephrectomy at the renal sinus. Seven agents were compared after a single application, namely thrombin/collagen granules, polyethylene glycol hydrogel, fibrin glue, thrombin/gelatin granules, cyanoacrylate glue, fibrin glue/gelatin sponge and sutured bolster. Failure and success were determined by the presence or absence of bleeding, respectively, after unclamping and by an increase in SBP to 100 and then to 200 mm Hg with dopamine infusion. RESULTS: Of 70 partial nephrectomies the success rates were 33% and 14% for thrombin/collagen granules, and 67% and 0% for polyethylene glycol hydrogel in small and medium resections; 100%, 71% and 0% for fibrin glue, and 100%, 86% and 0% for thrombin/gelatin granules in small, medium and large resections; and 67% and 80% for cyanoacrylate glue, 100% and 20% for fibrin glue/gelatin sponge, and 100% for sutured bolster in medium and large resections, respectively. Of the kidneys that did not bleed at an SBP of 100 mm Hg 31% bled at 200 mm Hg. CONCLUSIONS: There is considerable variability among agents. Most were effective for small resections and some worked for medium resections but for large resections only sutured bolster was consistently effective. SBP also appears to be an important factor. These results bear on the selection of techniques during laparoscopic partial nephrectomy.
Animals↗
Laparoscopic partial nephrectomy: technique, oncologic efficacy, and safety.
Laparoscopic partial nephrectomy is emerging as an attractive approach for selected renal masses, but has been performed with significant variability in technique. The procedure's evolution, a merger of proven open techniques with applicable laparoscopic techniques and limitations, is very much a work in progress. Just as long-term follow-up for open nephron-sparing surgery for selected renal masses has demonstrated recurrence-free survival equivalent to radical nephrectomy, a few large series of laparoscopic partial nephrectomy are beginning to surface that demonstrate its clinical efficacy, although duration of follow-up is still too short to make definitive statements. This article reviews the literature and the authors share their experience and preferences in technique, derived from 100 consecutive laparoscopic partial nephrectomies and from their assessment of the acute sealant effectiveness for partial nephrectomy in a large, hypertensive, porcine model that approximates clinical situations. This review aims to assist the urologic surgeon in determining which renal tumors to approach laparoscopically and which surgical approach best fits their laparoscopic expertise.
Female↗
Comparison of neuromuscular injuries to the surgeon during hand-assisted and standard laparoscopic urologic surgery.
BACKGROUND AND PURPOSE: Hand-assisted procedures have assumed a greater role in the practice of many laparoscopists. We surveyed major laparoscopy program directors to compare the incidence and location of neuromuscular injury to the surgeon during hand-assisted laparoscopic (HAL) and standard laparoscopic (SL) surgery. MATERIALS AND METHODS: A questionnaire on neuromuscular injuries was e-mailed to 42 laparoscopic program directors. Respondents were instructed to report only injuries or pain associated with laparoscopic surgery when they were the primary responsible surgeon and not during open or endoscopic procedures. RESULTS: Surveys were returned from 23 attending laparoscopic surgeons and 2 laparoscopic fellows. Surgeons reported an average of 3.9 HAL and 6.3 SL cases per month as the primary surgeon. The HAL was completed with the GelPort, LapDisk, Omniport, or a combination of devices 55%, 22%, 5%, and 14%, respectively, of the time. Comparing HAL with SL, there was significantly more hand/wrist, forearm, and shoulder pain/injuries associated with HAL (P < 0.004). There was significantly more neck pain associated with SL than HAL (P < 0.003), but no significant difference in lower-back pain (P = 0.40). Comparing the two most commonly used hand-assist devices (GelPort and LapDisk), the LapDisk demonstrated significantly more hand/wrist pain or injury (P = 0.001). CONCLUSION: Hand-assisted laparoscopy is associated with more frequent neuromuscular strain to the upper extremity than SL, but SL surgeons experience more neck pain or injury. Surgeon discomfort is also dependent on the type of hand-assist device. The long-term consequences of physical strain on the laparoscopic surgeon are unknown currently, but measures to minimize neuromuscular strain should be considered.
Adult↗
Retroperitoneoscopic radical and partial nephrectomy in the patient with cirrhosis.
PURPOSE: In patients with cirrhosis and a renal mass options may be limited by medical disease and the surgical difficulties associated with portal hypertension. We describe a retrospective review of patients with cirrhosis with renal masses who underwent radical or partial nephrectomy through a retroperitoneoscopic approach. MATERIALS AND METHODS: Ten consecutive patients, including 4 men and 6 women, with cirrhosis, of whom 2 had undergone liver transplantation, underwent radical (7) or partial (3) nephrectomy for a total of 5 right and 5 left renal neoplasms via the retroperitoneoscopic approach at our institution from March 2002 to February 2004. Recovery data were prospectively obtained and other information was gathered retrospectively from the medical record. RESULTS: Average patient age was 58 years and average American Society of Anesthesiology score was 2.8. Average renal tumor size for radical and partial nephrectomy was 4.6 (range 2.9 to 7) and 1.8 cm (range 1.3 to 2.3), respectively. Operative time was 140 to 315 minutes (median 172) and estimated blood loss was 100 to 5,000 ml (median 225). One patient required open conversion due to hemorrhage from left portosystemic venous communications. Mean postoperative hospitalization was 1.5 days (range 1 to 6). CONCLUSIONS: Although retroperitoneoscopic surgery avoids many surgical dangers associated with portal hypertension and it is our preferred approach to renal surgery in patients with cirrhosis, significant portosystemic venous communications exist in the retroperitoneum, especially on the left side, and they still lead to substantial blood loss in some patients.
Blood Loss, Surgical↗
Intermediate followup of hand assisted laparoscopic nephroureterectomy for urothelial carcinoma: factors associated with outcomes.
PURPOSE: We report our experience with hand assisted laparoscopic (HALS) nephroureterectomy and describe the associations of preoperative, operative and pathological factors with outcome. MATERIALS AND METHODS: HALS nephroureterectomy was performed in 54 consecutive patients using modified transurethral resection of the ureteral orifice (TURUO) or a 1 port transvesical endoscopic cuff technique for the distal ureter in all except 8. Data were collected prospectively and retrospectively, and followup was distinguished for bladder, contralateral upper tract and nonurothelial (local recurrence and distant metastases) sites. RESULTS: The endoscopic cuff was associated with significantly shorter mean operative time than the transurethral resection of the ureteral orifice method (234 vs 295 minutes, p = 0.002) but the comparison was confounded by the effect of experience. With 28% of patients having stage II or greater tumors and 49% having high grade bladder disease, contralateral upper tract and nonurothelial recurrences developed in 55%, 11% and 25% of evaluable patients at a median followup of 25.1, 24.4 and 24.9 months, respectively, in those without recurrence. At a median followup of 25.0 months cancer specific survival was 94%, 86% and 80% at 1 to 3 years, respectively. Three-year cancer specific survival was 100% in patents with grade 1 or 2, or stage 0 or I tumors but only 57% and 36% in patients with grade 3 and stage II or IV tumors, respectively. CONCLUSIONS: HALS nephroureterectomy is associated with 3-year outcomes that are strongly associated with stage and grade. We prefer the endoscopic cuff method for the distal ureter because it is performed after nephrectomy, does not require patient repositioning and is expedient.
Aged↗
Fibrin glue v sutured bolster: lessons learned during 100 laparoscopic partial nephrectomies.
PURPOSE: Laparoscopic partial nephrectomy (LPN) is performed with marked technical variations. We defined the limits of sutureless LPN and determined which closure technique is best in a particular situation. MATERIALS AND METHODS: During 100 consecutive LPNs fibrin glue products were used for closure in the first 75 (group 1) and sutured bolsters were applied when the collecting system (CS) or renal sinus was entered in the final 25 (group 2). RESULTS: In groups 1 and 2 hand assisted laparoscopy was used in 72% vs 40% of cases and hilar clamping was used in 27% vs 92%, respectively. Mean tumor size was 25 vs 26 mm, tumor depth was 11 vs 13 mm, distance to the renal sinus was 9 vs 5 mm, operating room time was 185 vs 210 minutes, estimated blood loss was 398 vs 247 cc and hospital stay was 2.9 vs 2.6 days in groups 1 and 2, respectively. Overall postoperative hemorrhage and urine leakage occurred in 9% and 2% of patients, respectively. Tumors associated with postoperative hemorrhage/leakage tended to be larger (35 vs 24 mm, p = 0.007) and closer to the renal sinus (0.5 vs 8.2 mm, p = 0.02). Postoperative hemorrhage or urine leakage occurred in 41% of the 17 patients in group 1 with CS or renal sinus entry but in only 2 of the 58 (3.4%) without entry (p <0.0001). In group 2 hemorrhage/leakage occurred in 11% of the 18 patients with CS or renal sinus entry (vs same subset in group 1, p = 0.04). CONCLUSIONS: LPN with closure using fibrin glue products provides adequate hemostasis when the CS or renal sinus is not entered. When the CS or renal sinus is entered, a sutured bolster is recommended.
Decision Trees↗
Wound complications after hand assisted laparoscopic surgery.
PURPOSE: Hand assisted laparoscopic surgery (HALS) provides benefits similar to standard laparoscopy but generally requires a larger incision. We assessed the nature of and risk factors for incisional complications after HALS. MATERIALS AND METHODS: All patients who underwent HALS at our institution from February 1997 through December 2003 were included in a prospective and retrospective review to assess postoperative wound complications. Literature regarding wound complications associated with open surgery and standard laparoscopy was reviewed. RESULTS: A total of 424 consecutive procedures performed on 422 patients were evaluated. Postoperative HALS incision site complications included 29 infections (6.8%), 15 hernias (3.5%) and 2 dehiscences (0.5%). Multivariate logistic regression models revealed that HALS incision site hernias were associated with current or past tobacco smoking (6.0%, p = 0.04), with a trend toward significance for diabetes mellitus (14%, p = 0.07), male gender (5.3%, p = 0.08) and renal failure (16%, p = 0.08). HALS incision site infections were associated with omission of perioperative antibiotics (13%, p = 0.007), obesity (12%, p = 0.03) and increased operative time (252 vs 222 minutes in patients with and without infection, respectively, p = 0.001). CONCLUSIONS: Our findings suggest that wound infections and hernias occur less frequently with HALS than with open surgery, but more often than with standard laparoscopy. Certain patient comorbidities (eg obesity), modifiable risk factors (eg smoking status) and procedural variables (eg omission of perioperative antibiotics or length of procedure) may adversely influence HALS wound complications. This information can be used to decide between HALS and standard laparoscopic approaches in particular patients.
Adult↗
En bloc stapling of renal hilum during laparoscopic nephrectomy and nephroureterectomy.
OBJECTIVES: To evaluate the safety and advisability of en bloc mass stapling of the renal pedicle during difficult laparoscopic nephrectomy to avoid conversion to an open procedure. METHODS: A retrospective chart review was performed of 433 consecutive patients undergoing laparoscopic simple or radical nephrectomy or laparoscopic nephroureterectomy between August 1998 and July 2003 by two surgeons. In all cases of en bloc hilar ligation, a stapler was deployed across the renal hilum without individual dissection of the renal artery and vein. RESULTS: The overall incidence of en bloc ligation was 6.0% (26 of 433 patients). The reasons for en bloc ligation were a difficult hilar dissection and/or the appearance of the renal hilum in 21 cases and urgent ligation secondary to bleeding in 5 cases. No correlation was found between surgeon experience and the frequency of en bloc ligation. No immediate or short-term complications related to this method of hilar division were observed with a mean follow-up of 26 months. CONCLUSIONS: In this study, no cases of arteriovenous fistula development occurred after en bloc stapling of the renal pedicle. Long-term follow-up is needed, because arteriovenous fistula development may be a late complication of nephrectomy. Although we do not advocate the generalized use of en bloc division of the renal pedicle, early data suggest that en bloc stapling can be performed to avoid conversion to an open procedure with no related short-term complications.
Arteriovenous Fistula↗
The evolution and progress of ureteroscopy.
Technology and refinements in urology have prospered with the bonding of engineers and surgeons. The introduction of fiberoptics and the development of the ureteroscope opened the doors to the field of ureteroscopy. Advances in rigid and flexible ureteroscopy with irrigating and working channels have expanded the capability of the urologist to diagnose and treat most abnormalities of the upper tracts in adult and pediatric populations. Instrument development has easily paralleled the growth and development of the ureteroscope and has improved success, patient safety, and comfort with the incorporation of access sheaths, nitinol materials, and Ho:YAG laser technology. Owing to their minimal morbidity and high success rate, ureteroscopic evaluation and therapeutic interventions in the upper tract represent the gold standard of management. Albert Einstein said, "There are only two ways to live your life. One is as though nothing is a miracle. The other is as though everything is a miracle." Contemporary ureteroscopy is a historical miracle that has opened a vista of endless limits in upper tract endoscopy (Fig. 4, Box 1).
Adult↗
The birth of fiberoptics from "light guiding".
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Fiber Optic Technology↗
Image converter eliminates mirror imaging during laparoscopy.
BACKGROUND AND PURPOSE: In laparoscopy, the term "mirror imaging" is used to describe a visual illusion resulting in paradoxical movements when a surgeon is positioned opposite the laparoscope. Mirror imaging is a common problem, creating difficulty in ergonomics and task performance. We introduce the use of a video image converter box (IC box) to overcome mirror imaging. The IC box converts the analog signal to a digital one, performs image rotation or inversion or both, and then reproduces an analog signal for monitor viewing. A laboratory study evaluated whether the IC box could improve performance during laparoscopic tasks. MATERIALS AND METHODS: Fourteen laparoscopic surgeons (10 novice and 4 experienced) completed three laparoscopic tasks while positioned opposite the camera and experiencing mirror imaging: (1). suture cutting; (2). multiple transfers of a piece of foam; and (3). multiple transfers of a pinto bean. Participants were timed during each test both with and without the use of the IC box. RESULTS: All surgeons completed each task faster using the IC box (P < 0.015). On average, use of the IC box allowed subjects to complete assignments in less than one-third the time needed without the IC box. In Task 3, requiring multiple transfers of a small bean, all participants using the IC box completed the task. However, without the box, only 1 of 14 participants accomplished the goal in the allotted time. CONCLUSION: Use of the IC box eliminates mirror imaging and improves performance and efficiency during laparoscopic tasks. The box would significantly benefit surgeons positioned opposite the camera during laparoscopic surgery.
Clinical Competence↗
Renal autotransplantation for renovascular hypertension: extraperitoneal renal approach and use of the ovarian vein for vascular reconstruction.
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Adult↗
Wireless teleradiology for renal colic and renal trauma.
BACKGROUND PURPOSE: Image transmission is an integral part of telemedicine, allowing evaluation of patients at remote sites. We developed a simple method of wireless transmission of digital images to a hand-held computer (PDA) and evaluated its feasibility and diagnostic accuracy in patients with acute renal colic or renal trauma. MATERIALS AND METHODS: The CT images from 11 patients with suspected renal colic and one patient with renal trauma were transmitted using a cellular telephone with a wireless modem link to a PDA (Sony Clie 615C). A diagnostic interpretation was recorded for the presence/absence of an upper-tract stone, stone location, estimated stone size, and signs of upper-tract obstruction. Radiologic staging of trauma was provided in the patient with a renal injury. Comparison was made with the final dictated report of a staff radiologist. RESULTS: Ten CT sets of patients with renal colic were used for comparison, the remaining one being excluded because of ambiguity in the final radiology report. An average of 5.9+/-1.6 images, average size 32.2+/-5.2 kb (range 21-42 kb) for each patient were sent at an average speed of 1 kb/sec. Interpretation correctly identified stone presence in 80%, hydronephrosis in 100%, and perinephric stranding in 80% and stone size within 1+/-1 mm. A stage-3 renal trauma was correctly identified and staged. CONCLUSION: Wireless teleradiology to PDA units provides image quality sufficient for diagnostic interpretation. Anticipated improvements in wireless transmission and PDA screen image resolution will enhance the speed, quality, and quantity of images transmitted. Wireless teleradiology may facilitate convenient rapid evaluation of patients at remote sites.
Abdominal Injuries↗