Extracorporeal Surgery Research Articles

Ultrasound in the field of urology.

Urological surgery has a long history. Bladder stones have been detected in the mummies of ancient Egypt dating back to 7,000 years ago. Papyrus Ebers, which is said to be the oldest medical book in the world (1550 BC), includes statements about urinary retention and urinary incontinence. In India, a medical monograph written by Susurta (600 BC) refers to urethral bougie and cystolithotomy, which is considered to be the first surgery performed in the world. In Greece, the Oath of Hippocrates (450–370 BC) includes the following statement: ‘‘Assign treatment of stones to specialists.’’ This statement suggests that cystolithotomy was performed often in ancient Greece. In the nineteenth century, anesthesia and sterilization were developed, leading to the beginning of surgical procedures similar to those often performed in the present age. Later, Nitze developed a cystoscope for clinical use, thus opening the path to endoscopic examinations and surgery. Since the advent of two-dimensional ultrasonography and computed tomography (CT) in the 1970s, diagnostic imaging has progressed. In the 1980s, treatment of stones was markedly modified. Extracorporeal shock wave lithotripsy (ESWL) and endoscopic surgery such as percutaneous nephrolithotripsy (PNL) and transurethral ureterolithotripsy (TUL) were introduced. These new procedures were the precursors of minimally invasive treatments not requiring open surgery. In the 1990s, laparoscopic nephrectomy began to be performed. In 1993, Go et al. performed adrenalectomy under laparoscopic guidance for the first time in Japan. At present, endoscopic surgery is the standard treatment for kidney and adrenal gland diseases. Many other urological surgical procedures are also beginning to be performed endoscopically. As illustrated above, surgery in the field of urology has advanced in an accelerated manner in the decades since the 1980s, following the long history of this kind of surgery beginning in 600 BC. Above all, ultrasound has played an important role in such changes in urological surgery. The advent of diagnostic ultrasound devices has allowed urological diseases such as kidney disease and urinary tract stones to be diagnosed easily. In addition, techniques for ultrasound-guided puncture were developed as an application of diagnostic technology and have been available for renal biopsy, PNL, percutaneous drainage, and so on. Transrectal ultrasonography was developed in Japan, stimulating the global spread of ultrasonic diagnosis of prostate disease. Transrectal ultrasonography has been shown to be useful particularly as a means of diagnostic imaging of prostate cancer and for prostate biopsy under ultrasound guidance. Later, Doppler ultrasonography was also developed, enabling the observation of vascular lesions, tumor blood flow distribution, and so on. More recently, elastography, which is capable of visualizing tissue hardness, has also begun to be used for the diagnosis of prostate cancer. The most important application of ultrasound to urological treatment is probably extracorporeal shock wave lithotripsy (ESWL). ESWL is used to treat urinary-tract stones by crushing the stones with shock waves (ultrasound) focused on them. The advent of this treatment technique resulted in innovative changes in the treatment of urinary tract stones. Furthermore, ultrasound is also used for lithotripters for endoscopic treatment techniques such as PNL and TUL, which were developed simultaneously with the development of ESWL. ESWL, PNL, and TUL spread across the world soon after their development. For Y. Itoh (&) Department of Urology, Kyoto Second Red Cross Hospital, 355-5 Haruobi, Kamigyo, Kyoto 602-8026, Japan e-mail: vanpra@aol.com

A comparative study of systems used for dynamic focusing of ultrasound

A comparative study of two methods used for dynamic focusing of ultrasound: the conventional phased arrays and a new method based on time reversal of acoustic signals is carried out. A laboratory model of the focusing system based on time reversal is developed and manufactured. One of the principal elements of the system is a reverberator with several piezoelectric transducers attached to its walls. Experiments are carried out to demonstrate the ability of such a system to generate one focus or several foci and to steer them electronically at considerable distances (50 mm at minimum) off the axis of the focusing system without causing the appearance of any grating lobes or other secondary intensity maxima. The focusing properties of the system are compared with the results of numerical simulation of two-dimensional phased arrays, whose parameters are taken to be typical for the arrays used in extracorporeal surgery. The important role of randomization is demonstrated for both of the aforementioned focusing methods. The prospects of practical application of the two methods are discussed.

An unusual cause of recurrent seizures

Since it was first introduced in 1982, mechanical lithotripsy, more CBD stones are treated endoscopically [1]. Many endoscopists claim that stones larger than the lithotripter basket are best managed by non-endoscopic techniques such as extracorporeal shock wave lithotripsy (ESWL) or surgery [2]. However, our patient had an unfavorable ASA grade and a previous history of procedure related complications. The grating of the side wall, partial grasping of the stone, and then crushing it piecemeal was the method we successfully used in this difficult case. In these situations it is important to remove the stones completely to avoid reformation [3]. Figure 2. Basket evacuating the crushed stone. Figure 3. Double stenting of the CBD.

Evolution of the Surgical Management of Neonatal Ovarian Cysts: Laparoscopic-Assisted Transumbilical Extracorporeal Ovarian Cystectomy (LATEC)

Since its first detailed description in 1995, the laparoscopic management of neonatal ovarian cysts has typically required multiple incisions, specialized equipment, and advanced laparoscopic skills. After some initial frustration with neonatal laparoscopy, we developed a simplified single-incision laparoscopic-assisted transumbilical extracorporeal cystectomy (LATEC). This paper reviews our experience with this technique and compares outcomes to those of our other surgically managed neonatal ovarian cyst patients. A retrospective record review of 20 patients treated surgically between 1992 and 2006. Student's t-tests were used for comparisons (P<0.05 was significant). Means were: age, 11 days; weight, 3.7 kg; and cyst diameter, 5.0 cm. Nineteen patients were diagnosed prenatally, at the mean gestational age of 33 weeks. Twelve of 20 (60%) had torsed cysts (1 bilateral). Three of 13 torsed cysts (23%) were less than 4 cm diameter (range, 2.9-3.5). Laparotomies were transverse lower abdominal incisions. Laparoscopic operations used 2 (3 patients) or 3 incisions (2 patients). LATEC involved transumbilical laparoscopy, complete cyst aspiration, and then cyst evisceration through the umbilicus for either ovarian cystectomy (simple cysts) or salpingo-oophorectomy (torsed cysts). Laparoscopic patients had similar time to feeds, length of stay, and postoperative narcotic requirements, when compared to laparotomy patients (P=nonsignificant). LATEC patients had shorter surgical times, more rapid advancement to full enteral feedings, shorter length of hospital stay, and equal ovarian preservation, when compared to laparoscopy. Cosmetic results with LATEC were outstanding. Both laparoscopic and "open" approaches have acceptable perioperative morbidity and rapid recovery. LATEC is a relatively simple procedure, which combines laparoscopy and traditional extracorporeal surgery, and may be successfully performed by experienced pediatric surgeons and with a single incision.

Place de la chirurgie dans le traitement de l’hypertension réno-vasculaire de l’enfant

The aim of this retrospective study was to report our experience of the surgical treatment of renovascular hypertension in children and to define the role of surgery in the treatment of this form of hypertension. The author's series included 83 patients (49 girls, 34 boys), 28 months to 18 years of age (mean: 10.3) operated on from 1970 to 2001. All patients had elevated blood pressure and underwent the investigations usually performed in patients with hypertension. Lesions were bilateral in 28 cases. The operation was decided after failure of percutaneous angioplasty in the patients treated since 1982. Due to bilateral procedures and to secondary or late re-operations, the number of surgical procedures was 114 (15 nephrectomies and 99 arterial repairs). The repairs were performed by extracorporeal surgery in 25 cases and by conventional in situ surgery in 74 cases. Whenever an arterial substitute was necessary, an arterial autograft was preferred since this material does not undergo late degenerative changes with time. Fibrodysplasia of the renal artery was the prevailing pathologic finding (70%). Associated lesions were observed in 59% of the patients: coarctation of the abdominal aorta (23 patients), stenoses, obstructions or aneurysms of splanchnic arteries (23 lesions in 17 patients), pheochromocytoma (2 patients), arterial lesions of distant arterial territories in patients with Takayasu's aortitis (7 patients). There was no postoperative death in this series. Seven postoperative thromboses occurred (7% of the repairs). In the long-term follow-up, three recurrent stenoses and two aneurysms of a venous autograft were repaired surgically. In two patients, a stenosis of the opposite artery occurred and was also repaired. In two patients, a stenosis of the abdominal aorta worsened and required an aortic by-pass 3 and 12 years after the renal artery repair. In patients with Takayasu's disease, operations in other arterial territories (supra-aortic trunks, coronary arteries) were required in two patients. The complete cure of arterial hypertension was obtained in 82% of the patients. In young children, growth of the repairs was normal when age increased. Surgery still keeps a major place in the treatment of renovascular hypertension in children. Its prognosis is favourable since atheroma, visceral or renal lesions are usually lacking.

Traitement chirurgical des lésions artérielles rénales chez l'enfant

Purpose The aim of this retrospective study was to report the modalities and results of the surgical treatment of renal artery lesions in children. Patients and methods The series included 78 patients (43 girls, 35 boys), 16 months to 18 years of age, operated on from between 1975 to 1998. Lesions were bilateral in 24 cases. Due to bilateral procedures and to secondary or late re-operations, the number of surgical procedures was 106 (91 repairs and 15 nephrectomies). The repairs were performed by extracorporeal surgery in 22 cases and by in situ surgery in 69 cases. Whenever an arterial substitute was necessary, an arterial autograft was preferred Results Fibrodysplasia of the renal artery was the prevailing pathologic finding (63%). Associated lesions were observed in 64% of the patients: coarctation of the abdominal aorta ( n=20), stenoses, obstructions, or aneurysms of splanchnic arteries ( n=15), and pheochromocytoma ( n=2). There was no postoperative death in this series. Seven postoperative thromboses occurred (7.7%). In the long-term follow-up, three recurrent stenoses, two stenoses of the opposite artery, and one aneurysm of a venous autograft were repaired surgically. In two patients, a stenosis of the abdominal aorta worsened and required an aortic by-pass at 3 and 12 years. A complete cure of arterial hypertension was observed in 87% of the patients. In young children, growth of the repairs appeared normal when age increased. Conclusions Surgery still has a prominent role in the treatment of these lesions. The prognosis is favorable since atheroma, visceral or renal lesions are usually lacking.

Book Review: Extracorporeal Renal Surgery and Autotransplantation

Book Review: Extracorporeal Renal Surgery and Autotransplantation

Concomitant surgical procedures for coronary artery disease and intraperitoneal double cancers: Report of a case

Concomitant surgical procedures for coronary artery disease and double cancers are reported. A 61-year-old man with severe triple-vessel coronary disease was found to have early gastric cancer and advanced rectal cancer. We successfully performed a concomitant coronary artery bypass graft using an extracorporeal ultrafiltration membrane and curative surgery for both cancers. Concomitant surgery thus appears to be a benefical and safe approach for the treatment of critical coronary artery disease and intraperitoneal double cancers in carefully selected patients.

Percutaneous nephrolithotripsy

– Percutaneous nephrolithotripsy is an excellent method for treating staghorn or coralliform stones rather than by extracorporeal lithotripsy or surgery. The method features relatively easy execution, low morbility, reduced hospital stay, rare and mostly modest complications. Greatly improved advanced lithotripsy techniques, easy identification of the approach route by echo-guided puncture and if necessary the combination with extracorporeal lithotripsy make the method today even more effective and safe. This study reviews the indications, advantages and complications of the technique.

Intraoperative ultrasound during ex situ liver resection

This report describes the application of intraoperative ultrasound at the explanted liver during ex situ liver surgery. A 55-year-old woman underwent extracorporeal liver resection for multilocular metastases of a duodenal leiomyosarcoma. At surgery, routine intraoperative ultrasound (5-MHz probe) was performed before hepatectomy at the completely mobilized but still normally perfused liver. After hepatectomy ultrasound of the liver was repeated at the back table. By use of the ultrasonographic examination at the back table all the metastases seen with usual intraoperative ultrasound could be confirmed. In addition, one metastasis with a diameter of 6 mm was detected which had neither been suggested by peroperative computer tomography and sonography nor by intraoperative ultrasound or surgical exploration. In cases of extracorporeal liver surgery the combination of in situ and ex situ sonography may improve the identification of hepatic metastases.

Extracorporeal membrane oxygenation and pediatric surgery (Part I)

Extracorporeal membrane oxygenation and pediatric surgery (Part I)

Extracorporeal renal artery reconstruction for renovascular hypertension

Extracorporeal reconstruction can be applied to the successful repair of stenoses in the distal renal artery and its hilar branches. This study evaluates the short- and long-term results of extracorporeal renal artery reconstruction in 65 patients, including 5 children, with renovascular hypertension who were treated from 1974 through 1989. The mean age of the patients was 37 years (range, 7 to 67 years). The cause of the stenoses was arteriosclerosis in 8 patients, fibrodysplasia in 54 patients, and miscellaneous in 3. Hypertension was severe before treatment with a mean blood pressure of 187/147 mm Hg that was reduced to a mean of 159/102 mm Hg after medical therapy. Ten patients had renal dysfunction. Results were evaluated both at short-term intervals (mean, 7.9 months; 64 patients) and long-term intervals (mean, 5.9 years; 60 patients), after surgery. Blood pressure responses were classified as beneficial (cured/improved) or failures. Anatomic results were evaluated by angiography in 98% of the patients at the short-term interval and in 77% of the patients at the long-term interval. Extracorporeal renal artery surgery was performed on 78 kidneys among 65 patients (unilateral, 45 patients; bilateral, 13 patients; unilateral extracorporeal and contralateral in situ, 7 patients). In most of the cases autologous arterial graft was used for reconstruction. Early in the series one patient died as a result of the operative procedure (1/65, 1.5%). A beneficial blood pressure response occurred in 53 patients (53/65; 82%) at the short-term interval and in 49 patients (49/61; 80%) at the long-term interval, with the average blood pressure at the short-term interval being 138/85 mm Hg and at the long-term interval being 139/85 mm Hg. Renal function improved in all patients with preoperative renal dysfunction. Graft stenosis or occlusion of the main renal artery was neither observed at the short-term interval nor at the long-term interval. However, residual stenoses were observed in 9 of the 163 reconstructed distal branches (5.5%). Extracorporeal renal artery reconstruction with autologous arterial grafts can be effectively applied to lesions of the distal main renal artery and its hilar branches with durable functional results.

Extracorporeal repair of renal artery branch lesions

Complex renal artery lesions which formerly would have been treated by nephrectomy may now be reconstructed by extracorporeal surgery and autotransplantation. Our experience in 15 patients (17 operations) with renal artery lesions extending into its branches or confined to them is described. Two patients underwent separate operations on both sides. The indications for surgery were severe renovascular hypertension (10 cases), renal artery aneurysm, (5 cases) and deteriorating renal function (2 cases). Overall clinical results after a mean follow up of 3 years were considered excellent in 13 procedures (11 patients). Improvement in 2 patients and failure in the other 2, who ultimately underwent nephrectomy. Discussion is focussed on results, vascular indications, (namely aneurysm, stenosis, dissecting aneurysm and trauma) and surgical techniques. Preservation of functioning renal tissue should be the ultimate goal of renovascular surgery where the ex vivo technique, when indicated, will achieve favorable results in most patients.

Renal autotransplantation and extra-corporeal surgery

Renal autotransplantation with/without extra-corporeal surgery was performed in 53 patients between September, 1975 and december, 1987. Original disease was obstructive disease of the upper urinary tract in 25 patients, renovascular hypertension and renal vascular disease in 13, renal calculous disease in 12 and renal cell carcinoma in 3. Ten of the 53 patients had solitary kidneys. Three patients died on 14, 21 and 49 postoperative days of massive bleeding with disseminated intravascular coagulopathy caused by the rupture of transplant arterial anastomosis (1 patient with urinary obstructive disease) and sepsis caused by wound infection (2 patients with renal calculous disease). Two kidneys were removed on operative day and 8 postoperative days due to arterial thrombosis in 2 patients with aneurysm of intrarenal artery. The deterioration of renal function was observed in previously damaged kidneys of two patients with extensively damaged ureter. No other severe complications were observed. In 23 of 24 patients with the obstructive disease of the upper urinary tract, disappearance or improvement of the obstructive change was observed after surgery. All 5 patients with renovascular hypertension showed normo-tension without administration of antihypertensive drugs after surgery. In 3 of 5 patients with an aneurysm of the intrarenal artery, the aneurysm was removed and reconstruction of the artery was performed successfully. Two patients with arterio-venous fistula and one patient with nut cracker syndrome had no severe hematuria with bladder tamponade after surgery. Ten of 12 patients with renal calculous disease were treated successfully without residual calculi by this procedure. Three patients who had solitary kidney with renal cell carcinoma were treated successfully by this procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Experience with Extracorporeal Surgery and Autotransplantation for Renal Cell and Transitional Cell Cancer of the Kidney

Of 21 patients who underwent bench surgery for renal malignancies (renal cell carcinoma in 16 and transitional cell carcinoma in 5) 15 also had autotransplantation and 6 did not. In 5 patients the contralateral kidney was removed simultaneously for synchronous bilateral renal malignancy, and 16 had cancer in a solitary kidney. In the 3 patients who underwent nephrectomy for complications after autotransplantation no evidence of residual tumor was noted on histopathological examination. Of 9 patients 1 (11 per cent) had local recurrence after successful autotransplantation (renal cell carcinoma). Two patients with transitional cell carcinoma died of metastatic disease. Treatment failed in 31 per cent of the 16 patients with renal cell carcinoma (metastatic disease in 4 and metastatic disease with local recurrence in 1).Removal of solitary or synchronous bilateral renal cell cancer by bench surgery with subsequent autotransplantation is effective. For high grade transitional cell carcinoma of a solitary kidney its value is doubtful without adjuvant systemic treatment.

Long-term results of in situ and extracorporeal surgery for renovascular hypertension caused by fibrodysplasia

In this study the early and late results of surgical reconstruction for renovascular hypertension caused by fibrodysplasia are evaluated in 53 patients treated between 1962 and 1983. There were 40 female and 13 male patients. The mean blood pressure was 208/126 mm Hg before medical therapy and 171/109 mm Hg thereafter. Bilateral renal artery stenoses were present in 12 patients. In situ revascularization was used in 26 patients and extracorporeal surgery to repair branch artery lesions was performed in 27 patients. Surgical therapy reduced the blood pressure to normal levels with minimal antihypertensive medications. This effect was already apparent 6 to 12 months after operation (mean blood pressure level of 140/90 mm Hg) and it was maintained during a mean follow-up period of 8.4 years (range 1 to 20 years) (mean blood pressure level of 134/85 mm Hg). At 6 to 12 months after operation, 79% of the patients were classified as either cured or improved. At this time the results did not appear to have been influenced by the preoperative duration of hypertension, nor by manifestations of extrarenal arteriosclerosis (ERA) as found in 10 patients, or by the surgical technique applied. But at the end of the long-term follow-up period (mean 8. 3 years) the beneficial response rate of 87% appeared to have been adversely influenced by the presence of preoperative ERA, since beneficial response rates were 93% for those without and 67% for those with ERA (p = 0. 17). We conclude that renal revascularization is effective both early and late for the treatment of renovascular hypertension caused by fibrodysplasia and that complex renovascular obstruction can be treated effectively with extracorporeal repair.

Long-term results of in situ and extracorporeal surgery for renovascular hypertension caused by fibrodysplasia

Long-term results of in situ and extracorporeal surgery for renovascular hypertension caused by fibrodysplasia

Extracorporeal renal surgery.

Renal autotransplantation and/or extracorporeal renal surgery has been done in 17 patients, including 10 with renovascular hypertension, 3 with arteriovenous malformation and 4 with bilateral or solitary renal cell carcinoma. Based on our institutional experiences, indication and limitation for the operation are dis-cussed, and 3 particular cases are presented. Our conclusion is that renal auto-transplantation and extracorporeal reconstruction can provide the best solution for selected renal problems not correctable by conventional methods, although actual number of such cases is thought to be limited.

Discussion: Drummond's “resource allocation decisions in health care: A role for quality of life assessment?”

DECISIONS about the allocation of resources in health care are being made throughout the world and promise to become more obvious and difficult as budgets become tighter. The issue is how allocation decisions are to be made, and what kinds of information and techniques are to be marshalled to guide decision makers. Michael Drummond’s paper introduces the issue of using quality of life indicators beyond clinical encounters to formulate policy, especially public policy. His paper presents an insightful overview of the growing use of economic evaluations for this purpose. He defines the problem of resource allocation; describes the components, processes, and uses of economic evaluations; and raises key issues about incorporating quality of life assessments into these evaluations. My comments center on the different frameworks of economic analysis and the use of results. They are intended primarily to clarify and less frequently to take issue with aspects of Drummond’s exposition. The role of quality of life indicators in economic evaluations can be clarified by examining the continuum of analytical frameworks that can be used. Consider the question of whether to use extracorporeal shock-wave lithotripsy or open surgery for certain stones in the upper urinary tract. Possible health effects to consider include mortality; days of illness, discomfort, and distress; and long-term consequences, such as damage and eventual loss of the kidney. If the probable health effects of the alternative medical interventions are the same, the problem becomes one of cost minimization, that is, managing the treatment of urinary stones with the least costly use of resources. But if, as is more likely, probable health effects differ among the alternatives and health effects go beyond mortality, one needs an index to combine health effects, so alternatives can be compared. This task calls on the expertise of biomedical researchers, clinicians, health services researchers, and policy analysts. And, as Margolese pointed out, health effects in additional to mortality are of greater importance with chronic disease than with acute infectious disease. Cost-benejit analysis addresses the problem of combining different health effects by using monetary units to express all effects. As Drummond explains, reduced morbidity can be valued by the extra productivity gained from increased working time or by the patients’ willingness to pay to avoid the discomfort associated with a medical condition. Despite the initial use of cost-benefit analysis in the health field during the 1950s and 196Os, there has been a decided trend away from using the technique and toward using cost-effectiveness analysis [ 11, probably because of the distaste for attaching a dollar value to health and life. Cost -e@tiveness analysis examines differences in monetary cost and health effects from using one medical intervention instead of another [2]. The cost-effectiveness ratio expresses the net cost to be expended to achieve a net change in health effects. Health effects may be measured in years of life, in cases of disease, or by a health index, such as quality-adjusted life years. Such an index adjusts changes in years of

Extracorporeal Renal Surgery and Autotransplantation for Complicated Stone Disease

Most patients with extensive renal calculous disease can be managed satisfactorily by percutaneous or in situ surgical techniques. However, in selected patients with advanced nephrolithiasis in whom prior surgical therapy has failed, extracorporeal renal lithotomy and/or autotransplantation may provide the best method of achieving complete stone removal and unobstructed urinary drainage from the upper urinary tract. The most common indications for this approach are recurrent nephrolithiasis with stenosis of the renal pelvis or ureter, recurrent renal colic, and extensive ureteral loss following prior operative therapy. In all cases, close postoperative follow-up, with prevention of infection and treatment of metabolic disorders, is integral to successful long-term management.