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Laparoscopic expertise increases hospital volume of adrenal surgery
S96
Urology and Reproductive Surgery
of native kidney structures. AFSC were able to survive, replicate, and follow the natural branching of the developing nephron. RT-PCR demonstrated appropriate gene expressions for the kidney and confirmed an initial step essential for commitment to a renal fate by the AFSC during organ culture. CONCLUSIONS: AFSC have the capacity to survive, replicate, and undergo normal branching development once injected into embryonic kidneys. AFSC could furnish a potentially limitless source of stem cells which may represent a novel cell therapeutic technique for whole organ regeneration.
Renal pelvis cuff pyeloplasty for ureteropelvic junction obstruction: an initial experience Juan M Proano MD, Jeffrey S Palmer MD, FACS, Lane S Palmer MD, FACS Rainbow Babies and Children’s Hospital, and Schneider Children’s Hospital, Cleveland, OH INTRODUCTION: Ureteropelvic junction (UPJ) obstruction can result from a high inserting ureter without intrinsic ureteral obstruction. We describe our initial experience using a renal pelvis cuff pyeloplasty technique to treat this cause of UPJ obstruction. METHODS: We reviewed all children who underwent renal pelvis cuff pyeloplasty. All patients had SFU grade 3 to 4 hydronephrosis on ultrasonography and radiographic confirmation of UPJ obstruction by diuretic MAG-3 renography. The pyeloplasty was performed through a flank incision. A circumferential incision of renal pelvis proximal to the ureteral insertion site into the renal pelvis was made. Then a catheter was passed through the UPJ to assure uniform patency. The cuff of pelvis with the attached ureter was then sutured to the dependent portion of the pelvis. Postoperative resolution of the obstruction was evaluated by ultrasonography and MAG-3 renography. RESULTS: Eleven children (6 boys and 5 girls) underwent a renal cuff pyeloplasty for UPJ obstruction due to a high inserting ureter. The median age was 6 months (range 2.5 months to 2.4 years) with median follow-up of 11 months (range 8 months to 3.4 years) All patients were discharged within 2 days postoperatively. No intraoperative or postoperative complications were noted. All patients demonstrated resolution of the UPJ obstruction on follow-up radiographs. CONCLUSIONS: The renal pelvis cuff pyeloplasty, a surgical technique for UPJ obstruction resulting from a high inserting ureter without intrinsic ureteral obstruction, is straightforward, with good results, and without complications in this initial experience.
Efficacy and safety of hand assisted laparoscopic nephrectomy for large renal masses J Slade Hubbard MD, Eric Wallen MD, Raj Pruthi MD University of North Carolina at Chapel Hill, Chapel Hill, NC INTRODUCTION: Laparoscopic nephrectomy has become a common, less-invasive option for extirpative renal surgery in recent years.
J Am Coll Surg
Currently, this approach is being applied to larger, more complex renal masses. This study sought to demonstrate the feasibility, efficacy and safety of hand-assisted laparoscopic nephrectomy for larger (⬎7 cm) renal lesions. METHODS: From a consecutive,modern series of 332 nephrectomies over a 42 month period (6/2000-12/2004) 66 patients(20%) had preoperative renal masses ⬎7 cm in size. Of these, 26 underwent planned laparoscopic RN via transperitoneal approach and with use of a hand-assist device (HALN). Medical records were retrospectively evaluated with regard to blood loss, TNM final pathology, conversion rate, and operative complications. RESULTS: Of the 26 cases, 19 had renal cell carcinomas (stage pT2-pT3c), 5 transitional cell carcinomas (stage pTa-pT4), 1 PNET, and 1 angiomyolipoma. There were no intraoperative complications. Four patients (15%) were converted to an open nephrectomy for reasons of bleeding (1), IVC thrombus (2), and difficult hilar dissection (1). One patient with a BMI of 35 developed a incisional hernia at the hand-port site which ultimately required repair. The 22 patients who had successful HALN) are shown in the table.Interestingly, when evaluated by academic year, an increasing percentage of T2 tumors underwent a laparoscopic approach in recent years: 6/007/01(20%), 7/01-6/02(10%), 7/02-6/03(67%), 7/03-6/04(57%), 7/04-12/04(55%). Table: Efficacy and safety of hand assisted laparoscopic nephrectomy for large renal masses Mean Tumor size (range) 9.2 cm (7.2–17 cm) Mean EBL (range) 173 ml (100–600 ml) Postop Bleed none Early Complications (⬍30 days) 3 (13%) Late Complication (hernia) 1 (5%) CONCLUSIONS: Laparoscopic radical nephrectomy is emerging as the standard of care for surgical management of renal malignancies. This modern series demonstrates that hand-assisted laparoscopic nephrectomy is a safe and effective approach even for large renal masses.
Laparoscopic expertise increases hospital volume of adrenal surgery Yuri Novitsky, Kent Kercher MD, Andrew Harrell MD, William Cobb MD, Rosen Michael MD, Ronald Sing DO, B Todd Heniford MD, FACS Carolinas Medical Center, Charlotte, NC INTRODUCTION: Widespread utilization of laparoscopic adrenalectomy may be limited by its technical challenges. We evaluated the effects of the availability of laparoscopic expertise on the volume of the adrenal surgery at a tertiary care hospital. METHODS: A retrospective review of all patients who underwent an adrenalectomy 5 years before and 5 years after laparoscopic expertise became available. Patient demographics, distance of travel, annual number of operations, indications, and lesion sizes were analyzed. In addition, North Carolina Hospital Association Patient Data
Vol. 201, No. 3S, September 2005
System was queried for all patients who underwent an adrenalectomy. RESULTS: From January 1993 to December 1997, 10 adrenalectomies were performed. During the 5 years (1999-2003) after laparoscopic expertise became available, 76 adrenalectomies were performed with the average annual volume of adrenalectomies increasing from 2 (0–5) to 15 cases (9–20), p⬍0.0001. The average distance of travel to the hospital was significantly greater for the latter patients (41vs20 miles, p⫽0.02) and significantly more were referred from outside the 40 mile radius (10%vs21%, p⫽0.04). The indica-
Urology and Reproductive Surgery
S97
tions for surgery were similar with regards to lesion sizes (4.6vs4.0 cm) and most common pathologies (adenoma in 30%vs26%, pheochromocytoma in 30%vs21%). Although the average state-wide annual number of adrenalectomies has not changed (82.5vs92.4 cases), the proportion of state-wide adrenalectomies performed at our institution has increased significantly (2.9%vs15.2%, p⫽0.001). CONCLUSIONS: Laparoscopic adrenalectomy has evolved as the procedure of choice for all indications at our institution. Offering a laparoscopic approach appears to have altered local physician referral patterns and significantly increased the volume of adrenal surgery.
Urology and Reproductive Surgery
of native kidney structures. AFSC were able to survive, replicate, and follow the natural branching of the developing nephron. RT-PCR demonstrated appropriate gene expressions for the kidney and confirmed an initial step essential for commitment to a renal fate by the AFSC during organ culture. CONCLUSIONS: AFSC have the capacity to survive, replicate, and undergo normal branching development once injected into embryonic kidneys. AFSC could furnish a potentially limitless source of stem cells which may represent a novel cell therapeutic technique for whole organ regeneration.
Renal pelvis cuff pyeloplasty for ureteropelvic junction obstruction: an initial experience Juan M Proano MD, Jeffrey S Palmer MD, FACS, Lane S Palmer MD, FACS Rainbow Babies and Children’s Hospital, and Schneider Children’s Hospital, Cleveland, OH INTRODUCTION: Ureteropelvic junction (UPJ) obstruction can result from a high inserting ureter without intrinsic ureteral obstruction. We describe our initial experience using a renal pelvis cuff pyeloplasty technique to treat this cause of UPJ obstruction. METHODS: We reviewed all children who underwent renal pelvis cuff pyeloplasty. All patients had SFU grade 3 to 4 hydronephrosis on ultrasonography and radiographic confirmation of UPJ obstruction by diuretic MAG-3 renography. The pyeloplasty was performed through a flank incision. A circumferential incision of renal pelvis proximal to the ureteral insertion site into the renal pelvis was made. Then a catheter was passed through the UPJ to assure uniform patency. The cuff of pelvis with the attached ureter was then sutured to the dependent portion of the pelvis. Postoperative resolution of the obstruction was evaluated by ultrasonography and MAG-3 renography. RESULTS: Eleven children (6 boys and 5 girls) underwent a renal cuff pyeloplasty for UPJ obstruction due to a high inserting ureter. The median age was 6 months (range 2.5 months to 2.4 years) with median follow-up of 11 months (range 8 months to 3.4 years) All patients were discharged within 2 days postoperatively. No intraoperative or postoperative complications were noted. All patients demonstrated resolution of the UPJ obstruction on follow-up radiographs. CONCLUSIONS: The renal pelvis cuff pyeloplasty, a surgical technique for UPJ obstruction resulting from a high inserting ureter without intrinsic ureteral obstruction, is straightforward, with good results, and without complications in this initial experience.
Efficacy and safety of hand assisted laparoscopic nephrectomy for large renal masses J Slade Hubbard MD, Eric Wallen MD, Raj Pruthi MD University of North Carolina at Chapel Hill, Chapel Hill, NC INTRODUCTION: Laparoscopic nephrectomy has become a common, less-invasive option for extirpative renal surgery in recent years.
J Am Coll Surg
Currently, this approach is being applied to larger, more complex renal masses. This study sought to demonstrate the feasibility, efficacy and safety of hand-assisted laparoscopic nephrectomy for larger (⬎7 cm) renal lesions. METHODS: From a consecutive,modern series of 332 nephrectomies over a 42 month period (6/2000-12/2004) 66 patients(20%) had preoperative renal masses ⬎7 cm in size. Of these, 26 underwent planned laparoscopic RN via transperitoneal approach and with use of a hand-assist device (HALN). Medical records were retrospectively evaluated with regard to blood loss, TNM final pathology, conversion rate, and operative complications. RESULTS: Of the 26 cases, 19 had renal cell carcinomas (stage pT2-pT3c), 5 transitional cell carcinomas (stage pTa-pT4), 1 PNET, and 1 angiomyolipoma. There were no intraoperative complications. Four patients (15%) were converted to an open nephrectomy for reasons of bleeding (1), IVC thrombus (2), and difficult hilar dissection (1). One patient with a BMI of 35 developed a incisional hernia at the hand-port site which ultimately required repair. The 22 patients who had successful HALN) are shown in the table.Interestingly, when evaluated by academic year, an increasing percentage of T2 tumors underwent a laparoscopic approach in recent years: 6/007/01(20%), 7/01-6/02(10%), 7/02-6/03(67%), 7/03-6/04(57%), 7/04-12/04(55%). Table: Efficacy and safety of hand assisted laparoscopic nephrectomy for large renal masses Mean Tumor size (range) 9.2 cm (7.2–17 cm) Mean EBL (range) 173 ml (100–600 ml) Postop Bleed none Early Complications (⬍30 days) 3 (13%) Late Complication (hernia) 1 (5%) CONCLUSIONS: Laparoscopic radical nephrectomy is emerging as the standard of care for surgical management of renal malignancies. This modern series demonstrates that hand-assisted laparoscopic nephrectomy is a safe and effective approach even for large renal masses.
Laparoscopic expertise increases hospital volume of adrenal surgery Yuri Novitsky, Kent Kercher MD, Andrew Harrell MD, William Cobb MD, Rosen Michael MD, Ronald Sing DO, B Todd Heniford MD, FACS Carolinas Medical Center, Charlotte, NC INTRODUCTION: Widespread utilization of laparoscopic adrenalectomy may be limited by its technical challenges. We evaluated the effects of the availability of laparoscopic expertise on the volume of the adrenal surgery at a tertiary care hospital. METHODS: A retrospective review of all patients who underwent an adrenalectomy 5 years before and 5 years after laparoscopic expertise became available. Patient demographics, distance of travel, annual number of operations, indications, and lesion sizes were analyzed. In addition, North Carolina Hospital Association Patient Data
Vol. 201, No. 3S, September 2005
System was queried for all patients who underwent an adrenalectomy. RESULTS: From January 1993 to December 1997, 10 adrenalectomies were performed. During the 5 years (1999-2003) after laparoscopic expertise became available, 76 adrenalectomies were performed with the average annual volume of adrenalectomies increasing from 2 (0–5) to 15 cases (9–20), p⬍0.0001. The average distance of travel to the hospital was significantly greater for the latter patients (41vs20 miles, p⫽0.02) and significantly more were referred from outside the 40 mile radius (10%vs21%, p⫽0.04). The indica-
Urology and Reproductive Surgery
S97
tions for surgery were similar with regards to lesion sizes (4.6vs4.0 cm) and most common pathologies (adenoma in 30%vs26%, pheochromocytoma in 30%vs21%). Although the average state-wide annual number of adrenalectomies has not changed (82.5vs92.4 cases), the proportion of state-wide adrenalectomies performed at our institution has increased significantly (2.9%vs15.2%, p⫽0.001). CONCLUSIONS: Laparoscopic adrenalectomy has evolved as the procedure of choice for all indications at our institution. Offering a laparoscopic approach appears to have altered local physician referral patterns and significantly increased the volume of adrenal surgery.