Gibson Incision Research Articles

Is Open Ureterolithotomy Finished? : A Case of Giant Ureteral Stone and Screening of the Literature

INTRODUCTION: Open surgery is an old method of urology in the treatment of ureteral stones. With the development of new technologies; Indications for open surgery in the treatment of stone disease have decreased to 1-5.4 %. In this case, we aimed to remove 4 stones with a diameter of 22 mm at the lower end of the left ureter by open ureterolithotomy and to report similar cases in the literature. CASE: In the direct urinary system X-ray and abdominal computed tomography of the patient who applied to us with the complaint of left flank pain, 4 stones with a diameter of 22 mm in the lower end of the left ureter, grade 4 hydroureteronephrosis in the left ureter and kidney were observed. Left open ureterolithotomy was planned. The patient's stones were removed using the left Gibson incision technique, and the ureteral incision area was sutured by placing a 6f double j catheter into the ureter. A drain was placed in the left ureteral tracing and the procedure was terminated by suturing the Gibson incision. The patient's foley catheter was removed on the 1st day and the drain was removed on the 2nd day, and he was discharged. No postoperative complications were encountered. Six weeks later, the patient's 6f double j catheter was removed and the surgical procedure was completed. DISCUSSION: Ureteral stones usually form in the primary kidney and then descend into the ureter. Ureteral stones usually pass spontaneously, but stones larger than 1 cm have fewer spontaneous passages. Ureteral stones are usually single and smaller than 2 cm. For stones larger than 5 cm, the term giant ureteral stone is used. Paik et al. reported a mean blood loss of 144 cc and a mean hospital stay of 6.5 days in seven patients with open ureterolithotomy. All patients in the series were stone-free and had no complications. In another study, open ureterolithotomy was performed in 56 patients, and 46.4% of the patients had stones in the distalureter. While the hospital stay was 4.2 days, no complications were encountered. CONCLUSION: Open ureterolithotomy has lost its status as the gold standard with the development of ureterorenoscopy, but as in our case, it is a surgical technique that should be considered in large ureteral stones.

V03-11 LAPAROSCOPIC NEPHRECTOMY FOR POLYCYSTIC KIDNEY: A VIDEO-ILLUSTRATED CASE SERIES OF TRANSPERITONEAL AND RETROPERITONEAL APPROACHES

You have accessJournal of UrologyCME1 Apr 2023V03-11 LAPAROSCOPIC NEPHRECTOMY FOR POLYCYSTIC KIDNEY: A VIDEO-ILLUSTRATED CASE SERIES OF TRANSPERITONEAL AND RETROPERITONEAL APPROACHES Daniele D'Agate, Giorgio Calleris, Marco Allasia, Marco Oderda, Alessandro Marquis, Giancarlo Marra, Federico Vitiello, Federico Lavagno, Matteo de Bellis, Gabriele Montefusco, Francesco Bracco, and Paolo Gontero Daniele D'AgateDaniele D'Agate More articles by this author , Giorgio CallerisGiorgio Calleris More articles by this author , Marco AllasiaMarco Allasia More articles by this author , Marco OderdaMarco Oderda More articles by this author , Alessandro MarquisAlessandro Marquis More articles by this author , Giancarlo MarraGiancarlo Marra More articles by this author , Federico VitielloFederico Vitiello More articles by this author , Federico LavagnoFederico Lavagno More articles by this author , Matteo de BellisMatteo de Bellis More articles by this author , Gabriele MontefuscoGabriele Montefusco More articles by this author , Francesco BraccoFrancesco Bracco More articles by this author , and Paolo GonteroPaolo Gontero More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Both transperitoneal (TP) and retroperitoneal (RP) laparoscopic nephrectomies (NT) have been described for autosomal dominant polycystic kidney disease (APKD), and no conclusive evidence exists about the best approach. We present in this video the step-by-step procedure for both techniques. Perioperative data of a single-institutional case-series are reported. METHODS: A retrospective review of the NTs in APKD patients in between June 2020 and April 2022 was conducted. The TP approach requires the positioning of three 12-mm ports and one 5-mm ports, the mobilisation of the colon, the incision of Gerota’s fascia and the development of the psoas plane to identify the renal pedicle. Renal vessels and ureter are clipped by Hem-o-lok ® and divided. The RP approach usually requires the positioning of a first 12-mm trocar at the apex of the XII rib; the RP space is developed using a dedicated balloon; two more 12-mm trocars are placed at the posterior axillary line and in the iliac fossa. The psoas plane allows an early access to the renal pedicle; the renal vessels and the ureter are ligated by Hem-o-lok ® and divided. In both approaches, the puncture and the suction of the major cysts is frequent during dissection; adrenal-sparing approach was feasible in all cases; a modified Gibson incision is made for kidney extraction. RESULTS: Six consecutive patients were enrolled, 3 of whom were treated by TP and 3 by RP-NT. Two patients were on haemodialysis and 2 had already undergone a renal transplantation. Mean age was 49 and 57 years, maximum kidney diameter was 28.25 and 30 cm and mean operative time was 171 and 210 min, respectively for RP and TP. No conversion to open surgery was made. The reason for NT was represented by symptomatic polycystic kidney in 5 cases; surgery was required solely in preparation to kidney transplantation in 1 TP case. No Clavien 3 grade complications or greater were recorded; postoperative sepsis occurred in 2 TP patients, haematoma in 1 TP and 1 RP cases, blood transfusions were required in 2 TP and 1 RP cases, 1 RP patient experienced a deep venous thrombosis. The hospitalization time ranged from 5 to 31 days. No significant worsening of the renal function was observed at discharge. CONCLUSIONS: At present, the scarce existing data do not suggest the superiority of an approach over the other one. Both RP and TP approaches for nephrectomy of polycystic kidneys are feasible in experienced hands and the choice must be tailored on patient characteristics and surgeon’s preference. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e249 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniele D'Agate More articles by this author Giorgio Calleris More articles by this author Marco Allasia More articles by this author Marco Oderda More articles by this author Alessandro Marquis More articles by this author Giancarlo Marra More articles by this author Federico Vitiello More articles by this author Federico Lavagno More articles by this author Matteo de Bellis More articles by this author Gabriele Montefusco More articles by this author Francesco Bracco More articles by this author Paolo Gontero More articles by this author Expand All Advertisement PDF downloadLoading ...

PD31-01 IMPACT OF TRANSVERSUS ABDOMINUS PLANE NERVE BLOCK DURING KIDNEY TRANSPLANTATION ON PATIENT POST-OPERATIVE OPIOID USAGE: A PROSPECTIVE, RANDOMIZED, DOUBLE-BLINDED STUDY

You have accessJournal of UrologyCME1 Apr 2023PD31-01 IMPACT OF TRANSVERSUS ABDOMINUS PLANE NERVE BLOCK DURING KIDNEY TRANSPLANTATION ON PATIENT POST-OPERATIVE OPIOID USAGE: A PROSPECTIVE, RANDOMIZED, DOUBLE-BLINDED STUDY William Jevnikar, Michael Gross, Hannah Kerr, Venkatesh Krishnamurthi, Alvin Wee, Yi-Chia Lin, and Mohamed Eltemamy William JevnikarWilliam Jevnikar More articles by this author , Michael GrossMichael Gross More articles by this author , Hannah KerrHannah Kerr More articles by this author , Venkatesh KrishnamurthiVenkatesh Krishnamurthi More articles by this author , Alvin WeeAlvin Wee More articles by this author , Yi-Chia LinYi-Chia Lin More articles by this author , and Mohamed EltemamyMohamed Eltemamy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003324.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Kidney transplantation is a life-altering procedure with excellent surgical outcomes. However, options for post-operative analgesia are limited by pre-existing renal dysfunction and most centers rely heavily on opioids for pain control. Transversus Abdominus Plane (TAP) blocks provide abdominal wall analgesia and may reduce surgical site pain. We aim to determine the effectiveness of intraoperative surgeon-administered TAP block for reducing post-operative opioid usage and pain in kidney transplantation patients. METHODS: Patients undergoing kidney transplantation via either a standard Gibson incision or the anterior rectus sheath (ARS) approach were randomized intraoperatively 1:1 to TAP block (a combination of liposomal and unbound bupivacaine) or normal saline via the reflected abdominal wall prior to bringing the kidney into the field. Patients and treating team were blinded to randomization. Post-operative opioid usage, pain via dedicated survey, and length of stay for both groups were recorded. Differences between groups were calculated via t-test, χ2 and Mann Whitney U tests. RESULTS: 128 patients were randomized and were evenly distributed (Table 1). Patients receiving the TAP block required fewer morphine milligram equivalents (MME) (30.0 vs 60.3, p=0.002) and had a lower maximum pain score (6 vs 7, p=0.039) compared to placebo. MME was reduced with TAP in both the ARS (p=0.024) and Gibson subsets (p=0.020). 27 of the patients receiving an ARS incision used no opiates while inpatient, with significantly more patients having received the TAP vs placebo (20 vs 7, p=0.001). CONCLUSIONS: TAP block reduced MME usage by half for each surgical approach. 26% of the cohort did not require any opioids following transplantation including half of all patients receiving the combination of ARS and TAP block. The TAP block is an easily-implemented adjunct with the ability to significantly decrease the post-operative opioid use in renal transplantation with the additional possibility of opioid-free transplantation in select patients. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e900 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information William Jevnikar More articles by this author Michael Gross More articles by this author Hannah Kerr More articles by this author Venkatesh Krishnamurthi More articles by this author Alvin Wee More articles by this author Yi-Chia Lin More articles by this author Mohamed Eltemamy More articles by this author Expand All Advertisement PDF downloadLoading ...

Total Intracorporeal Versus Open Bladder Cuffing in Robotic Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma

To evaluate a single institution experience of total intracorporeal bladder cuffing and distal ureterectomy (DUBC) in robotic radical nephrouretectomy (RNU) for upper tract urothelial carcinoma (UTUC). One hundred sixty-eight patients treated for UTUC with robotic RNU at our institution from May 2009 to October 2019 were retrospectively analyzed. Ninety-two patients underwent total intracorporeal DUBC after robotic dock repositioning, whereas 76 patients underwent open methods via Gibson incision. Perioperative outcomes including operation time, estimated blood loss (EBL), transfusion rates, use of painkillers, Visual analogue scale (VAS) pain scores, and complication rates were compared, as well as pathological and oncological outcomes. Uni- and multi-variate Cox regression models were performed for survival analysis. There were no significant differences in baseline patient characteristics between the 2 groups. Patients who underwent intracorporeal bladder cuffing had less EBL (169.8 ± 150.4 vs 214.6 ± 157.0, P = .091) and decreased pain at 1 week (VAS score 1.18 ± 1.1 vs 2.2 ± 1.1, P = .017). Pathological outcomes were not significantly different, and oncological outcomes including local and intravesical recurrence, cancer-specific and overall mortality were comparable to patients who received extracorporeal bladder cuffing. Intracorporeal bladder cuffing was not associated with increased risk of progression on univariate analysis (HR 0.600, 95% CI, 0.314-1.147; P = .122). Based on our experience, intracorporeal DUBC can be a safe and oncologically non-inferior alternative method to RNU, with benefits of decreased EBL and postoperative pain. Future prospective trials are necessary to further validate our results.

V10-12 COMPLEX PARTIAL NEPHRECTOMY IN SOLITARY KIDNEY

You have accessJournal of UrologyCME1 May 2022V10-12 COMPLEX PARTIAL NEPHRECTOMY IN SOLITARY KIDNEY Nimrod Barashi Gozal, Brijesh Patel, Mark Biebel, Joseph Ippolito, and Robert Figenshau Nimrod Barashi GozalNimrod Barashi Gozal More articles by this author , Brijesh PatelBrijesh Patel More articles by this author , Mark BiebelMark Biebel More articles by this author , Joseph IppolitoJoseph Ippolito More articles by this author , and Robert FigenshauRobert Figenshau More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002623.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Management of renal masses in solitary kidneys can pose a challenging dilemma. Important considerations include feasibility of mass resection with adequate renorrhaphy, limiting ischemia time, and preservation of nephrons to avoid dialysis. We present a complex robot-assisted partial nephrectomy (RAPN) in a 55 year-old female with a solitary left kidney, incidentally found to have a 5.7cm left renal mass that was centrally located, completely endophytic, with a R.E.N.A.L Nephrometry score of 11, and a baseline creatinine of 1.06 mg/dL. METHODS: The patient was placed in right lateral decubitus position with the left flank flexed. Pneumoperitoneum was achieved with a Veress needle, and four robotic 8 mm ports were placed in a straight line along the lateral edge of the rectus with a 12 mm assistant port in the midline. A remotely operated suction irrigation (ROSI) system was utilized. After the colon was medialized, hilar dissection was started with identifying the renal vein (RV), and immediately posterior and cephalad was the renal artery (RA). Intraoperative ultrasonography was performed to demarcate borders of mass excision, since the mass was completely endophytic. Approximately 50% of mass excision was performed with selective clamping of the artery supplying the tumor, but the main RA was eventually clamped to help control bleeding. The mass, along with a segment of tumor thrombus, was grossly excised to completion. Renorrhaphy was started with a 3-0 v-lock suture over-sewing the base of mass excision to control bleeding followed by simple interrupted 0-vicryl suture to bring edges of resection together. These were secured with two Hem-o-lok clips. Gerota’s fascia was re-approximated with a 3-0 v-lock suture, and the specimen was placed in a Endocatch bag for extraction through a Gibson incision. RESULTS: Procedure time was 5 hours and 13 minutes. Estimated blood loss (EBL) was 1,500 mL. Pathology showed clear cell RCC, Furhman grade 3, with lymphovascular invasion and a positive surgical margin at the RV. Post-operatively, the patient experienced a oliguric renal failure, with creatinine (Cr) peaking at 8.5 mg/dL on postoperative day 4. Following that, urine output increased to over 2 liters daily, and Cr fell to 5.5 mg/dL by POD#9, at which time the patient was discharged. At one month follow-up, Cr was 1.49 mg/dL. At no point did the patient have any dialysis needs. CONCLUSIONS: A number of difficult challenges exist for complex RAPN in solitary kidneys. Performing as much of the procedure as possible without clamping the main renal artery may increase blood loss but will also facilitate renal recovery. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e852 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nimrod Barashi Gozal More articles by this author Brijesh Patel More articles by this author Mark Biebel More articles by this author Joseph Ippolito More articles by this author Robert Figenshau More articles by this author Expand All Advertisement PDF DownloadLoading ...

Treatment of Distal Upper Tract Urothelial Cancer with Distal Ureterectomy Preserves Renal Function without Increasing Local Recurrence Rate Compared with Radical Nephroureterectomy

Introduction: Kidney sparing surgery like endoscopic resection and distal ureterectomy has been recently proposed as alternative surgical options to manage distal Upper Tract Urothelial Cancer. This study aims to compare the surgical, oncological and functional outcomes of distal ureterectomy and Radical Nephroureterectomy for distal Upper Tract Urothelial Carcinoma. Methods and Material: Out of 57 patients with Upper Tract Urothelial Carcinoma treated surgically at a single institution between 2010 and 2016, nineteen patients had distal Upper Tract Urothelial Carcinoma. A retrospective review was performed on these 19 patients (11 Radical Nephroureterectomy and 8 distal ureterectomy). Radical Nephroureterectomy was performed using an open or laparoscopic approach (n= 4 and 7 respectively). All Distal Ureterectomy patients were performed via an open extra-peritoneal Gibson incision. Pelvic lymphadenectomy and Subsequent ureteroneocystostomy in the Distal Ureterectomy group was performed directly and was augmented by psoas hitch or using boari flap reconstruction. Demographic, clinical features and post-operative outcomes were compared between the Radical Nephroureterectomy and Distal Ureterectomy groups. Results: There was a trend towards shorter mean duration of surgery (238±34 vs. 286 ±90 min) and length of hospital stay (LOS) (7.6±2.8 vs. 17.3±20.7 days) in the Distal Ureterectomy group compared to the Radical Nephroureterectomy group (P=NS). Peri-operative Complication of Clavien grade 1-2 was seen in 4(33.33%) Radical Nephroureterectomy and 3 (37.5%) Distal Ureterectomy cases respectively. All patients had high grade Upper Tract Urothelial Carcinoma with equivalent pTNM staging in both groups with clear surgical margins. Immediate post-operative renal function improvement was statistically significant in the Distal Ureterectomy group (Radical Nephroureterectomy 2.27±5.93 vs 10.86±9.92 Distal Ureterectomy, p=0.034). Three out of 11 Radical Nephroureterectomy group patients required dialysis. Conclusions: Local recurrences were similar after Distal Ureterectomy and Radical Nephroureterectomy with equivalent pathological outcomes in distal Upper Tract Urothelial Carcinoma. There was a clear trend towards shorter hospital stay and better renal function preservation in favor of Distal Ureterectomy with fewer patients requiring dialysis.

Simultaneous Hand-assisted Laparoscopic Bilateral Native Nephrectomy and Kidney Transplantation for Patients With Large Polycystic Kidneys

To describe our technique of simultaneous hand-assisted laparoscopic bilateral native nephrectomy (BNN) and kidney transplantation (KT) in patients with autosomal dominant polycystic kidney disease and present our experience. We retrospectively reviewed a cohort of adult ESRD patients with symptomatic autosomal dominant polycystic kidney disease who underwent a hand-assisted laparoscopic BNN at the time of KT. We reviewed patients' and donor characteristics, and perioperative and postoperative outcomes. A total of 52 patients underwent hand-assisted laparoscopic BNN at the time of KT from January 2014 to October 2019. The median age of the recipients was 53.4 years, 57.7% were males, and the median body mass index was 29.0 kg/m2. All but one received a kidney from a living donor and the majority (86.5%) were pre-emptive. One patient required a small bowel resection due to an intraoperative small bowel injury. There was no solid organ injury during the procedure. All patients showed immediate allograft function and a steady decline in serum creatinine. The median decline in the creatinine and hemoglobin on day 1 was 1.2 mg/dL (inter quartile range 0.6-2.3) and 2.2 g/dL (inter quartile range 1.4-3.0), respectively. Simultaneous hand-assisted laparoscopic bilateral nephrectomy with KT through a modified Gibson incision is feasible and safe in the hands of an experienced laparoscopic surgeon without compromising allograft function.

Native Ureter Ventriculo-Ureteral Shunt Placement for Management of Refractory Hydrocephalus in a Child With a History of Renal Transplant: Case Report and Technical Note

This report describes the case of a 5-year-old male with intractable hydrocephalus secondary to neonatal intraventricular hemorrhage who was ultimately managed with the placement of a ventriculo-ureteral (VU) shunt. He had previously failed numerous attempts at cerebrospinal fluid shunting, choroid plexus cauterization, and endoscopic third ventriculostomy. The patient had a history of end stage renal disease, and had previously undergone renal transplant. In an operation that involved Neurosurgeons, Pediatric Urologists, and Transplant surgeons, a Gibson incision was used to avoid the patient's multiple intra-abdominal adhesions, and his nonfunctioning renal unit was used to implant a VU shunt without early or late complications.

Pure retroperitoneoscopic extravesical standardized seeable (PRESS) excision of distal ureter and bladder cuff in radical nephroureterectomy: step-by-step technique.

Concerns have been raised regarding the management of bladder cuff with these minimally invasive approaches. The aim of this study was to describe a modified radical nephroureterectomy (RNU) with pure retroperitoneoscopic extravesical standardized seeable (PRESS) bladder cuff excision (BCE) and to assess its outcomes based on a novel concept of intraoperative "trifecta." Twenty-four patients with upper urinary tract urothelial carcinoma underwent retroperitoneoscopic RNU from August 2017 to August 2019. A modified RNU with PRESS BCE and lymph node dissection (LND) was performed. Descriptive analysis of patients' characteristics, surgical technique, perioperative outcomes, and follow-up data was performed. BCE trifecta was defined as en-bloc excision, mucosa-to-mucosa reliable closure and no urine spillage. In 23 out of 24 cases (95.8%) the procedure was successfully completed. One patient was converted to open distal ureterectomy with a Gibson incision due to peritoneum rupture during dissection of the distal ureter. BCE trifecta was achieved in 95.7% (22/23) cases of all patients finished with PRESS technique. Median OT was 260 min (IQR: 220-305) with median EBL of 100 mL (IQR: 100-250). Median OT for distal ureterectomy was 52 min (IQR: 40-69). No positive surgical margin occurred. Median postoperative hospital stay was 6 d (IQR: 5-7). Median follow-up time was 7 mo (IQR: 5-17). One patient (4.3%) experienced bladder recurrence and no patient developed distant metastasis or died of the disease. Herein, we demonstrate a standardized retroperitoneoscopic RNU technique that is safe and reproducible, enabling the visual confirmation of complete BCE and facilitating LND. BCE trifecta should be a routine goal in minimally invasive RNU. Prospective comparison with the standard open surgical technique is warranted.

Pure retroperitoneoscopic extravesical standardized seeable (PRESS) excision of distal ureter and bladder cuff in radical nephroureterectomy: step-by-step technique.

Background Concerns have been raised regarding the management of bladder cuff with these minimally invasive approaches. The aim of this study was to describe a modified radical nephroureterectomy (RNU) with pure retroperitoneoscopic extravesical standardized seeable (PRESS) bladder cuff excision (BCE) and to assess its outcomes based on a novel concept of intraoperative trifecta. Methods Twenty-four patients with upper urinary tract urothelial carcinoma underwent retroperitoneoscopic RNU from August 2017 to August 2019. A modified RNU with PRESS BCE and lymph node dissection (LND) was performed. Descriptive analysis of patients' characteristics, surgical technique, perioperative outcomes, and follow-up data was performed. BCE trifecta was defined as en-bloc excision, mucosa-to-mucosa reliable closure and no urine spillage. Results In 23 out of 24 cases (95.8%) the procedure was successfully completed. One patient was converted to open distal ureterectomy with a Gibson incision due to peritoneum rupture during dissection of the distal ureter. BCE trifecta was achieved in 95.7% (22/23) cases of all patients finished with PRESS technique. Median OT was 260 min (IQR: 220-305) with median EBL of 100 mL (IQR: 100-250). Median OT for distal ureterectomy was 52 min (IQR: 40-69). No positive surgical margin occurred. Median postoperative hospital stay was 6 d (IQR: 5-7). Median follow-up time was 7 mo (IQR: 5-17). One patient (4.3%) experienced bladder recurrence and no patient developed distant metastasis or died of the disease. Conclusions Herein, we demonstrate a standardized retroperitoneoscopic RNU technique that is safe and reproducible, enabling the visual confirmation of complete BCE and facilitating LND. BCE trifecta should be a routine goal in minimally invasive RNU. Prospective comparison with the standard open surgical technique is warranted.

Management of ureteral endometriosis and review of the literature.

Endometriosis can affect 10-15% of the women in their reproductive age and it is characterized with the presence of the functional endometrium tissue outside the uterine cavity. Up to 10% of the cases with urinary system endometriosis may involve the ureter. Left distal ureter is the most common site of involvement. The differentiation between intrinsic and extrinsic endometriosis is very substantial for the selection and application of definitive treatment. Medical and surgical treatment alternatives are available for endometriosis management and histopathologic examination is required for definitive diagnosis. In this case report, a 33-year-old patient underwent segmental ureter excision and ureteroureteral anastomosis due to endometriosis causing obstruction in the left distal ureter. The operation was performed through a left Gibson incision and a 6 Fr double J stent was implanted in the ureter. The stent was removed after 4 weeks and the control magnetic resonance imaging-urography was performed at 3 months postoperatively. Obstruction and hydroureteronephrosis were observed to be completely regressed in control. If there is no other obvious etiology for the presence of unilateral hydroureteronephrosis in women in their reproductive age, the diagnosis of endometriosis should be considered.

Renal pyelocalyceal squamous cell carcinoma in a patient with an ectopic kidney presenting with chronic pyelonephritis: a case report

BackgroundUntil now, few cases of pelvis squamous cell carcinoma in various renal anomalies have been reported. To our knowledge, primary squamous cell carcinoma arising from a pelvic ectopic kidney has never been described. In this report, we describe a case of renal pyelocalyceal squamous cell carcinoma in a patient with an ectopic kidney presenting with chronic pyelonephritis.Case summaryA 73-year-old Caucasian woman presented to our hospital with pyelonephritis symptoms. Abdominopelvic computed tomography revealed heterogeneous and irregular minimal contrast enhancement in the pelvic ectopic kidney parenchyma. Radiologists reported that the images were consistent with chronic pyelonephritis. A Tc-99m dimercaptosuccinic acid renal scan demonstrated a nonfunctioning right pelvic ectopic kidney. The patient underwent open simple nephrectomy via modified Gibson incision. The whole mass was a distended, saclike structure without any grossly visible renal tissue. Pathological examination showed renal pelvis squamous cell carcinoma 8 cm in diameter infiltrating into the renal capsule and perinephritic fatty tissue. The patient was staged as T4N0M1 renal pelvis squamous cell carcinoma. The patient was being treated in the intensive care unit for respiratory distress on the seventh day after the operation. By the first-month follow-up visit, the patient had died of acute respiratory distress syndrome.ConclusionsAlthough rare, renal pelvis squamous cell carcinoma should be considered in the differential diagnosis of a renal mass in patients who have renal anomalies and chronic pyelonephritis.

Vessel Disposition Technique in Kidney Transplantation: Long-term Follow-up at Cho Ray Hospital, Vietnam

In this clinical serial, we would like to introduce a surgical technique for kidney transplantation (KTx) from living donor (LD); we call the vessel disposition technique (VDT), with long-term follow-up results. A prospective study at Cho Ray Hospital. The patients underwent the KTx from 1998-2011 and following-up until 2016. There were 201pts., 130 males (64.7%) and 71 females (35.3%). Average age is 33.56 ± 8.62 year old (yo), [15 to 61yo]. We divided it into two groups (at the back table and recipient surgical table): Group A: The Kidney graft (KG) with short vein (≤20 mm) was transplanted on right iliac fossa: 63/201pts. (31.34%), 13/63 from the left (20.63%) and 50/63 from the right (79.37%): the renal vein was dissected, liberated and prolonged; for the right KG, a renal VDT would be done. On the pts., right Gibson incision, made an iliac VDT: dissection of the right iliac vessels (RIV), moved the external iliac vein (IV) to the right side of the external iliac artery; and a termino-lateral venous anastomosis. The renal artery anastomosis would be done as usual. Group B: The KG with the long vein enough (>20 mm) was also transplanted on RIF: 138/201pts (68.66%). Usually, the KG is the left, the KTx was performing as usual, vascular postoperative follow-up by Doppler ultrasound. There wasn’t any surgical vascular complication during the average FU of: 8.0±3.44 years (group A) and 8.79±4.07 years (group B). During the long time follow-up on the serial, the VDT was satisfactory. The KTx from LD was safety for the short KG vein and we could perform on the right side of the pts for the left and the right KG. We could avoid other risky venous reconstructive techniques.

Spigelius' line incision as a successful route to extract the kidney during retroperitoneal laparoscopic live-donor nephrectomy

Objective To introduce the advantages, incision designing methods and surgical procedures of spigelius’ line incision in retroperitoneal laparoscopic living donor nephrectomy. Methods Among the 114 donors, 39 were obtained by spigeliu’line incision (13 males and 26 females), with an average age of 35 years, 35 left kidneys and 4 right kidneys. Gibson incision was performed in 75 patients (28 males and 47 females), with an average age of 31 years, 73 left kidneys and 2 right kidneys.The clinical data of 114 donors undergoing retroperitoneal laparoscopic living donor nephrectomy from September 2012 to July 2017 were analyzed retrospectively. The operation was performed by laparoscopic surgery to separate the ureter, renal vessels and perirenal fat. Finally, the renal vessels were removed and the kidneys were removed with hand-assistant. 75 cases were taken out of the kidney through the inguinal parallel incision(Gibson incision), while the other 39 cases used the spigelius’ line incision(Through the linea pararectalis, the anterior sheath is cut opened at the margin of the rectus sheath (spigelius’ line) and the lateral peritoneum is pushed into the midline between the arcuate line and the inferior abdominal vessels to expose the retroperitoneal space). The intraoperative data were collected. Results All the operations were not converted to open surgery. The incision length of the spigelius’ line incision group was (6.8±0.6)cm, and the incision length of the Gibson incision group was (7.0±0.4)cm, P=0.02. The blood loss of the operation of the spigelius’ line incision group was (59.2±33.4)ml, while the Gibson incision group was(80.7±32.8)ml, P=0.002. The warm ischemia time of the spigelius’ line incision group was (2.8±1.1)min, while the Gibson incision group was(3.1±1.7)min, P=0.31. The operation time of the spigelius’ line incision group was (160.8±30.7)min, while the Gibson incision group was(162.5±28.1)min, P=0.77. There was no significant difference between the two groups in the warm ischemia time and the operation time. No incisional hernia was found in these two groups. Conclusions Compared with Gibson incision, the spigelius’ line incision is safe. It can completely avoid to cut the abdominal muscles, and effectively avoid the abdominal nerves injury. Without damaging the integrity of the peritoneum, it can avoid abdominal organ injury. Key words: Living donor kidney transplantation; Retroperitoneal laparoscopes; Living donor nephrectomy; Incision

Uretero-appendicular fistula: A rare case mimicking ureterolithiasis in a child

Uretero-appendicular fistulas represents a rare entity, closely related to appendicitis and are usually encountered intraoperatively. A literature review showed six published cases –only one of them involving a pediatric patient. We describe the case of a ten year-old girl with history of recurrent urinary tract infections (UTIs) since the age of three. Following a six-year asymptomatic period, she was referred for evaluation after a new diagnosis of UTI complicated by a right distal ureteral stone. The patient underwent ureteroscopy and laser stone fragmentation. During the endoscopic procedure a mature, well-epithelialized ureteral tract to the peritoneal cavity was encountered. The procedure was converted to open exploration through a right Gibson incision, where an appendicular phlegmon associated with an uretero-appendicular fistula with passing of faecoliths to the ureteral lumen was found. An appendectomy was performed along with primary fistula closure. Uretero-appendicular fistulas represent a rare entity. Our case highlights the relation between this type of fistula with appendicitis, its unexpected intraoperative diagnosis and the unusual presentation, as the patient did not present clinical findings compatible with acute abdomen.

Minimally Invasive, Laparoscopic, and Robotic-assisted Techniques Versus Open Techniques for Kidney Transplant Recipients: A Systematic Review

ContextLiterature on conventional and minimally invasive operative techniques has not been systematically reviewed for kidney transplant recipients. ObjectiveTo systematically evaluate, summarize, and review evidence supporting operating technique and postoperative outcome for kidney transplant recipients. Evidence acquisitionA systematic review was conducted in PubMed–Medline, Embase, and Cochrane Library between 1966 up to September 1, 2016, according to Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Articles were included and scored by two independent reviewers using Group Reading Assessment and Diagnostic Evaluation (GRADE), Newcastle–Ottawa Quality Assessment Scale (NOS), and Oxford guidelines for level of evidence. Main outcomes were graft survival, surgical site infection, incisional hernia, and cosmetic result. In total, 18 out of 1954 identified publications were included in this analysis. Evidence synthesisIncluded reports described conventional open, minimally invasive open, laparoscopic, and robotic-assisted techniques. General level of evidence of included studies was low (GRADE: 1–3; NOS: 0–4; and Oxford level of evidence: 4–2). No differences in graft or patient survival were found. For open techniques, Gibson incision showed better results than the hockey-stick incision for incisional hernia (4% vs 16%), abdominal wall relaxation (8% vs 24%), and cosmesis. Minimally invasive operative recipient techniques showed lowest surgical site infection (range 0–8%) and incisional hernia rates (range 0–6%) with improved cosmetic result and postoperative recovery. Disadvantages included prolonged cold ischemia time, warm ischemia time, and total operation time. ConclusionsAlthough the level of evidence was generally low, minimally invasive techniques showed promising results with regard to complications and recovery, and could be considered for use. For open surgery, the smallest possible Gibson incision appeared to yield favorable results. Patient summaryIn this paper, the available evidence for minimally invasive operation techniques for kidney transplantation was reviewed. The quality of the reviewed research was generally low but suggested possible advantages for minimally invasive, laparoscopic, and robot-assisted techniques.

Femoral nerve palsy due to Iliopsoas hematoma

Femoral nerve palsy seconder to iliacus hematoma has been rarely reported in terms of blood coagulation abnormalities, either from anticoagulant medications or from hemophilia. The clinical symptoms vary from femoral neuropathy to fatal hypovolemic shock with increased used of anticoagulant agents; femoral nerve palsy subsequent to hemorrhage within the iliopsoas muscle has become a frequent clinical problem. In our case, a 73-year-old male patient presented to hospital with left leg pain and weakness. Lumbar magnetic resonance imaging (MRI) and abdomen computed tomography (CT) showed a left-sided iliopsoas hematoma. An extraperitoneal inguinal incision (Gibson incision) was made. The hematoma was superior of the external iliac artery in the iliopsoas muscle. It was nearly 8 cm deep and was drained and evacuated. After the operation, the left leg pain decreased, and the weakness of left leg improved (3/5).

Robotic kidney transplantation: current status and future perspectives.

For the treatment of patients with end-stage renal disease, kidney transplantation is preferred to renal replacement modalities such as hemodialysis and peritoneal dialysis. Although open surgery remains the gold standard, minimally invasive approaches have recently been applied in transplant kidney surgery. Despite growing enthusiasm and potential benefits of robotic kidney transplant, many aspects of this novel technique remain controversial. Aim of this study was to analyze the current status and future developments in robotic-assisted surgery for kidney transplantation. A systematic PubMed search for peer-reviewed studies was performed using keywords such as "Minimally invasive surgery" or "Robotic" or "Robot assisted" AND "Kidney transplantation". Eligible articles were reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Eleven studies evaluated reported the feasibility, safety, and reproducibility of robotic kidney transplantation using either a transperitoneal or an extraperitoneal approach. The graft kidney is usually introduced via a periumbilical or Gibson incision. The functional outcomes of the robotic approach are equivalent to those of open kidney transplantation in terms of mean serum creatinine at 6 month and delayed graft function. The benefits of robotic kidney transplantation include easier vascular anastomosis, better cosmetic results, and a lower complication rate, including in the obese population. Many concerns remain over the potential impairment of graft function due to pneumoperitoneum and warm ischemia and the technical difficulties related to the vascular anastomosis. Refinement of the robotic tactile feedback and development of a cold ischemia device may lead to further improvement in this novel technique. Robotic surgery allows kidney transplantation to be performed under optimal operative conditions, reducing complications while maintaining the functional results achieved by the open approach. The evolution of this technique is in progress.

Extraperitoneal pancreatic transplant

We describe a technique where pancreas transplants are positioned in the pre-peritoneal space with violation of only a few centimeters of the peritoneum necessary for the creation of the duodeno-enteric anastomosis. Retrieval and back-table of the pancreatic graft are performed in the standard fashion. After a Gibson incision is performed, the common and external iliac vessels are isolated and the head of the pancreas is laid in caudal position in the iliac fossa. The graft portal vein is anastomosed end-to-side to the recipient's common or external iliac vein. The arterial inflow is obtained anatomosing the “Y” iliac artery graft to the recipient's common or external iliac artery. After reperfusion, a 3–4 cm peritoneal incision in the medial aspect of the surgical field is performed and a loop of the recipient's small intestine is brought into the retroperitoneal space and anastomosed with a side to side or end to side to the free surface of the donor's duodenum without a Roux-en-Y intestinal loop. After completion of the duodeno-enteric anastomosis, the loop of intestine is repositioned in the peritoneal cavity and the suture line is approximated to the level of the recipient's peritoneal window. The advantages of this technique are several. Among them, the extra-peritoneal location of the pancreatic graft prevents formation of intestinal adhesions, facilitates percutaneous pancreatic graft biopsies and decreases the risk of diffuse peritonitis in patients who develop enteric leaks or peripancreatic infections.

MP64-20 RETROPERITONEOSCOPIC RADICAL NEPHRECTOMY WITH THE PATIENT IN A COMPLETELY SUPINE POSITION

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy III1 Apr 2016MP64-20 RETROPERITONEOSCOPIC RADICAL NEPHRECTOMY WITH THE PATIENT IN A COMPLETELY SUPINE POSITION Han-Yu Weng, Chien-Hui Ou, and Wen-Horng Yang Han-Yu WengHan-Yu Weng More articles by this author , Chien-Hui OuChien-Hui Ou More articles by this author , and Wen-Horng YangWen-Horng Yang More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.970AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We evaluated the feasibility of retroperitoneoscopic radical nephrectomy for renal cell carcinoma with the patient completely supine. METHODS From October 2006 to Oct 2015 hand assisted retroperitoneoscopic radical nephrectomy was performed in 62 patients with renal cell carcinoma. The patient was placed supine with the legs extended and abducted at 45 to 60 degrees, and the arms stretched out to the sides in the spread-eagle position. The patient was secured to the operation table with 3-inch tapes to permit lateral table tilt. The operation was completed via a 7 or 8 cm Gibson incision plus 2 laparoscopic ports. RESULTS All procedures were successful. The mean time needed for hand assisted retroperitoneoscopic radical nephrectomy was 127 minutes. Mean estimated blood loss was 167ml. Time to oral intake was 2.1 days and time to ambulation was 2.5 days. No specific complication was related to the position. All patients recovered to normal daily activity uneventfully. CONCLUSIONS Hand assisted retroperitoneoscopic radical nephrectomy with the patient completely supine is feasible and safe. The completely supine position has several advantages, including ease of patient positioning and the ability to avoid potential risks associated with the lateral decubitus position. Bowel interference with the visual field and mechanical bowel injury are not a concern using this approach. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e838 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Han-Yu Weng More articles by this author Chien-Hui Ou More articles by this author Wen-Horng Yang More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...