Laparoscopic Transperitoneal Research Articles

Laparoscopic Transperitoneal Ureterouretrostomy for Retrocaval Ureter-a Case Report.

Retrocaval ureter is a rare developmental anomaly with an incidence of 1 in 1500 births. The inferior vena cava compresses the ureter posteriorly, causing upstream dilatation of the proximal ureter and the kidney. We report a 16-year-old girl who presented with right flank pain, diagnosed as retrocaval ureter with ultrasound, intravenous urogram and CECT, and was treated with laparoscopic transperitoneal ureteroureterostomy. Embryological aspects and laparoscopic technical considerations are highlighted in this case report.

Minimally Invasive Management of Concomitant Vesicovaginal and Ureterovaginal Fistulas After Transabdominal Hysterectomy: Laparoscopic Vesicovaginal Fistula Repair With Ureteroneocystostomy Using a Boari Flap

Study ObjectiveTo demonstrate a laparoscopic approach for repair of concomitant vesicovaginal and ureterovaginal fistulas as a troublesome complication of transabdominal hysterectomy (TAH). DesignVideo presentation with narration demonstrating a laparoscopic approach for repair of a vesicovaginal fistula and ureter reimplantation using a bladder (Boari) flap (Canadian Task Force Classification III). SettingMothers and Children Hospital, Shiraz University of Medical Sciences. The local Institutional Review Board deemed this video exempt from formal approval. InterventionsThis 55-year-old woman had a history of continuous urine leakage from the vagina for 10 days after undergoing a complicated TAH. She had sustained an injury to the posterior bladder wall and right ureteral transection during TAH, which had been recognized and managed by ureteroneocystostomy into the posterior bladder wall over a double-J stent and bladder repair. A 4-week course of conservative therapy failed to manage her continuous urine leakage. After cystoscopic evaluation and catheterization of the fistula tract and left ureter, 4-port transperitoneal laparoscopy was performed. The right ureter was identified, divided, and mobilized. The vesicovaginal pouch was entered, the posterior wall of the bladder was opened at the level of the fistula, and the fistula tract was dissected. Once the bladder was separated from the vaginal cuff, both were repaired with absorbable sutures, and an omental flap was interposed between them. The Retzius space was developed, and a 7 × 2-cm bladder (Boari) flap was harvested from the anterior bladder wall to bridge the gap between the bladder and the ureter. After the bladder flap was tabularized, it was anastomosed to the right ureter, and the anterior bladder wall was closed. The total operating time was 250 minutes. Excellent laparoscopic visualization and magnification, along with the presence of a catheter in the fistula tract, allowed for meticulous dissection in the retrovesical space between the bladder and the vaginal cuff, as well as resection of the fistula tract with minimal manipulation of the bladder, without the need for a large cystotomy. The Foley and the ureter catheters were removed at 2 and 4 weeks after the operation, respectively. Intravenous pyelography at 3 months postsurgery showed no hydronephrosis, and the patient remained symptom-free during the follow-up period. ConclusionWith adequate laparoscopic experience and patient counseling, complex genitourinary fistulas can be approached with a minimally invasive technique. The laparoscopic approach provides excellent exposure to a poorly exposed area of the retrovesical space while minimizing bladder manipulation.

Robot-assisted laparoscopic transperitoneal infrarenal lymphadenectomy in patients with locally advanced cervical cancer by single docking: Do we need a backup procedure?

To present our initial experience on the feasibility of robotic transperitoneal para-aortic lymphadenectomy up to left renal vein via single docking approach by high port insertion technique followed by left shoulder docking as a rescue backup procedure in surgically obstructed patients undergoing surgical staging because of locally advanced cervical cancer (LACC). Prospective observational preliminary study. Canadian Task Force classification II-3. Tertiary-care academic affiliated private hospital. Ten patients with LACC who underwent robotic transperitoneal infrarenal para-aortic lymphadenectomy between January 2012 and December 2014. All patients with pathologically proven cervical cancer underwent a PET/CT scanning in a similar fashion at the department of nuclear medicine. PET/CT scans were evaluated by the nuclear medicine specialist. Following pre-operative work-up, robot-assisted transperitoneal infrarenal para-aortic lymphadenectomy was performed up to left renal vein by the same experienced surgeon. Sections of 5mm were performed and stained with routine hematoxylin and eosin (H&E), and node count was done separately by experienced gynecopathologist. During the study period, 12 consecutive patients with LACC were counseled for pre-therapeutic robot-assisted transperitoneal para-aortic lymphadenectomy. Two patients declined the procedure and underwent standardized chemo-radiation therapy whereas remaining ten patients constituted the study group. In the study group, the median age was 46years (range 33-59years), and the median body mass index 28.5kg/m2 (range 18.5-35.1kg/m2). Clinical staging was stage IIB in four patients, IIIB in four, and IVA in one. Histopathological diagnosis was squamous cell carcinoma in nine patients, and adenocarcinoma in one. On PET/CT scans, seven out of ten patients were positive for pelvic lymph node metastasis. With respect to para-aortic area, only one of the ten patients had suspected metastasis in PET/CT. For nine patients with LACC, the median docking time was 6.5min (range 4-15min), and the median operating time for para-aortic lymphadenectomy was 120min (range 60-165min). The median trocar time was 14.5min (range 5-45min). In two out of ten patients, the surgical removal of whole lymphatic tissue between inferior mesenteric artery and left renal vein was not completely possible by a single docking of robotic column. Therefore, a new optic trocar was placed in the umbilicus and the robotic column was relocated over the left shoulder of the patient and residual lymphatic tissue measuring approximately 2cm in the long axis immediately below the left renal vein was removed and the surgery was completed up to the left renal vein. All para-aortic lymphadenectomies have been completed by robotic route. There were no intra-operative complications. No patient received a blood transfusion. Early post-operative grade 2 and 3a complications according to Dindo classification occurred in two patients: one symptomatic lymphocyst and one local infection on assistant port site in one patient. The patient with suspected para-aortic lymph node metastasis in PET/CT showed no metastatic disease on histopathologic exam of para-aortic lymph nodes. The patient with recurrent disease and negative para-aortic lymph nodes on frozen section examination underwent robot-assisted total pelvic exenteration. Five of the residual eight patients had histologically proven metastasis in the para-aortic lymph node(s). Treatment modification occurred in six patients related to pre-treatment staging surgery. According to pathological results, extended field radiation therapy has been added in five patients and it was omitted in one patient. The median time interval between surgery and initiation of radiotherapy was 12days (range 6-23days). Robotic transperitoneal infrarenal para-aortic lymphadenectomy up to left renal vein by high port insertion technique is a safe and feasible option for staging and treatment planning. However, technically, it is obstructed in a small group of patients and nodal staging surgery up to left renal vein can be completed by consecutive left shoulder docking approach as a backup rescue plan.

Laparoscopic re-implantation of refluxing ureter in children: A feasibility study

ObjectiveTo report our initial experience in the application of laparoscopy in the management of children with unilateral vesico-ureteric reflux (VUR) using the laparoscopic extravesical transperitoneal approach following the Lich–Gregoir technique, and to evaluate the results and benefits of this technique for such patients. Patients and methodsBetween February 2013 and August 2014, 17 children [13 girls and four boys, with a median (range) age of 60 (24–120)months] presented with recurrent febrile urinary tract infections and were diagnosed with unilateral VUR. They underwent transperitoneal extravesical laparoscopic ureteric re-implantation following the Lich–Gregoir technique. Postoperatively abdomino-pelvic ultrasonography was done at 1month after surgery and voiding cystourethrography (VCUG) at 3months after surgery, and in cases with persistent VUR or de novo contralateral VUR another VCUG was done at 6months after surgery. ResultsThe median (range) operative time was 90 (80–120)min and the postoperative hospital stay was 2 (2–5)days. Intraoperative and postoperative complications were minimal. Patients were followed-up for a median (range) of 6 (3–21)months. All the children had complete resolution symptomatically and on VCUG, without further intervention. ConclusionsThe laparoscopic extravesical transperitoneal approach for ureteric re-implantation, following the Lich–Gregoir technique, is feasible and very effective in the management of VUR. Prospective randomised studies are eagerly awaited to define the benefits of this technique to patients, as well as to determine the cost-effectiveness of this approach.

Transperitoneal Intravesical Technique for Laparoscopic Ureteral Reimplantation to Treat Terminal Ureteral Stenosis.

To describe a newly developed transperitoneal intravesical technique for laparoscopic ureteral reimplantation in patients with terminal ureteral stenosis. Between July 2009 and May 2015, laparoscopic transperitoneal intravesical ureteral reimplantation was performed in 16 patients with terminal ureteral stenosis without vesicoureteral reflux (VUR). An incision was made in the superior bladder wall of the affected side with an electric hook. The bladder mucosa was then circumferentially cut away from the ureteral orifice to a distance of 0.5 cm, and the intramural portion of the ureter was freed from the bladder wall and dissected until 4 to 5 cm of terminal ureter was mobilized. The stenotic segment was resected, and a longitudinal cut was made in the mobilized ureter. The terminal ureter was then evaginated and sutured to the bladder wall to form a papilla. All patients underwent standard postoperative examinations. All of the 16 operations were successful, and none required conversion to an extravesical approach or open surgery. The operation time ranged from 85 to 135 minutes (mean 98 minutes), and the estimated blood loss was ∼30-60 mL (mean 42 mL). There were no obvious intraoperative or postoperative complications. Resolution of hydronephrosis was achieved in all 16 patients, and VUR of the operated ureter was not detected at postoperative follow-up. The transperitoneal intravesical technique of laparoscopic ureteral reimplantation that we describe was safe and feasible in our 16 patients and may be an alternative surgical treatment for terminal ureteral stenosis in patients without VUR.

Laparoscopic Transperitoneal Approach for Vesicovaginal Fistula Repair: the First Experience

Objective: To report our first experience in transperitoneal laparoscopic repair of vesicovaginal fistula in Dr. Hasan Sadikin Hospital.
 Method: A 31-year-old female presented with vesicovaginal fistula
 after cesarean section. Patient complained of urinary incontinence
 since 5 years ago. After a failed trial of conservative treatment with
 catheter drainage, a transperitoneal laparoscopic repair was performed.
 Initially, cystoscopy was performed to confirm the fistula location
 and for bilateral ureteric catheterization. A 4-port technique
 was performed with the patient in lithotomy position and slightly
 Trendelenburg. Without opening the bladder, the fistula tract was
 excised and the bladder was separated from the anterior vaginal
 wall. Both the bladder and vaginal walls were then closed separately
 using intracorporeal suturing, interposed with the omentum.
 Result: Total operative time was 270 minutes. Normal diet was resumed on day 1, drain was removed on the first day after surgery,
 and the patient was discharged on the second day with an indwelling
 catheter. Surgical wound showed good cosmetic result and no
 leakage was identified from cystogram after 2 weeks. The catheter
 was removed after 2 weeks.
 Conclusion: Laparoscopic transperitoneal repair of vesicovaginal
 fistula with omentum inteposition is feasible in Dr. Hasan Sadikin
 Hospital with good outcome, short hospital stay, and good cosmetic
 result.
 [Indones J Obstet Gynecol 2014; 4: 223-225]
 Keywords: laparoscopy, vesicovaginal fistula

Single-incision retroperitoneoscopic adrenalectomy: a North American experience.

Endoscopic adrenalectomy is currently performed using multiple ports placed either transabdominally or retroperitoneally. We report our initial experience with single-incision retroperitoneoscopic adrenalectomy (SIRA). A prospective database of patients undergoing adrenalectomy from December 2013 through March 2016 was analyzed. We adopted conventional retroperitoneoscopic adrenalectomy (CORA) in December 2013 and transitioned to SIRA in March 2015. SIRA was performed using three trocars placed through a single 2-cm incision below the 12th rib. Clinical characteristics and outcomes were compared between patients undergoing SIRA and CORA. One hundred and five adrenalectomies were performed in 102 patients: 34 laparoscopic transperitoneal, 24 CORA, 37 SIRA and 7 open. The SIRA and CORA groups were similar with respect to clinical characteristics (SIRA vs. CORA: mean BMI 27.0 vs. 28.8kg/m2, maximum BMI 38.9 vs. 44.3kg/m2; mean nodule size 3.2 vs. 3.2cm, maximum nodule size 8.0 vs. 6.0cm). One patient undergoing SIRA required placement of an additional 5-mm port because of extensive adhesions. No patients who underwent SIRA or CORA required conversion to open adrenalectomy. There were no deaths, and blood loss remained <10mL for all cases. Operative length was similar between SIRA and CORA (105 vs. 92min, P=0.26). In multivariable linear regression analysis, nodule size>5cm (effect=1.75, P<0.001) and pheochromocytoma (effect=1.30, P=0.05) were significant predictors of increased operative length for SIRA. BMI and laterality (right vs. left) did not affect operative length. Rates of postoperative temporary abdominal wall relaxation, length of stay and postoperative pain medication use were similar between the two groups. SIRA is safe and feasible to implement as a refinement of CORA and may be applied to technically challenging cases involving obese patients or large nodules. The use of three ports allows for two-handed dissection, which may shorten the learning curve for many surgeons.

Single-Port Laparoscopic Transperitoneal Infrarenal Para-Aortic Lymphadenectomy as Part of Staging Operation for Early Ovarian Cancer and High Grade Endometrial Cancer

Single-Port Laparoscopic Transperitoneal Infrarenal Para-Aortic Lymphadenectomy as Part of Staging Operation for Early Ovarian Cancer and High Grade Endometrial Cancer

Laparoscopic transperitoneal adrenalectomy in morbidly obese patients is not associated with worse short-term outcomes.

To evaluate the impact of obesity and morbid obesity on short-term outcomes after laparoscopic adrenalectomy. The study included 520 consecutive patients undergoing laparoscopic adrenalectomy for adrenal tumor. The entire study group was divided depending on the body mass index: group 1 (normal weight), <25 kg/m2 ; group 2 (overweight), 25-30 kg/m2 ; and group 3 (obese) 30-40 kg/m2 . Additionally, group 4 (morbidly obese) was distinguished. Study end-points were: operative time, intraoperative blood loss, total length of hospital stay, morbidity rate and 30-day readmission rate. The mean operative times were 88.8, 94.7, 93.5, and 99.9 min in groups 1, 2, 3 and 4, respectively (P = 0.1444). Complications were comparable between groups (12.8% vs 8.8% vs 8.2% vs 11.5%, P = 0.5295). The mean intraoperative blood loss was 66.8 versus 78.3 versus 60.7 versus 92.4, P = 0.1399. There were no differences in conversion rate between groups. Obesity has no influence on short-term outcomes of laparoscopic transperitoneal adrenalectomy. This procedure is feasible regardless of the body mass index. Therefore, it can be offered to all patient groups including those morbidly obese individuals in whose case preoperative weight loss seems unnecessary.

Outcome of laparoscopic upper pole heminephroureterectomy in children: A two-centre experience

ObjectiveTo report our multicentre experience and outcomes with laparoscopic transperitoneal and retroperitoneal upper pole heminephroureterectomy (HNU) in children with renal duplex systems and impaired upper pole. Patients and methodsLaparoscopic HNU was performed in 22 children (15 girls, seven boys) with a mean age of 5.9years. A retroperitoneal approach was used in 17 patients and a transperitoneal approach in the remaining five, between 2005 and 2010. Urinary tract infection was the initial presenting symptom in all children except for one with urinary retention caused by a large ureterocele. Voiding cystourethrography and renal scintigraphy revealed dual collecting systems on the right side in 11 and on the left in 11 cases. The upper pole collecting system was non-functioning in all cases. Postoperative ultrasonography was done at 1 and 3months, with renal scintigraphy at 3months, to check the remaining function of the lower moiety. ResultsOverall, the mean operation time was 152min (144min for retroperitoneal and 160min for transperitoneal). Blood loss was 10–50mL and there were no intraoperative complications. The mean (SD) hospitalisation and postoperative follow-up were 3.5 (1.25)days and 22 (9.83)months, respectively. Postoperative recovery was uneventful and at the 3-month follow-up renal scintigraphy revealed no parenchymal loss of the remaining renal moiety. ConclusionLaparoscopic HNU in children can be performed via transperitoneal or retroperitoneal approach, both with low morbidity and with the typical benefits of laparoscopic surgery.

Laparoscopic Resection and End-to-End Ureteroureterostomy for Midureteral Obstruction in Children.

Midureteral obstruction is an extremely rare condition. This retrospective study assessed the outcomes of laparoscopic ureteroureterostomy (UU) in 13 children with midureteral obstructions. Records of patients with midureteral obstruction who underwent laparoscopic end-to-end UU between July 2011 and August 2015 were reviewed. The medical records comprised patient demographic data, intraoperative details, postoperative outcomes, and related complications. Renal ultrasound, magnetic resonance urography, and radioisotope renography were used for pre- and postoperative assessment. Success was defined as removal of symptomatic obstruction or improvement of hydronephrosis. Thirteen patients from 3.0 months to 12 years old were identified: 6 patients presented with asymptomatic hydronephrosis (according to the renal ultrasonography), 3 with intermittent abdominal pain, and 2 with gross hematuria. The remaining 2 patients presented with urinary extravasation after inguinal hernia repair and the Soave procedure, respectively. All patients underwent laparoscopic end-to-end UU. Procedures were performed using either the laparoscopic transperitoneal approach or laparoscopic retroperitoneal approach. All surgeries were performed successfully except for one case that required open surgery because of difficult anastomosis. There were no intraoperative or immediate postoperative complications. The etiology of the midureteral obstruction included congenital midureteral stricture, ureteral polyp, retrocaval ureter, and iatrogenic injury. The mean surgical time was 148.4 min, and postoperative hospital stay was 4.0-9.0 d. Postoperative outcomes were successful in all 13 patients (100%); median follow-up was 19.1 months. Laparoscopic UU was found to be feasible and safe for the management of midureteral obstruction in children.

Bilateral adrenalectomy: a review of 10 years' experience.

INTRODUCTION The 2012 British Association of Endocrine and Thyroid Surgeons audit report showed that only 86 of 1359 patients who underwent adrenalectomy had a bilateral operation; thus the experience with this procedure remains limited. METHODS Retrospective review of patients undergoing bilateral adrenalectomy in a tertiary referral centre. RESULTS Between November 2005 and January 2016, bilateral adrenalectomy was performed in 23 patients (6 male, 17 female, age 43 ± 4 years) diagnosed with Cushing's disease (n = 13), hereditary phaeochromocytomas (n = 6), adrenocortical cancer (n = 2), colorectal metastatic disease (n = 1) and adrenocortical adenomas (n = 1). A laparoscopic transperitoneal approach was used in 17 patients, with one conversion to open. Three patients had open adrenalectomies for adrenocortical cancer and for simultaneous phaeochromocytomas and pancreatic neuroendocrine tumours in a patient with Von Hippel-Lindau syndrome. Three patients with Cushing's had a bilateral retroperitoneoscopic operation. The mean operating time was 195 ± 16 minutes for laparoscopic operations (n = 16), 243 ± 44 minutes for open adrenalectomies (n = 4) and 151 ± 12 minutes for retroperitoneal operations. It was significantly shorter for Cushing's disease than for phaeochromocytomas (162 ± 8 vs. 257 ± 39 minutes, P < 0.01). Median length of hospital stay was 5 days. Postoperative complications (Clavien-Dindo classification) included one chest infection (level 2), one postoperative haemorrhage and two chest drains for pneumothorax (level 3), two postoperative cardiac arrests (level 4) and one late cancer death from complications related to uncontrolled hypercortisolism (level 5). DISCUSSION Synchronous bilateral adrenalectomy remains an infrequent operation. The laparoscopic approach is feasible in the majority of patients. It is likely that the retroperitoneoscopic adrenalectomy will become the standard approach for bilateral operations.

How to Quantify Recovery After Laparoscopic Adrenalectomy: An Assessment of Patient-reported Health-related Quality of Life.

Minimally invasive approaches to adrenal surgery were adopted in an attempt to reduce surgical morbidity. Despite the widespread use, few studies objectively evaluate health-related quality of life (HRQOL) in patients undergoing laparoscopic adrenalectomy (LA). We assessed patients' health status and recovery after LA with the use of validated questionnaires. Patients seen in urology clinic for evaluation of adrenal surgery were enlisted in our prospective, patient-reported, HRQOL study assessing postoperative recovery. HRQOL was measured using Convalescence And Recovery Evaluation (CARE) and Short Form-12 questionnaires administered before surgery and at 2, 4, 8, 12 weeks and annually after surgery. All operations were performed using a laparoscopic transperitoneal approach by a single fellowship-trained surgeon. A total of 30 patients who met study inclusion criteria from July 2009 to November 2014 were included in our evaluation. Mean patient age was 53 years. Tumor size ranged from 2.0 to 5.5 cm and consisted of benign lesions, adrenal metastasis, and 1 adrenocortical carcinoma. Mean operative time was 98 minutes and median estimated blood loss was 50 mL. Median length of hospital stay was 1 day. Quality of life reflected by the CARE survey was impacted at 2 weeks postoperative and returned to baseline after 4 weeks. Pain and activity domains of CARE showed a significant decrease from baseline status. Physical component summary of Short Form-12 questionnaire supported the finding of negative impact of surgery on activity level within first 4 weeks of recovery. Despite minimally invasive approach, patients undergoing LA may require about 4 weeks to return to baseline activity, gastrointestinal, and pain status.

MP12-02 INCIDENTAL ADRENAL MASS: DO OUR RESULTS SUPPORT THE GUIDELINES?

You have accessJournal of UrologyAdrenal1 Apr 2016MP12-02 INCIDENTAL ADRENAL MASS: DO OUR RESULTS SUPPORT THE GUIDELINES? Paulo Dinis, Pedro Nunes, Arnaldo Figueiredo, Maria José Freire, Mario Lourenço, Belmiro Parada, and Alfredo Mota Paulo DinisPaulo Dinis More articles by this author , Pedro NunesPedro Nunes More articles by this author , Arnaldo FigueiredoArnaldo Figueiredo More articles by this author , Maria José FreireMaria José Freire More articles by this author , Mario LourençoMario Lourenço More articles by this author , Belmiro ParadaBelmiro Parada More articles by this author , and Alfredo MotaAlfredo Mota More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2442AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Incidental adrenal nodules are benign in their majority. It is recommended a functional study to detect subclinical hormonal hypersecretion. In nonfunctioning lesions with a diameter = 4cm surgery is indicated due to the increased risk of malignancy. Laparoscopic adrenalectomy is currently the surgical technique of choice with low complication rates. However there is a high rate of benign lesions excision. The objective of the study is to analyze our results evaluating the 4cm cut-off recommended by the guidelines. METHODS Retrospective study of 51 patients undergoing laparoscopic transperitoneal adrenalectomy in our department between March 2009 and June 2015. Of these, 25 (49%) were performed in the context of an imaging incidental finding of adrenal lesion and were the object of our study. We analyzed the histo-pathological findings and tried to gauge the real importance of size in distinguishing between benign and malignant lesions and if the 4cm recommended cut-off is suitable for surgical decision. RESULTS Most of the 25 analyzed patients women (60%) and the average age was 56 ± 3 years. Nine of incidental masses were located on the right (36%) and 16 on the left (64%) and the average size was 42 ± 5mm. All adrenalectomies were preceded by functional study, and 6 (24%) showed a subclinical hypersecretion (aldosterone - 33.3%, catecholamines - 50%; DHEA - 16.7%). The functioning masses had an average size of 37 ± 11mm. The nonfunctioning operated masses (76%) had an average size of 44 ± 5 mm. Overall, the pathological examination of the pieces revealed 11 adenomas (44%), 4 pheochromocytomas with benign features (16%), 3 carcinomas (12%) and 7 of other nature (28%). Regarding only nonfunctioning masses, there were 9 adenomas (47.4%), 2 benign pheochromocytoma (10.5%), 2 carcinomas (10.5%) and 6 of other nature (31.6%). Adenomas (31 ± 4mm) were significantly smaller than carcinomas (57 ± 13mm) - p 0.027. Eleven of the nonfunctioning incidental masses were larger than 40mm, and two of these were carcinomas (18.2%). None of the 8 masses with size < 40mm revealed no malignancy. These data translate into a sensitivity of 100% and a specificity of 47.1% for cancer detection using the 4cm cut-off size for nonfunctioning operated incidental adrenal masses. CONCLUSIONS The size of the incidental nonfunctioning lesions of the adrenal gland significantly influences the risk of malignancy and therefore the decision to perform surgical treatment. In our series, the usually recommended 4cm cut-off despite having a sensitivity for malignant lesions of 100%, showed a specificity of only 47.1%. Other features should be evaluated to try to increase specificity and reduce the excision of benign nonfunctioning lesions. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e126 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Paulo Dinis More articles by this author Pedro Nunes More articles by this author Arnaldo Figueiredo More articles by this author Maria José Freire More articles by this author Mario Lourenço More articles by this author Belmiro Parada More articles by this author Alfredo Mota More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

UROLOGY RETROPERITONEOSCOPY: INITIAL EXPERIENCE IN CIPTO MANGUNKUSUMO HOSPITAL

Objective: This study was conducted to evaluate the initial experience of retroperitoneoscopy surgery. Material &amp; method: This is a descriptive study with cross-sectional design. Data was collected from medical records of Urology Department in Cipto Mangunkusumo General Hospital Jakarta, from March 2013 until February 2014. Subjects were all patients who performed retroperitoneoscopic surgery between the time periods. Results: Patients consisted of 9 males (42.85%) and 11 females (57.14%). Mean age was 38.95 + 21.88 years old. Proportion based on diagnosis were 5 renal failures (23.8%), 5 ureteral stones (23.8%), 3 renal cysts (14.3%), 2 PUJOs (9.5%), double 3 collecting systems (14.3%), 1 tumor (4.8%), 1 ureteral tumor (4.8%), and 1 renal diverticle (4.8%). Proportion based on kind of retroperitoneoscopy were ureterolithotomy (23.8%), nephrectomy 3 (14.3%), nephroureterectomy 3 (14.3%), renal cyst unroofing 3 (14.3%), heminephrectomy 3 (14.3%), pyeloplasty 2 (9.5%), partial nephrectomy 1 (4.8%), and diverticle coagulation 1 (4.8%). Mean operating time was 178.81 + 55.72 minutes with mean length hospitalization 8.05 + 4.4 days. Mean amount of bleeding was 98 + 69.47 cc, wound operation infection 0 (0%), peritoneal perforation 1 (4.76%), open surgery conversion 2 (9.52%), and transperitoneal laparoscopy conversion 1 (4.76%). Conclusion: In this study, total number of retroperitoneoscopy surgery cases still less than others abroad. Demographic characteristic showed variety than other study. Compared to other studies, the operating time was comparable but the length of stay was longer. We had higher open surgery conversion rate, while another complication was relatively the same.

Outcomes of Re-Intervention for Laparoscopic Transperitoneal Pyeloplasty in Children.

There is no consensus for the management of failed laparoscopic pyeloplasty in pediatric surgical patients, and only limited publications are available. We evaluated here the clinical outcomes of re-intervention for failed laparoscopic transperitoneal pyeloplasty in infants and children. Retrospective review of all children who had undergone laparoscopic transperitoneal dismembered Anderson-Hynes pyeloplasty for ureteropelvic junction obstruction from 2002 to 2013 was performed. Patients' demographics, indications, operative details, and outcomes for primary operation as well as re-intervention were studied. There were 42 patients with a median age of 20 months (range, 3-192 months) and a median body weight of 12 kg (range, 6-56 kg) who underwent a total of 46 laparoscopic transperitoneal pyeloplasties during the study period. The median operative time and blood loss were 193 minutes (range, 115-480 minutes) and trace amount (range, trace amount to 400 mL), respectively. No conversion was reported. Ten cases (22%) required re-intervention. No statistically significant risk factor for failed pyeloplasty was identified. Indications for re-intervention included deterioration of differential renal function (n = 6), progressive hydronephrosis (n = 1), urinary ascites (n = 2), and urosepsis (n = 1). Median time of re-intervention was 6.5 ± 38 months postpyeloplasty. Re-intervention was categorized into the redo pyeloplasty group (n = 6) and the urinary diversion group (n = 4) (insertion of double-J ureteral stent or endopyelotomy) with success rates of 50% and 25%, respectively. Among the redo pyeloplasty group, 3 patients underwent redo laparoscopic pyeloplasty, and all of them had drainage restored with a median improvement in differential renal function of 11%. The mean follow-up duration was 77 ± 38 months. Laparoscopic transperitoneal pyeloplasty is safe and feasible in children. Redo pyeloplasty is a more favorable re-intervention compared with urinary diversion in our series. Redo laparoscopic pyeloplasty has been shown to improve differential renal function.

Single-port laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy as part of staging operation for early ovarian cancer and high grade endometrial cancer.

ObjectiveThe aim of this paper was to demonstrate the techiniqes of single-port laparoscopic transperitoneal infrarenal paraaortic lymphadenectomy as part of surgical staging procedure in case of early ovarian cancer and high grade endometrial cancer.MethodsAfter left upper traction of rectosigmoid, a peritoneal incision was made caudad to inferior mesenteric artery. Rectosigmoid was mobilized, and then the avascular space of the lateral rectal portion was found by using upward traction of rectosigmoid mesentery. Inframesenteric nodes were removed without injury to the ureter and the left common iliac nodes were easily removed due to the upward traction of the rectosigmoid. The superior hypogastric plexus was found overlying the aorta and sacral promontory, and presacral nodes were removed at subaortic area. Peritoneal traction suture to right abdomen was needed for right para-aortic lymphadenectomy. After right lower para-aortic node dissection, operator was situated between the patient’s legs. After upper traction of the small bowel, left upper para-aortic nodes were removed. To prevent chylous ascites, we used hemolock or Ligasure application (ValleyLab Inc.) to upper part of infrarenal and aortocaval nodes.ResultsSingle-port laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy was performed without serious perioperative complications.ConclusionEven though the technique of single-port surgery is still a difficult operation, the quality of single-port laparoscopic transperitoneal infrarenal para-aortic node dissection is excellent, especially mean number of para-aortic nodes. In cases of staging procedures for ovary and endometrial cancer, single-port transperitoneal para-aortic lymphadenectomy is acceptable as an oncologic procedure.

Large proximal ureteral stones: Ideal treatment modality?

Background and Purpose:Ideal treatment modality for patients with large impacted proximal ureteral stone remains controversial. We compared laparoscopic transperitoneal ureterolithotomy (Lap-TPUL) and semirigid ureteroscopy for large proximal ureteric stones to evaluate their efficacy and safety.Patients and Methods:From November 2012 to December 2014, we enrolled 122 patients with large (≥1.5 cm) proximal ureteral stone in the study. Patients were randomly divided into two groups: Group A (60 patients), retrograde ureteroscopic lithotripsy using a semirigid ureteroscope; Group B (62 patients), transperitoneal LU (Lap-TPUL).Results:The overall stone-free rate was 71.6% and 93.5% for Group A and Group B respectively (P = 0.008). Auxiliary procedure rate was higher in Group A than in Group B (27.3% vs. 5.6%). The complication rate was 11.2% in Group B versus 25% in Group A. Mean procedure time was higher in laparoscopy group as compared to ureterorenoscopy (URS) groups (84.07 ± 16.80 vs. 62.82 ± 12.71 min). Hospital stay was 4.16 ± 0.67 days in laparoscopy group and 1.18 ± 0.38 days in URS group (P < 0.0001).Conclusion:Laparoscopic transperitoneal ureterolithotomy is a minimally invasive, safe and effective treatment modality and should be recommended to all patients of impacted large proximal stones, which are not amenable to URS or extracorporeal shock-wave lithotripsy or as a primary modality of choice especially if patient is otherwise candidate for open surgery.

Laparoscopic Anterior Adrenalectomy and Paraganglioma Resection in an Adolescent

Abstract Pheochromocytomas and paragangliomas are rare neuroendocrine tumors in the pediatric population; however, they represent the most common endocrine tumor in childhood. We present a 16-year-old male treated laparoscopically for concurrent left adrenal pheochromocytoma and a paraganglioma located at the Organ of Zuckerkandl. His medical history was significant for headaches, and idiopathic erythrocytosis managed with repeated phlebotomy and saline infusions. Due to vision changes in his right eye, an ophthalmologic examination was performed with evidence of papilledema. An episode of malignant hypertension developed requiring intensive care unit admission and systematic evaluation. Computed tomography of the abdomen and pelvis demonstrated a mass in the left adrenal gland and another mass inferior to the aortic bifurcation. Alpha-blockade and volume resuscitation were performed. Briefly, with the patient in the modified lithotomy position, a laparoscopic transperitoneal (anterior) resection of a bil...

A Novel and Simple Modification for Management of Distal Ureter During Laparoscopic Nephroureterectomy Without Patient Repositioning: A Bulldog Clamp Technique and Description of Modified Port Placement.

To describe a novel and pure laparoscopic approach using a custom-made bulldog clamp with modified port placement for management of distal ureter during laparoscopic nephroureterectomy. Between October 2013 and December 2014, 31 patients found to have upper tract urothelial carcinoma were treated using this technique. After finishing a standard laparoscopic transperitoneal nephrectomy in a 45° to 60° recumbent position, an additional 12-mm trocar was inserted at the lower abdomen to allow the surgeon to continue dissecting the ureter caudally toward the bladder wall without repositioning the patient. The intramural ureter was separated from the surrounding detrusor muscle and down to the bladder mucosa, until a tent-shaped bladder cuff and intramural ureter could be formed by retraction in the superior and lateral directions. Then, a custom-made laparoscopic bulldog clamp was placed at the bottom of the tent-shaped structure to prevent urine spillage, and the bladder was closed by two-layer running closure using a barbed suture. All surgeries were completed uneventfully. The mean operative time and estimated blood loss were 146.6 minutes and 47.3 mL, respectively. The median duration of the postoperative hospital stay was 6 days. No complications were noted. There were no positive margins in any specimen. No patients experienced stone formation or local or bladder recurrence during the 10.5-month follow-up period. Our novel technique fully replicates the open excision technique and conforms to the strictest oncologic principles while avoiding patient repositioning and the use of staplers (EndoGIA or Hemolock) to prevent stone formation.