Laparoscopic Urologic Surgery Research Articles

Laparoscopic Transperitoneal Nephrectomy is Feasible in the First Year of Life and is Not Affected by Kidney Size

We analyzed the feasibility of laparoscopic nephroureterectomy in children younger than 1 year, with regard to size of impaired kidney. A total of 40 consecutive children underwent transperitoneal laparoscopic nephrectomy during a 4-year period. Of the patients 19 (48%) were younger than 1 year and were analyzed in detail. Nine of these patients (47.4%) had a multicystic dysplastic kidney, 9 (47.4%) had reflux nephropathy and 1 (5.3%) had obstructive nephropathy. The duration of operation, reasons for conversion, and intraoperative and postoperative complications were prospectively documented. Mean operative time was 133 minutes (range 60 to 240), and did not differ significantly between patients up to age 12 months compared to children 1 year and older (126 vs 148 minutes, NS). Nephroureterectomy was completed laparoscopically in 17 of 19 children (89%) up to age 12 months vs 20 of 21 (95%) 1 year and older (NS). In 1 child younger than 1 year suture dislocation at the renal artery required laparoscopic resuturing. No further complications were seen. In children younger than 1 year the mean operating time was not significantly different for resection of multicystic dysplastic kidney (8 patients, 113 minutes) compared to reflux nephropathy (9, 134 minutes, NS). Mean operating time did not differ significantly for kidney volumes less than 10 cc (8 patients, 119 minutes) compared to kidney volumes greater than 10 cc (9, 129 minutes, NS). The feasibility of transperitoneal laparoscopic nephroureterectomy in children younger than 1 year is excellent. The duration of operation is not affected by patient age, underlying disease or kidney size.

Robotic-Assisted Laparoscopic Correction of Pediatric Retrocaval Ureter

Journal of Laparoendoscopic & Advanced Surgical TechniquesVol. 16, No. 4 Case ReportsRobotic-Assisted Laparoscopic Correction of Pediatric Retrocaval UreterMohan S. Gundeti, Patric G. Duffy, and Imran MushtaqMohan S. GundetiSearch for more papers by this author, Patric G. DuffySearch for more papers by this author, and Imran MushtaqSearch for more papers by this authorPublished Online:12 Sep 2006https://doi.org/10.1089/lap.2006.16.422AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byUréter retrocavoEMC - Urología, Vol. 54, No. 3Proximal and Mid-Ureteral Reconstruction in the Pediatric Population6 November 2021Proximal Ureteral Reconstruction: Ureteroureterostomy, Buccal Mucosa Graft, Retrocaval Ureter6 November 2021Robotics in Pediatric Urology30 October 2022Robotic Ureteral ReconstructionUrologic Clinics of North America, Vol. 48, No. 1Laparoscopic retroperitoneal approach for retrocaval ureter in children11 June 2019 | World Journal of Urology, Vol. 38, No. 8Laparoscopic and robotic transperitoneal repair of retrocaval ureter: A comparison of the surgical outcomes from two centres with a comprehensive literature reviewJournal of Minimal Access Surgery, Vol. 16, No. 2Laparoscopic and robotic-assisted repair of retrocaval ureter in children: a multi-institutional comparative study with open repair5 December 2018 | World Journal of Urology, Vol. 37, No. 9Diagnosis and laparoscopic management of retrocaval ureter: A review of the literature and our case seriesInternational Journal of Surgery Case Reports, Vol. 59Transperitoneal laparoscopic ureteroureterostomy with excision of the compressed ureter for retrocaval ureter and review of literatureInvestigative and Clinical Urology, Vol. 60, No. 2High retrocaval ureter: An unexpected intraoperative finding during robotic redo pyeloplastyUrology Case Reports, Vol. 20Role of Robotics in Children: A brave New World!European Urology Focus, Vol. 3, No. 2-3Robotic surgery in pediatric urologyAsian Journal of Urology, Vol. 4, No. 1Retroperitoneoscopic ureteroplasty for retrocaval ureter: report of nine cases and literature review6 May 2016 | Scandinavian Journal of Urology, Vol. 50, No. 4Current perspectives in robotic assisted pediatric surgeryApollo Medicine, Vol. 11, No. 3Bladder and Ureteral Imaging18 November 2013Robot-Assisted Surgery: Current Status Evaluation in Abdominal and Urological Pediatric Surgery Yann Chaussy, François Becmeur, Hubert Lardy, and Didier Aubert3 June 2013 | Journal of Laparoendoscopic & Advanced Surgical Techniques, Vol. 23, No. 6Early experience in robotic-assisted laparoscopic bilateral intravesical ureteral reimplantation for vesicoureteral reflux in children11 June 2011 | Journal of Robotic Surgery, Vol. 6, No. 3Robotic repair of retrocaval ureter: A case seriesAfrican Journal of Urology, Vol. 18, No. 3Robotic paediatric urology19 March 2012 | BJU International, Vol. 110, No. 1Ectopic Ureter, Ureterocele, and Ureteral AnomaliesComplex robotic reconstructive surgical procedures in children with urologic abnormalitiesCurrent Opinion in Urology, Vol. 21, No. 4Robot-Assisted Laparoscopic Reconstruction of Retrocaval Ureter: Description and Video of Technique Timothy J. LeRoy, David D. Thiel, and Todd C. Igel12 May 2011 | Journal of Laparoendoscopic & Advanced Surgical Techniques, Vol. 21, No. 4Ureteral Defects and Retrocaval Ureter3 February 2012Robotic Surgery Complications and Safety3 February 2012Uretère rétrocaveEMC - Urologie, Vol. 4, No. 1Uréter retrocavoEMC - Urología, Vol. 43, No. 2Experience With Robot Assisted Laparoscopic Surgery for Upper and Lower Benign and Malignant Ureteral PathologiesUrology, Vol. 76, No. 6Retroperitoneal Laparoscopic Ureteroureterostomy for Retrocaval Ureter: Report of 10 Cases and Literature ReviewUrology, Vol. 76, No. 4Retrocaval ureter with stone in the retrocaval segment of the ureter30 April 2010 | Pediatric Surgery International, Vol. 26, No. 8Robot-assisted laparoscopic ureteroureterostomy for proximal ureteral obstructions in childrenJournal of Pediatric Urology, Vol. 5, No. 6Laparoscopic Repair of Circumcaval Ureter: One-year Follow-up of Three Patients and Literature ReviewUrology, Vol. 74, No. 1Robotic-Assisted Laparoscopic Surgery in Pediatric Urology: An Update1 June 2009 | Scandinavian Journal of Surgery, Vol. 98, No. 2Other Robotic-Assisted Laparoscopic Genitourinary Operations30 July 2009Pure robotic retrocaval ureter repairInternational braz j urol, Vol. 34, No. 6Robotic Surgical Technique for Pediatric Laryngotracheal ReconstructionOtolaryngologic Clinics of North America, Vol. 41, No. 5Origin of the Infrarenal Part of the Caudal Vena cava in the PigAnatomia, Histologia, Embryologia, Vol. 37, No. 5Current status of robotic surgery in pediatric urology31 July 2008 | Pediatric Surgery International, Vol. 24, No. 9Right Retrocaval Ureter and Left Nutcracker Syndrome: A Case ReportUrology, Vol. 71, No. 6Robotic Pediatric Urology11 August 2008 Volume 16Issue 4Aug 2006 InformationCopyright 2006, Mary Ann Liebert, Inc.To cite this article:Mohan S. Gundeti, Patric G. Duffy, and Imran Mushtaq.Robotic-Assisted Laparoscopic Correction of Pediatric Retrocaval Ureter.Journal of Laparoendoscopic & Advanced Surgical Techniques.Aug 2006.422-424.http://doi.org/10.1089/lap.2006.16.422Published in Volume: 16 Issue 4: September 12, 2006PDF download

Robotic surgery for ureteropelvic junction obstruction

Robotic surgery for ureteropelvic junction obstruction is an evolving technique. We review the current literature related to this technique and discuss the current technique and outcomes of robotic pyeloplasty. Recent advances in robotic-assisted surgery have allowed the successful completion of complex reconstructive procedures in the pediatric population, including the robotic-assisted laparoscopic pyeloplasty. Robotic-assisted laparoscopic pyeloplasty can be performed by either a transperitoneal or a retroperitoneal approach. Overall, the procedure is safe, efficacious, and may have particular benefits over open surgery. The evolution of laparoscopic surgery in pediatric urology has been limited by the challenge of laparoscopic suturing. Robotic systems may offer the means to overcome this major impediment of laparoscopic surgery. The results of this review demonstrate that robotic-assisted laparoscopic pyeloplasty is safe, technically feasible, and efficacious in the pediatric population, and may be comparable to a contemporary series of open pyeloplasty. As the technology continues to evolve, the efficiency of the robotic system is likely to improve; however, the ultimate role of robotic-assisted or computer-assisted surgical systems remains unclear. To further determine the role of robotic systems in the management of ureteropelvic junction obstruction, rigorous prospective research is needed that combines surgical and technical outcomes with overall subjective or cosmetic outcome and economic analysis.

Retroperitoneoscopic Renal Surgery in Children: Our Experience

Laparoscopic renal surgery has become an accepted approach for benign disease in adult and pediatric urology. We present our experience in renal laparoscopy in infants during the past 5 years and evaluate our series to establish the safety and efficacy of such procedures in children. From August 1999 to December 2004, we performed 32 renal laparoscopic procedures on 31 children aged 12 months to 16 years (mean, 42 months). Twenty-seven patients underwent unilateral retroperitoneal nephrectomy; 1 child with Denis Drash syndrome underwent transperitoneal bilateral nephrectomy; 2 children underwent renal cyst unroofing; and 1 child with lymphoma underwent retroperitoneal laparoscopic renal biopsy. Indications for surgery were: renal function <9% in cases of unilateral nephrectomy; the prevention of renal neoplastic changes in the patient with Denys-Drash syndrome; symptomatic large renal cysts; and suspected lymphoma not diagnosed with a previous percutaneous biopsy. All procedures were completed laparoscopically. In 6 cases, the accidental opening of the peritoneum did not require conversion to open surgery. Intraoperative blood loss was minimal. One patient who underwent a retroperitoneal nephrectomy required a blood transfusion for postoperative bleeding into the retroperitoneal space. Twenty-four of 27 unilateral retroperitoneal nephrectomy patients were discharged on postoperative day 2. Mean follow-up was 30 months (range, 6-64 months). Cosmetic results were excellent in all patients and no long-term complications have been encountered so far. Laparoscopic urologic surgery may be performed in children with minimal morbidity, minimal postoperative discomfort, improved cosmetic results, and a short hospital stay.

Methods of training using pelvic trainers

During the past decade, the clinical applications of laparoscopic surgery in urology have been growing steadily. The laparoscopic version of various procedures, such as nephrectomy, is becoming the standard of care. This has led to an increased need for laparoscopic training in urology and focused the attention on the various modalities for laparoscopic skill acquisition. The common training modalities for laparoscopy are box trainers, animal and cadaveric laparoscopy, and virtual reality simulators. Each modality carries its own benefits to the practicing surgeon. The box trainers are the first practiced and are basic training simulators. They were first designed to help with training in basic laparoscopic skills and to assist surgeons in getting acquainted with instruments. However, these simple boxes are being upgraded constantly by tissue- and organ-specific models, allowing the surgeon to train in a convenient and cost-effective environment. This article describes the ways to work with box trainers, from basic skills to advanced laparoscopic tasks, and discusses the contribution of these trainers to real surgery as well as their role in defining criterion levels of surgical performance.

84: Management of Intraoperative Splenic Injury During Laparoscopic Urologic Surgery

84: Management of Intraoperative Splenic Injury During Laparoscopic Urologic Surgery

Hemodynamic and Respiratory Effects of Pediatric Urological Retroperitoneal Laparoscopic Surgery: A Prospective Study

Our understanding of the effects of retroperitoneal CO(2) insufflation on cardiopulmonary variables in children remains limited. This study was designed to investigate prospectively the effect of CO(2) insufflation in a pediatric population undergoing retroperitoneal laparoscopic surgery. We prospectively evaluated a consecutive series of patients enrolled between July 2003 and August 2004. Anesthesia was administered following a standardized protocol. Data collection included respiratory rate, PAP, O(2) saturation, ETCO(2), HR, MAP, electrocardiogram and insufflation pressure. All variables were recorded before, during and after CO(2) insufflation at regular intervals of 1 to 2 minutes, with up to 23 measurements recorded for each period. A total of 18 participants were recruited. Mean +/- SD for age and weight were 79.4 +/- 53.2 months and 26.7 +/- 15.5 kg, respectively. Mean retroperitoneal CO(2) insufflation pressure was kept at 12 mm Hg. Significant differences (p <0.05) in average ETCO(2), PAP and MAP were noted after CO(2) insufflation compared to baseline (pre-pneumoretroperitoneum) values. HR and temperature did not change. At completion of the laparoscopic intervention physiological variables exhibited a trend to return to baseline values. This prospective study documents significant changes in systemic hemodynamic variables that seem to be directly associated with the insufflation of CO(2) during pediatric retroperitoneal laparoscopic surgery. This ongoing evaluation confirms the effect of laparoscopic urological surgery and CO(2) insufflation on cardiopulmonary function in children.

55 Local anaesthetic reduces postoperative analgesic requirements in laparoscopic urological surgery

Objective: To determine if local anaesthetic reduces patient discomfort following laparoscopic urological surgery.Methods: Sixty‐seven patients undergoing laparoscopic urological surgery were randomly assigned to either the treatment (0.5% bupivacaine) arm or the placebo (0.9% normal saline) arm. Patients, surgeon and data collector were blinded. The port sites and the hand assist port site (when present) were infiltrated at the outset of the procedure. Postoperative pain was determined with a standardized 10 point visual analog scale at consistent intervals.Results: Thirty‐three individuals were treated with the placebo (13 standard laparoscopic [SL] and 20 hand assisted laparoscopic [HALS]) and 34 with bupivacaine (17 SL and 17 HALS). Average pain scores for the placebo vs. bupivacaine group at 4, 12, 24 h were 3.9, 3.1, 3.6 vs. 3.0, 2.1, 2.0 (P &lt; 0.10). Mean use of morphine for the placebo group vs. bupivacaine group was: 26.1 mg (range 0–91.9) vs. 15.4 mg (range 0–49.5) at 12 h (P &lt; 0.05), 43.5 mg (range 0–136.9) vs. 26.2 mg (range 0–71.0) at 24 h (P = 0.07) and 50.4 mg (range 0–154.9) vs. 28.3 mg (range 0–71.0) for total hospital stay (P &lt; 0.05). In multivariable anova, use of bupivacaine, but not SL vs. HALS, was associated with reduced morphine use at all three time points (P &lt; 0.05).Conclusions: At the outset of laparoscopic urological surgery in the upper retroperitoneum, port site and other incision infiltration with a long acting local anaesthetic reduces postoperative parenteral opioid requirements when compared with placebo controls.

Pediatric Robotic-Assisted Laparoscopy: A Description of the Principle Procedures

The advent of clinically useful robotic devices to facilitate reconstructive laparoscopic surgery in pediatric urology opens new doors to minimally invasive procedures. Previously limited by the challenge of delicate suturing and reconstruction using conventional laparoscopic instruments, robotic assistance offers a more rapid climb up the learning curve. Initial procedures that have been safely and efficaciously performed with robotic assistance include nephrectomy, partial nephrectomy, pyeloplasty, and antireflux surgeries. These techniques and their outcomes will be reviewed, as well as some of the challenges still posed by this methodology.

Serum Laboratory Values Following Uncomplicated Laparoscopic Urological Surgery

Serum Laboratory Values Following Uncomplicated Laparoscopic Urological Surgery

Physiological effects of pediatric urological laparoscopic surgery

There is an increasing trend of laparoscopy in pediatric urological practice with more complex and reconstructive procedures being performed in smaller children. The physiological impact of these procedures is not well documented in the pediatric literature and cannot be simply extrapolated from the adult data. This article reviews the current pediatric literature on the physiological effects of both transperitoneal and retroperitoneal laparoscopy. The clinical implication of these changes and the need for proper monitoring is stressed. As surgeons strive to stretch the indications of laparoscopy in pediatric urological practice, the overall beneficial effects of laparoscopy must be balanced with these potential hemodynamic and respiratory changes.

Serum Laboratory Values Following Uncomplicated Laparoscopic Urological Surgery

Presentation of complications following laparoscopic surgery can be different from corresponding open surgical complications. While leukopenia has been identified as a common finding in patients with unrecognized bowel injury following laparoscopy, to our knowledge no study has determined if leukopenia or other serum abnormalities are unique to patients with laparoscopic complications. We present an analysis of postoperative laboratory values from patients after uncomplicated urological laparoscopic surgery. A retrospective review of 50 adult patients who had previously undergone uncomplicated laparoscopic urological procedures was performed. Exclusion criteria were preexisting hematological, immune, liver or pancreatic disorders. Common serum laboratory values were measured on postoperative day 1. All values for bilirubin were within normal limits. Of patients undergoing a right side renal procedure, 10 of 16 (63%) had a postoperative increase in liver function tests. Amylase or lipase was increased in a total of 12 (24%) patients. Patients undergoing laparoscopic prostatectomy accounted for the majority of this group with 9 of 21 (43%) patients having increased amylase or lipase. Finally, there were no patients with immediate postoperative leukopenia. Following uncomplicated laparoscopic procedures, bilirubin levels are rarely affected, amylase and lipase may be acutely increased following laparoscopic prostatectomy, and white blood count is commonly increased. While 16 (36%) patients had postoperative leukocytosis, leukopenia was not detected after uncomplicated laparoscopic urological surgery and should alert the surgeon to the possibility of an undiagnosed complication.

Laparoscopic Urology Training in South Africa

Laparoscopic urologic surgery is not widely practiced in South Africa. After presenting a laparoscopic training course, we evaluated how effectively this training translated into clinical practice. Invitations to the course were sent to all South African urologists. Ten applicants attended the course, which consisted of dry and in-vivo animal surgery. Two questionnaires were sent out after the course. Questionnaire 1 (at course completion) aimed at identifying the precourse laparoscopic experience and expectations of the trainee. Questionnaire 2 (6 months postcourse) assessed how much laparoscopic surgery the participant had performed since the course. Seventeen percent of all South African urologists responded to the invitation. Prior to the course, 40% of trainees had performed >or=10 laparoscopic cases, 30% had performed <10 cases, and 30% had never performed laparoscopy, whereas 60% expected to be doing one or two cases a month after completing the course. Six months after the course, 60% had performed no laparoscopic cases. Of the three trainees who had never before done laparoscopic procedures, none had started to perform procedures since the course. The commonest procedures performed were varicocelectomy and diagnostic laparoscopy for nonpalpable testis. A hands-on laparoscopic training course to introduce laparoscopic urology into South African private urology practice has not translated into a satisfactory number of clinical cases being performed. The causes are likely multifactorial but are greatly influenced by social and economic forces. One possible solution may be to offer a mentor-based training program.

Laparoscopy in urology

Progress in most fields of surgery and in Urology in particular has been marked by an increasing use of minimal access surgery. The advantages of minimal access techniques are legion and do not need repetition. What does need reminding is the fact that the surgery is only as good as the surgeon performing it. Increasing public awareness and easier access to information through literature and the internet have made most patients aware of their options and has fueled the demand for laparoscopy. It is routine to get patients who will question your advice of open surgery and reasons for not offering minimal invasive or “laser” surgery as it is known in lay language. This knowledge is healthy and improves the patient-doctor communication. However, it has also led to a situation where open surgery is considered “infradig” and a surgeon may be considered incompetent if he does not offer laparoscopy to his patient. Consequently, surgeons may be tempted to attempt something that they actually are not confident doing or should not be doing. The articles in this special issue of the Journal of Minimal Access Surgery have been tailored to address these particular problems in urology. Each article deals specifically with the indications and contraindications of each procedure. It is important that patient selection be meticulous if complications are to be avoided. The articles then describe the basic technique of the procedure including common variants followed by results. The articles do not aim to make expert laparoscopists out of the readers. They have been written to serve as guides in planning a procedure. Laparoscopic urology has a steep learning curve with significant potential for complications. Even today, it is a subspecialty of urology and these surgeries are being performed by dedicated urologic surgeons. When we talk of laparoscopic uro-oncology, the bar becomes even higher because of the need to ensure not only a safe surgery but also one that has oncological and functional results comparable to open surgery. Lest we may do more harm to our patients than benefit, laparoscopic urologic surgery should be performed only by surgeons adept at the open version of the procedure with appropriate training and experience. The editors are grateful to the authors who have spent valuable time in writing these articles. These authors are among the leaders in their field and have considerable personal experience in the procedure that they describe. The manuscripts contain a wealth of knowledge and tips that only masters can provide. We are also grateful to the editors and publisher of the Journal of Minimal Access Surgery who have given us the opportunity to compile this special issue. It clearly highlights the importance that laparoscopic urology has in today's surgical practice.

Urological robotic surgery: Preliminary experience with the Zeus system

We performed robotic or robotically-assisted laparoscopic surgery for urological diseases, and evaluated the ef ficacy and safety of this surgery. Between November 2003 and June 2004, we performed laparoscopic surgery with the Zeus system in eight cases. Three adrenalectomy cases of cortical adenoma presenting with Cushing syndrome and primary aldosteronism, and two cases of nephrectomy for renal cell carcinoma in dialyzed patients were performed solely with Zeus. In two cases of ureteral stenosis, Zeus was used for ureteral anastomosis after partial ureterectomy by manual laparoscopy. In one prostatectomy case, vesico-urethral anastomosis was performed with Zeus after extraperitoneal prostatectomy by manual laparoscopy. All of the cases were successfully treated without any complications during or after operation. All patients were discharged from hospital within 12 days postoperatively. As for adrenalectomy, nephrectomy and pyeloplasty, this may be the fi rst report in Japan. Our preliminary experiences suggest that such a robot system, which is being developed day by day, might become more beneficial in future in urological laparoscopic surgery.

100-MINUTE RETROPERITONEOSCOPIC RADICAL NEPHRECTOMY: A NEW RETROPERITONEAL APPROACH WITH A HAND ASSISTED METHOD

A new approach for retroperitoneoscopic radical nephrectomy is introduced. The point of our surgical method is the application of a combination of hand assistance and pure laparoscopic procedures with appropriate surgical steps via the retroperitoneal approach. In our early series we had good surgical results and we completed radical nephrectomy in about 100 minutes using this procedure. A total of 20 consecutive patients with renal cell carcinoma (cT1-2) who were operated on with this surgical method were analyzed. Surgical procedures occurred in 5 steps. In step 1 the retroperitoneal space was created manually from a pararectal incision at the umbilicus level. In step 2 the lateroconal fascia was incised and the renal hilar area was exposed with hand assistance. In step 3 hilar dissection was performed by pure laparoscopic procedure with another surgical instrument inserted from the hand device. Step 4 involved the application of hand assistance again for the quick mobilization of the kidney and adrenal gland. In step 5 the intact surgical specimen was retrieved from the hand device. Mean operative time and estimated blood loss were 103 +/- 21 minutes (range 70 to 145) and 49 +/- 85 ml (range 5 to 360), respectively. Mean days to oral intake and ambulation were 1.0 and 1.1, respectively. Operative times of the steps of hilar dissection and mobilization of the kidney and adrenal were shorter than in other series performed by standard retroperitoneoscopic radical nephrectomy. Major complications were not experienced. At this point, no metastasis has been experienced. Our surgical method may have the benefits of the retroperitoneal approach and hand assistance. The retroperitoneoscopic hand assisted method may be another important option in the 3 major approaches for laparoscopic radical nephrectomy, although longer-term followup is clearly required.

VENOUS THROMBOSIS PROPHYLAXIS FOR UROLOGICAL LAPAROSCOPY: FRACTIONATED HEPARIN VERSUS SEQUENTIAL COMPRESSION DEVICES

Venous thromboembolism (VTE) is a significant postoperative complication. Common methods of VTE prophylaxis include subcutaneous fractionated heparin (FH) and lower extremity sequential compression devices (SCD). There is no conclusive evidence supporting 1 method compared to the other for urological laparoscopy. We examined the rates of postoperative hemorrhagic and thrombotic complications after laparoscopic urological procedures in patients treated with FH or SCD as VTE prophylaxis. A prospective database augmented by retrospective chart review included all patients who underwent urological laparoscopic surgery of the upper retroperitoneum at our institution from June 2000 to December 2002. Patients nonrandomly received FH or SCD as VTE prophylaxis beginning on the day of surgery. A total of 344 patients were included in this study, 172 in the FH group and 172 in the SCD group. Thrombotic complications included VTE and/or pulmonary embolism. Hemorrhagic complications were minor or major, the latter requiring transfusion or other intervention. In both groups the rate of thrombotic complication was 2 of 172 (1.2%). The rate of hemorrhagic complication was 16 of 172 (9.3%) in the FH group, of which 12 of 172 (7.0%) were major. The hemorrhagic complication rate was 6 of 172 (3.5%), with 5 of 172 (2.9%) being major in the SCD group. After urological laparoscopy of the upper retroperitoneum, subcutaneous fractionated heparin is associated with increased hemorrhagic complications (p = 0.045), without a reduction in thrombotic complications (p >0.999), compared with sequential compression devices.

Comparison of Neuromuscular Injuries to the Surgeon during Hand-Assisted and Standard Laparoscopic Urologic Surgery

Hand-assisted procedures have assumed a greater role in the practice of many laparoscopists. We surveyed major laparoscopy program directors to compare the incidence and location of neuromuscular injury to the surgeon during hand-assisted laparoscopic (HAL) and standard laparoscopic (SL) surgery. A questionnaire on neuromuscular injuries was e-mailed to 42 laparoscopic program directors. Respondents were instructed to report only injuries or pain associated with laparoscopic surgery when they were the primary responsible surgeon and not during open or endoscopic procedures. Surveys were returned from 23 attending laparoscopic surgeons and 2 laparoscopic fellows. Surgeons reported an average of 3.9 HAL and 6.3 SL cases per month as the primary surgeon. The HAL was completed with the GelPort, LapDisk, Omniport, or a combination of devices 55%, 22%, 5%, and 14%, respectively, of the time. Comparing HAL with SL, there was significantly more hand/wrist, forearm, and shoulder pain/injuries associated with HAL (P < 0.004). There was significantly more neck pain associated with SL than HAL (P < 0.003), but no significant difference in lower-back pain (P = 0.40). Comparing the two most commonly used hand-assist devices (GelPort and LapDisk), the LapDisk demonstrated significantly more hand/wrist pain or injury (P = 0.001). Hand-assisted laparoscopy is associated with more frequent neuromuscular strain to the upper extremity than SL, but SL surgeons experience more neck pain or injury. Surgeon discomfort is also dependent on the type of hand-assist device. The long-term consequences of physical strain on the laparoscopic surgeon are unknown currently, but measures to minimize neuromuscular strain should be considered.

Laparoscopic Radical Nephrectomy: A Single Center Experience

Renal cell carcinoma has become one of the most important indications for urological laparoscopic surgery. The laparoscopic technique combines the benefits of a minimal invasive approach with basic surgical principles. We report our experience with 52 procedures. Materials and methods Between June 2000 and December 2003 we performed 52 transperitoneal laparoscopic radical nephrectomies for clinical stage T1-T2 renal cell carcinoma. Median age of patients was 59 yrs (range 31–77 yrs). The mean tumor size was 5.4 cm (range 3–12 cm). Results In three patients (5.7%) conversion to open surgery was necessary. The mean operating time was 215 min (150–305 min). Post-operative hospitalization was 5.1 days (3–11 days). Median follow-up was 19.5 months (3–36 months). No cases of local recurrence or port metastasis occurred during observation. Conclusions In our center, a transperitoneal laparoscopic approach with the removal of intact specimens in endobags has become the standard treatment for stage T1-T2 N0 M0 renal cell carcinoma.

Correlation of Preoperative Three-Dimensional Magnetic Resonance Angiography with Intraoperative Findings in Laparoscopic Renal Surgery

Contrast-enhanced three-dimensional magnetic resonance angiography (3D-MRA) with image reconstruction has important applications in laparoscopic urologic surgery. We now use 3D-MRA as part of our preoperative evaluation in selected patients undergoing laparoscopic donor nephrectomy, pyeloplasty, radical nephrectomy, and partial nephrectomy. From June 2001 to December 2002, 50 patients underwent preoperative 3D-MRA at 1.5 T prior to laparoscopic renal surgery. In general, preoperative 3D-MRA was obtained for donor nephrectomies and pyeloplasties and for cases where prior imaging suggested a possible vascular anomaly. Patients who underwent preoperative imaging included those having donor nephrectomy (N = 28), pyeloplasty (N = 12), radical nephrectomy (N = 5), partial nephrectomy (N = 3), and other laparoscopic renal procedures (N = 2). The 3D-MRA studies were interpreted by one radiologist, and all laparoscopic cases were performed by one of two surgeons. The findings of 3D-MRA were correlated with the intraoperative findings with special attention to aberrant vasculature, including duplicated renal arteries or veins, accessory vessels, or crossing vessels. Among patients undergoing laparoscopic donor nephrectomy, 3D-MRA correctly predicted the number of renal vessels in 27 of 28 cases (96%), including all 3 cases of left retroaortic renal vein. Also, 3DMRA correctly predicted the presence or absence of a crossing vessel in 10 of 12 cases (83%) of laparoscopic pyeloplasty. The imaging study also correctly predicted the number of hilar vessels in all five cases of radical nephrectomy, all three cases of partial nephrectomy, and both cases of other renal operations. Overall, 3D-MRA correctly defined the renal hilar anatomy in 48 of 50 patients, for an overall accuracy of 96%. Three-dimensional MRA findings correlate well (96%) with intraoperative findings in laparoscopic renal surgery. The imaging study provides exquisite vascular detail and is highly accurate, making it sufficient imaging prior to laparoscopic donor nephrectomy and useful for pyeloplasty and other complex renal operations.