- Email: [email protected]
Urolithiasis, Endourology and Laparoscopy
1944
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY A Sealed Laparoscopic Nephroureterectomy: A New Technique A. Tsivian, S. Benjamin and A. A. Sidi, Department of Urologic Surgery, Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Eur Urol 2007; 52: 1015–1019. Objectives: To describe a purely laparoscopic nephroureterectomy approach that avoids the disadvantages of transurethral bladder cuff excision and open/laparoscopic distal ureterectomy using the EndoGIA. Methods: A standard transperitoneal laparoscopic nephrectomy is carried out through three or four ports in the flank. The ureter is dissected caudally into the pelvis. Two additional (5- and 10-mm) trocars are placed in the ipsilateral lower abdomen. Caudal ureteral dissection continues until the detrusor muscle fibers at the ureterovesical junction are identified. A 1-cm area of bladder adventitia around the ureterovesical junction is cleared. The ureter is retracted upward and laterally, tenting up the bladder wall. The bladder cuff is excised using a 10-mm LigaSure Atlas and detached from the bladder. A 6-cm lower-quadrant incision is used to remove the specimen in an Endocatch bag. An indwelling 16F Foley catheter is then placed. Results: Thirteen adult patients with suspected upper-tract transitional cell carcinoma underwent this surgical technique (operative time: 170 –270 min): none had local recurrence, and two had recurrence remote from the bladder cuff scar (follow-up: 1–23 months). Conclusions: The described procedure adheres strictly to oncologic principles (removal of the affected renal unit without opening the urinary tract), and circumvents the need for transurethral/intraureteral instrumentation and patient repositioning. Editorial Comment: Great idea! The authors use a 10 mm LigaSure Atlas™ to secure the bladder cuff. This approach avoids any staples in the bladder, ensures that the tissue that is sealed is likewise destroyed (unlike with staples), and precludes time-consuming or difficult suturing, or ureteral detachment “pluck” procedures, thereby maintaining bladder integrity throughout a nephroureterectomy! Catheters were removed just before discharge home on postoperative day 3 or 4, provided that the cystogram was unremarkable. My only concern is that of making sure the entire ureteral tunnel and orifice are included in the bladder cuff. The authors note this was accomplished in all 13 of their patients, of whom 10 were males. I have been consistently disappointed with how poor my judgment is with regard to how far down along the bladder I need to go to secure the entire ureter within the excised bladder cuff. As such, we routinely use the flexible cystoscope to enable the surgeon to know when the cuff is low enough—and yet even with this method there are times when after release of the stapler there is still a ureteral orifice remaining, which then necessitates an unroofing procedure, which is time consuming. However, with the LigaSure the remnant cuff would be only a few mm in width, compared to 6 mm with the stapler, so what the cystoscopist sees is what you would likely achieve. I look forward to trying this simpler approach, which will save us the cost of the staple load and may reduce our operative time. Ralph Clayman, M.D.
Robotic Versus Standard Laparoscopic Partial/Wedge Nephrectomy: A Comparison of Intraoperative and Perioperative Results From a Single Institution L. A. Deane, H. J. Lee, G. N. Box, O. Melamud, D. S. Yee, J. B. Abraham, D. S. Finley, J. F. Borin, E. M. McDougall, R. V. Clayman and D. K. Ornstein, Departments of Urology, University of Illinois at Chicago, Chicago, Illinois, and University of California, Irvine, Medical Center, Orange, California, and Department of Surgery, University of Maryland, Baltimore, Maryland J Endourol 2008; 22: 947–952. Purpose: Laparoscopic partial/wedge nephrectomy, similar to laparoscopic radical prostatectomy, is a technically challenging procedure that is performed by a limited number of expert laparoscopic surgeons. The incorporation of a robotic surgical interface has dramatically increased the use of minimally invasive pelvic surgery such that robotic laparoscopic radical prostatectomy is commonly performed even by laparoscopically naïve surgeons. This analysis compares the outcomes of our initial experience with robot-assisted laparoscopic partial nephrectomy (RLPN) performed by an experienced open surgeon to that of standard laparoscopic partial nephrectomy (LPN)
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY performed by two experienced laparoscopic surgeons. Patients and Methods: We reviewed the medical records of 11 consecutive patients who underwent 12 standard LPNs (EMM, RVC) (one patient had two unilateral tumors) and 10 consecutive patients (representing the first 11 of such robotic procedures performed at our institution) who underwent 11 RLPNs (one patient had bilateral tumors managed in an asynchronous manner) (DKO). Results: The mean tumor size was 2.3 cm (range 1.7– 6.2 cm) for LPN and 3.1 cm (range 2.5– 4 cm) for RLPN. The mean total procedure time was 289.5 minutes (range 145–369 min) for LPN and 228.7 minutes (range 98 –375 min) for RLPN (P ⫽ 0.102). The mean estimated blood loss was 198 mL (range 75–500 mL) for LPN v 115 mL (25–300 mL) for RLPN (P ⫽ 0.169). The mean warm ischemia time was 35.3 minutes (range 15– 49 min) in the LPN group and 32.1 minutes (range 30 – 45 minutes) in the RLPN group (P ⫽ 0.501). Conclusions: Introducing a robotic interface for laparoscopic partial/wedge resection allowed a fellowship-trained urologic oncologist with limited reconstructive laparoscopic experience to achieve results comparable to those for laparoscopic partial/wedge resection performed by experienced laparoscopic surgeons. In this regard, the learning curve appears truncated, similar to that with robot-assisted laparoscopic prostatectomy. Editorial Comment: As in 2003 with regard to laparoscopic vs robotic prostatectomy,1 so it is in 2008 with respect to laparoscopic vs robotic partial nephrectomy that the skills of the experienced and able open surgeon transfer readily to the robotic platform, enabling him or her to perform laparoscopic procedures equivalent to highly experienced laparoscopic surgeons. ’Nuff said. Ralph Clayman, M.D. 1. Ahlering TE, Skarecky D, Lee D and Clayman RV: Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy. J Urol 2003; 170: 1738.
Percutaneous Fibrin Glue Injection for Urine Leakage in Laparoscopic Partial Nephrectomy I. Y. Seo, Y. H. Lee and J. S. Rim, Departments of Urology and Radiology, Wonkwang University School of Medicine, Iksan, Republic of Korea J Endourol 2008; 22: 959 –962. As laparoscopic techniques have advanced in the recent decade, laparoscopic partial nephrectomy (LPN) has been performed in patients with renal-cell carcinoma (RCC). Until recently, however, it has been a challenging procedure to perform because of its technical difficulty. We treated a 71-year-old man with a single kidney and RCC who subsequently underwent LPN. Urine leakage was detected postoperatively and continued for 30 days. It was managed with a percutaneous fibrin glue injection. Our report shows the therapeutic feasibility of fibrin glue for urine leakage, a complication of LPN. Editorial Comment: Following a laparoscopic transperitoneal partial nephrectomy for a 7 ⴛ 8 cm interpolar renal mass, a persistent urine leak developed. The 500 cc plus per day fistulous tract was sealed immediately with the injection of 4 cc fibrin glue (Tissucol®) on postoperative day 31. The fibrin glue was instilled through the 8.5Fr pigtail catheter that was draining the urinoma by passing the fibrin glue applicator through the pigtail catheter. Certainly, this approach seems like a simple solution to a difficult problem. If it did not work, it would not appear to have a negative impact on any subsequent therapy. Ralph Clayman, M.D.
UROLOGICAL ONCOLOGY: BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY Prognostic Implications of Lymphangiogenesis in Muscle-Invasive Transitional Cell Carcinoma of the Bladder M. I. Fernandez, C. Bolenz, L. Trojan, A. Steidler, C. Weiss, P. Alken, R. Grobholz and M. S. Michel, Department of Urology, University Hospital Mannheim, Mannheim, Germany Eur Urol 2008; 53: 571–578.
1945
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY A Sealed Laparoscopic Nephroureterectomy: A New Technique A. Tsivian, S. Benjamin and A. A. Sidi, Department of Urologic Surgery, Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Eur Urol 2007; 52: 1015–1019. Objectives: To describe a purely laparoscopic nephroureterectomy approach that avoids the disadvantages of transurethral bladder cuff excision and open/laparoscopic distal ureterectomy using the EndoGIA. Methods: A standard transperitoneal laparoscopic nephrectomy is carried out through three or four ports in the flank. The ureter is dissected caudally into the pelvis. Two additional (5- and 10-mm) trocars are placed in the ipsilateral lower abdomen. Caudal ureteral dissection continues until the detrusor muscle fibers at the ureterovesical junction are identified. A 1-cm area of bladder adventitia around the ureterovesical junction is cleared. The ureter is retracted upward and laterally, tenting up the bladder wall. The bladder cuff is excised using a 10-mm LigaSure Atlas and detached from the bladder. A 6-cm lower-quadrant incision is used to remove the specimen in an Endocatch bag. An indwelling 16F Foley catheter is then placed. Results: Thirteen adult patients with suspected upper-tract transitional cell carcinoma underwent this surgical technique (operative time: 170 –270 min): none had local recurrence, and two had recurrence remote from the bladder cuff scar (follow-up: 1–23 months). Conclusions: The described procedure adheres strictly to oncologic principles (removal of the affected renal unit without opening the urinary tract), and circumvents the need for transurethral/intraureteral instrumentation and patient repositioning. Editorial Comment: Great idea! The authors use a 10 mm LigaSure Atlas™ to secure the bladder cuff. This approach avoids any staples in the bladder, ensures that the tissue that is sealed is likewise destroyed (unlike with staples), and precludes time-consuming or difficult suturing, or ureteral detachment “pluck” procedures, thereby maintaining bladder integrity throughout a nephroureterectomy! Catheters were removed just before discharge home on postoperative day 3 or 4, provided that the cystogram was unremarkable. My only concern is that of making sure the entire ureteral tunnel and orifice are included in the bladder cuff. The authors note this was accomplished in all 13 of their patients, of whom 10 were males. I have been consistently disappointed with how poor my judgment is with regard to how far down along the bladder I need to go to secure the entire ureter within the excised bladder cuff. As such, we routinely use the flexible cystoscope to enable the surgeon to know when the cuff is low enough—and yet even with this method there are times when after release of the stapler there is still a ureteral orifice remaining, which then necessitates an unroofing procedure, which is time consuming. However, with the LigaSure the remnant cuff would be only a few mm in width, compared to 6 mm with the stapler, so what the cystoscopist sees is what you would likely achieve. I look forward to trying this simpler approach, which will save us the cost of the staple load and may reduce our operative time. Ralph Clayman, M.D.
Robotic Versus Standard Laparoscopic Partial/Wedge Nephrectomy: A Comparison of Intraoperative and Perioperative Results From a Single Institution L. A. Deane, H. J. Lee, G. N. Box, O. Melamud, D. S. Yee, J. B. Abraham, D. S. Finley, J. F. Borin, E. M. McDougall, R. V. Clayman and D. K. Ornstein, Departments of Urology, University of Illinois at Chicago, Chicago, Illinois, and University of California, Irvine, Medical Center, Orange, California, and Department of Surgery, University of Maryland, Baltimore, Maryland J Endourol 2008; 22: 947–952. Purpose: Laparoscopic partial/wedge nephrectomy, similar to laparoscopic radical prostatectomy, is a technically challenging procedure that is performed by a limited number of expert laparoscopic surgeons. The incorporation of a robotic surgical interface has dramatically increased the use of minimally invasive pelvic surgery such that robotic laparoscopic radical prostatectomy is commonly performed even by laparoscopically naïve surgeons. This analysis compares the outcomes of our initial experience with robot-assisted laparoscopic partial nephrectomy (RLPN) performed by an experienced open surgeon to that of standard laparoscopic partial nephrectomy (LPN)
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY performed by two experienced laparoscopic surgeons. Patients and Methods: We reviewed the medical records of 11 consecutive patients who underwent 12 standard LPNs (EMM, RVC) (one patient had two unilateral tumors) and 10 consecutive patients (representing the first 11 of such robotic procedures performed at our institution) who underwent 11 RLPNs (one patient had bilateral tumors managed in an asynchronous manner) (DKO). Results: The mean tumor size was 2.3 cm (range 1.7– 6.2 cm) for LPN and 3.1 cm (range 2.5– 4 cm) for RLPN. The mean total procedure time was 289.5 minutes (range 145–369 min) for LPN and 228.7 minutes (range 98 –375 min) for RLPN (P ⫽ 0.102). The mean estimated blood loss was 198 mL (range 75–500 mL) for LPN v 115 mL (25–300 mL) for RLPN (P ⫽ 0.169). The mean warm ischemia time was 35.3 minutes (range 15– 49 min) in the LPN group and 32.1 minutes (range 30 – 45 minutes) in the RLPN group (P ⫽ 0.501). Conclusions: Introducing a robotic interface for laparoscopic partial/wedge resection allowed a fellowship-trained urologic oncologist with limited reconstructive laparoscopic experience to achieve results comparable to those for laparoscopic partial/wedge resection performed by experienced laparoscopic surgeons. In this regard, the learning curve appears truncated, similar to that with robot-assisted laparoscopic prostatectomy. Editorial Comment: As in 2003 with regard to laparoscopic vs robotic prostatectomy,1 so it is in 2008 with respect to laparoscopic vs robotic partial nephrectomy that the skills of the experienced and able open surgeon transfer readily to the robotic platform, enabling him or her to perform laparoscopic procedures equivalent to highly experienced laparoscopic surgeons. ’Nuff said. Ralph Clayman, M.D. 1. Ahlering TE, Skarecky D, Lee D and Clayman RV: Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy. J Urol 2003; 170: 1738.
Percutaneous Fibrin Glue Injection for Urine Leakage in Laparoscopic Partial Nephrectomy I. Y. Seo, Y. H. Lee and J. S. Rim, Departments of Urology and Radiology, Wonkwang University School of Medicine, Iksan, Republic of Korea J Endourol 2008; 22: 959 –962. As laparoscopic techniques have advanced in the recent decade, laparoscopic partial nephrectomy (LPN) has been performed in patients with renal-cell carcinoma (RCC). Until recently, however, it has been a challenging procedure to perform because of its technical difficulty. We treated a 71-year-old man with a single kidney and RCC who subsequently underwent LPN. Urine leakage was detected postoperatively and continued for 30 days. It was managed with a percutaneous fibrin glue injection. Our report shows the therapeutic feasibility of fibrin glue for urine leakage, a complication of LPN. Editorial Comment: Following a laparoscopic transperitoneal partial nephrectomy for a 7 ⴛ 8 cm interpolar renal mass, a persistent urine leak developed. The 500 cc plus per day fistulous tract was sealed immediately with the injection of 4 cc fibrin glue (Tissucol®) on postoperative day 31. The fibrin glue was instilled through the 8.5Fr pigtail catheter that was draining the urinoma by passing the fibrin glue applicator through the pigtail catheter. Certainly, this approach seems like a simple solution to a difficult problem. If it did not work, it would not appear to have a negative impact on any subsequent therapy. Ralph Clayman, M.D.
UROLOGICAL ONCOLOGY: BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY Prognostic Implications of Lymphangiogenesis in Muscle-Invasive Transitional Cell Carcinoma of the Bladder M. I. Fernandez, C. Bolenz, L. Trojan, A. Steidler, C. Weiss, P. Alken, R. Grobholz and M. S. Michel, Department of Urology, University Hospital Mannheim, Mannheim, Germany Eur Urol 2008; 53: 571–578.
1945