498 THE JOURNAL OF UROLOGY® Vol. 169, No.4, Supplement, Wednesday, April 30, 2003 METHODS: We retrospectively reviewed our HALN data from 10/01-04/02 to ascertain the most common reasons for presentation and to determine the impact of renal masses found with FBS CT on our practice. Patients were divided into categories based on mode of presentation. The patients' demographic information was collected along with intraoperative findings and compared to the other patients who underwent HALN in the specified period. RESULTS: Thirty HALNs were performed between 10/01-04/02. The seven patients that were diagnosed solely by full body screening CT were in general younger (mean age 49.7 years) and healthier, with hypertension as their only comorbidity. This group also tended to have the largest tumor volume with an average of 6.5 cm. None of these patients were found to complain of any symptoms or signs of pathology at time of CT scan. Each of these patients also had a normal urine analysis and serum creatinine level at and prior to presentation. Patients found to have tumors discovered incidentally during the work up of another unrelated ailment were considered a separate entity from those diagnosed by PBS CT's. Patients presenting secondary to the diagnosis of a renal tumor detected by FBS CT accounted for 23.3% of our HALN volume over this seven month period. CONCLUSIONS: Full body screening CT scans appear to be an increasingly more common procedure performed in our community. The tumors found by this diagnostic modality in these asymptomatic individuals referred to this university have not been small, all requiring nephrectomy. This new trend in scanning has given rise to a new breed of "incidentalorna" in patients with relatively fewer comorbidi ties and has had a significant impact on our practice accounting for 23.3% of our hand assisted laparoscopic surgeries over a seven month period. Data from 30 Consecutive HALN's PRESENTATION #of Comorbidities Avg. Avg. Tumor Pathology Pts. Age Size(em) FBSCT HTN 49.7 6.5 6ReC, 1 Onco- cytoma HTN, AFIB, zrcc 11 RCC, Symptomatic* 12 ASTHMA, CAD, 63 4.5 1XGP COPD Incidental HTN. CAD. AFIB 59.2 5.7 1 TCC, BRCC *2 Bilateral HALN Source of Funding: None. Endoscopic Management of Renal Diseases Video Session Wednesday, April 30, 2003 1:30·3:30 PM V1865 APPLICATION OF THE URETERAL ACCESS SHEATH TO FACILITATE PERCUTANEOUS NEPHROLITHOTOMY Ramakrishna Venkatesh*, David I Lee, Richard Vanlangendonk, St. Louis, MO; Chandru P Sundaram, Indiana, IN; Jaime Landman, St. Louis, MO INTRODUCTION AND OBJECTIVE: Commonly endourologists initiate PCNL, by retrograde passage of a ureteral catheter or a balloon occlusion catheter with inflation of the balloon at the UPI to prevent migration of stone fragments into the ureter and to allow retrograde instillation of air and/or contrast material to facilitate puncture. We have altered our technique for PCNL due to revisions in the design of the ureteral access sheath; this video will demonstrate this use of the access sheath. METHODS: The patient is positioned in the prone with the legs on spreader bars. Using the Amplatz superstiff wire, a l21l4Fr Ureteral Access Sheath (Applied Medical, Rancho Santa Margarita, CAl is advanced up to the ureteropelvic junction under fluroscopic guidance. The sheath can be used to instill contrast, air or saline to facilitate the percutaneous access. The access sheath facilitates passage of a guide wire through the percutaneous tract down the ureter out of the urethra for a safe maintenance of access. Initial assessment of the stone is performed with a flexible ureteroscope and if the stone is soft it could be treated by this approach, otherwise percutaneous nephrolithotomy is performed. Nephroscopy and ultrasonic lithotripsy is performed. The access sheath facilitates the passage of stone fragments down the ureter directly out of the body. Between 8/2001 and 712002, 22 combined antegrade and retrograde PCNL's were performed by a single surgeon (IL). Nine complete or partial staghom calculi were treated during this time period. The records of these 9 patients were retrospectively reviewed. RESULTS: Mean OR time was 3.1hours. Mean EBL was 290mL(lOO-900 mL),and patients required a mean of 33.2mg MS04 equivalents. The mean hospital stay was 3.2 days. Complete stone clearance was achieved in 7/9 (78%) of patients. One patient did not undergo a second look procedure due to pulmonary complications. This patient had a 4-mm uric acid residual fragment and underwent oral alkalinization that resulted in stone resolution. A second patient was found to *Presenting author. have multiple small fragments in the lower pole at I-month follow-up that required a subsequent ureteroscopic stone extraction. CONCLUSIONS: Application of the ureteral access sheath during PCNL improves renal access and thus allows the endourologist to unite the upper and lower urinary tract. Presently we have altered our technique to include the ureteral access sheath for all our PCNL procedures. Source of Funding: None. V1866 THE EFFICACY OF THE STONE CONE FOR PROXIMAL URETERAL STONES Steven D Maislos", Brooklyn, NY; Michael A Volpe, Peter S Albert, Adley Raboy, Staten Island, NY INTRODUCTION AND OBJECTIVE: While ureteroscopic lithotripsy is at least as efficacious as ESWL in treating lower ureteral stones, the same can not be said of its ability to treat proximal ureteral stones. Since failed proximal ureteral lithotripsy is often due to the ensuing complications associated with stone migration into the renal pelvis and calyces, an instrument that can prevent this migration is a potentially important tool in the ureteroscopic tool armamentarium. This study seeks to assess the role for just such an instrument, the stone cone, in proximal ureteral lithotripsy. METHODS: For a 3 month period, we treated all patients with proximal ureteral stones using semirigid ureteroscopy, a stone cone nitinol urological retrieval coil, and holmium- YAG laser lithotripsy. A total of 10 such patients were treated in this fashion. In all 10 patients, both a stone cone and a holmium-YAG laser fiber (200 or 365 micron) were deployed and utilized under visual guidance through the same working channel of the ureteroscope. RESULTS: All 10 patients were rendered stone free after holmium-YAG laser ureteral lithotripsy in conjunction with a stone cone. The stones ranged in size from 6 mm to 2 em. No stone fragments were noted to migrate into the renal pelvis. In all 10 cases the stone cone was easily deployed. The simultaneous use of both the stone cone and either a 200 or a 365 micron holmium-YAG laser fiber in a solitary 4 French working channel still allowed for excellent irrigation. Likewise, the simultaneous use of the stone cone in a 3 French working channel with a 200 or 365 micron holmium-YAG laser fiber in a parallel 2 French working channel also allowed for excellent irrigation. It should be noted that the stone cone did not break and never became entrapped in any of the 10 cases. Finally, it was also observed that the stone cone appeared to minimize the amount of ureteral motion normally associated with respirations; thereby facilitating lithotripsy. CONCLUSIONS: The stone cone is a powerful new tool for proximal ureteral lithotripsy which will likely revolutionize the treatment of proximal ureteral stones. The savings in morbidity, time, and money associated with not having to chase stone fragments using flexible ureteroscopy is invaluable. Source of Funding: None. V1867 NEOINFUNDIBULOTOMY FOR THE MANAGEMENT OF SYMPTOMATIC CALYCEAL DIVERTICULA Fernando C Delvecchio*, Steven A Terranova, Brian K Auge, Paul K Pietrow, Glenn E Newman, Glenn M Preminger, Durham, NC INTRODUCTION AND OBJECTIVE: Shock-wave lithotripsy (SWL) and ureteroscopy may be used to manage stones within a calyceal diverticulum, yet percutaneous nephrolithotomy (PNL) remains the preferred and optimum method of attaining stone-free and symptom-free results. However, passing a guide wire through a stenotic infundibulum is, at times, impossible. Herein we illustrate an alternative technique that creates a neoinfundibulum during percutaneous management of calyceal diverticula. METHODS: Over a six year period, 18 of 22 patients undergoing PNL for management of calyceal diverticula required neoinfundibulotomy for secure through-and-through wire placement. Presenting complaints included pain, UTI and nausea with emesis. Seventeen of eighteen (94.4%) had stones within the diverticulnm (mean 11.7 x 12 mm). Under fluoroscopy, once a wire is unsuccessfully passed through the narrow infundibulum of the diverticulum, the access needle is advanced directly through the wall of the diverticulum into the collecting system, and the nephroscopy tract is dilated. Percutaneous stone removal is accomplished in the usual manner, and a 22F Councill catheter is placed into the collecting system to allow epithelialization of the new infundibulum. RESULTS: Complete resolution of symptoms occurred in 11 of 12 patients, with the improvement in pain in the remaining individual. 80% of patients with followup imaging were stone free at an average of 6 weeks postop (2 patients failed to return). The average residual stone burden was 2.6 x 2 mm. The diverticulum was absent on contrast imaging in 10/16 patients (63%). Two intrathoracic complications occurred after supra-11th rib access, both successfully managed with chest tubes.
Transcript
498 THE JOURNAL OF UROLOGY® Vol. 169, No.4, Supplement, Wednesday, April 30, 2003
METHODS: We retrospectively reviewed our HALN data from 10/01-04/02 toascertain the most common reasons for presentation and to determine the impact ofrenal masses found with FBS CT on our practice. Patients were divided intocategories based on mode of presentation. The patients' demographic informationwas collected along with intraoperative findings and compared to the other patientswho underwent HALN in the specified period.
RESULTS: Thirty HALNs were performed between 10/01-04/02. The sevenpatients that were diagnosed solely by full body screening CT were in generalyounger (mean age 49.7 years) and healthier, with hypertension as their onlycomorbidity. This group also tended to have the largest tumor volume with anaverage of 6.5 cm. None of these patients were found to complain of any symptomsor signs of pathology at time of CT scan. Each of these patients also had a normalurine analysis and serum creatinine level at and prior to presentation. Patientsfound to have tumors discovered incidentally during the work up of anotherunrelated ailment were considered a separate entity from those diagnosed by PBSCT's. Patients presenting secondary to the diagnosis of a renal tumor detected byFBS CT accounted for 23.3% of our HALN volume over this seven month period.
CONCLUSIONS: Full body screening CT scans appear to be an increasinglymore common procedure performed in our community. The tumors found by thisdiagnostic modality in these asymptomatic individuals referred to this universityhave not been small, all requiring nephrectomy. This new trend in scanning hasgiven rise to a new breed of "incidentalorna" in patients with relatively fewercomorbidi ties and has had a significant impact on our practice accounting for23.3% of our hand assisted laparoscopic surgeries over a seven month period.
Data from 30Consecutive HALN's
PRESENTATION #of Comorbidities Avg. Avg. Tumor PathologyPts. Age Size(em)
Endoscopic Management of Renal DiseasesVideo Session
Wednesday, April 30, 2003 1:30·3:30 PM
V1865APPLICATION OF THE URETERAL ACCESS SHEATH TOFACILITATE PERCUTANEOUS NEPHROLITHOTOMYRamakrishna Venkatesh*, David I Lee, Richard Vanlangendonk, St. Louis,MO; Chandru P Sundaram, Indiana, IN; Jaime Landman, St. Louis, MO
INTRODUCTION AND OBJECTIVE: Commonly endourologists initiatePCNL, by retrograde passage of a ureteral catheter or a balloon occlusion catheterwith inflation of the balloon at the UPI to prevent migration of stone fragments intothe ureter and to allow retrograde instillation of air and/or contrast material tofacilitate puncture. We have altered our technique for PCNL due to revisions in thedesign of the ureteral access sheath; this video will demonstrate this use of theaccess sheath.
METHODS: The patient is positioned in the prone with the legs on spreaderbars. Using the Amplatz superstiff wire, a l21l4Fr Ureteral Access Sheath (AppliedMedical, Rancho Santa Margarita, CAl is advanced up to the ureteropelvic junctionunder fluroscopic guidance. The sheath can be used to instill contrast, air or salineto facilitate the percutaneous access. The access sheath facilitates passage of aguide wire through the percutaneous tract down the ureter out of the urethra for asafe maintenance of access. Initial assessment of the stone is performed with aflexible ureteroscope and if the stone is soft it could be treated by this approach,otherwise percutaneous nephrolithotomy is performed. Nephroscopy and ultrasoniclithotripsy is performed. The access sheath facilitates the passage of stonefragments down the ureter directly out of the body. Between 8/2001 and 712002, 22combined antegrade and retrograde PCNL's were performed by a single surgeon(IL). Nine complete or partial staghom calculi were treated during this time period.The records of these 9 patients were retrospectively reviewed.
RESULTS: Mean OR time was 3.1hours. Mean EBL was 290mL(lOO-900mL),and patients required a mean of 33.2mg MS04 equivalents. The mean hospitalstay was 3.2 days. Complete stone clearance was achieved in 7/9 (78%) of patients.One patient did not undergo a second look procedure due to pulmonarycomplications. This patient had a 4-mm uric acid residual fragment and underwentoral alkalinization that resulted in stone resolution. A second patient was found to
*Presenting author.
have multiple small fragments in the lower pole at I-month follow-up that requireda subsequent ureteroscopic stone extraction.
CONCLUSIONS: Application of the ureteral access sheath during PCNLimproves renal access and thus allows the endourologist to unite the upper andlower urinary tract. Presently we have altered our technique to include the ureteralaccess sheath for all our PCNL procedures.
Source of Funding: None.
V1866THE EFFICACY OF THE STONE CONE FOR PROXIMALURETERAL STONES Steven D Maislos", Brooklyn, NY; Michael AVolpe, Peter S Albert, Adley Raboy, Staten Island, NY
INTRODUCTION AND OBJECTIVE: While ureteroscopic lithotripsy is atleast as efficacious as ESWL in treating lower ureteral stones, the same can not besaid of its ability to treat proximal ureteral stones. Since failed proximal ureterallithotripsy is often due to the ensuing complications associated with stonemigration into the renal pelvis and calyces, an instrument that can prevent thismigration is a potentially important tool in the ureteroscopic tool armamentarium.This study seeks to assess the role for just such an instrument, the stone cone, inproximal ureteral lithotripsy.
METHODS: For a 3 month period, we treated all patients with proximalureteral stones using semirigid ureteroscopy, a stone cone nitinol urologicalretrieval coil, and holmium- YAG laser lithotripsy. A total of 10 such patients weretreated in this fashion. In all 10 patients, both a stone cone and a holmium-YAGlaser fiber (200 or 365 micron) were deployed and utilized under visual guidancethrough the same working channel of the ureteroscope.
RESULTS: All 10 patients were rendered stone free after holmium-YAGlaser ureteral lithotripsy in conjunction with a stone cone. The stones ranged insize from 6 mm to 2 em. No stone fragments were noted to migrate into therenal pelvis. In all 10 cases the stone cone was easily deployed. Thesimultaneous use of both the stone cone and either a 200 or a 365 micronholmium-YAG laser fiber in a solitary 4 French working channel still allowedfor excellent irrigation. Likewise, the simultaneous use of the stone cone in a3 French working channel with a 200 or 365 micron holmium-YAG laser fiberin a parallel 2 French working channel also allowed for excellent irrigation. Itshould be noted that the stone cone did not break and never became entrappedin any of the 10 cases. Finally, it was also observed that the stone cone appearedto minimize the amount of ureteral motion normally associated withrespirations; thereby facilitating lithotripsy.
CONCLUSIONS: The stone cone is a powerful new tool for proximal ureterallithotripsy which will likely revolutionize the treatment of proximal ureteral stones.The savings in morbidity, time, and money associated with not having to chasestone fragments using flexible ureteroscopy is invaluable.
Source of Funding: None.
V1867NEOINFUNDIBULOTOMY FOR THE MANAGEMENT OFSYMPTOMATIC CALYCEAL DIVERTICULA Fernando CDelvecchio*, Steven A Terranova, Brian K Auge, Paul K Pietrow, Glenn ENewman, Glenn M Preminger, Durham, NC
INTRODUCTION AND OBJECTIVE: Shock-wave lithotripsy (SWL) andureteroscopy may be used to manage stones within a calyceal diverticulum, yetpercutaneous nephrolithotomy (PNL) remains the preferred and optimum methodof attaining stone-free and symptom-free results. However, passing a guide wirethrough a stenotic infundibulum is, at times, impossible. Herein we illustrate analternative technique that creates a neoinfundibulum during percutaneousmanagement of calyceal diverticula.
METHODS: Over a six year period, 18 of 22 patients undergoing PNL formanagement of calyceal diverticula required neoinfundibulotomy for securethrough-and-through wire placement. Presenting complaints included pain, UTIand nausea with emesis. Seventeen of eighteen (94.4%) had stones within thediverticulnm (mean 11.7 x 12 mm). Under fluoroscopy, once a wire isunsuccessfully passed through the narrow infundibulum of the diverticulum,the access needle is advanced directly through the wall of the diverticulum intothe collecting system, and the nephroscopy tract is dilated. Percutaneous stoneremoval is accomplished in the usual manner, and a 22F Councill catheter isplaced into the collecting system to allow epithelialization of the newinfundibulum.
RESULTS: Complete resolution of symptoms occurred in 11 of 12 patients,withthe improvement in pain in the remaining individual. 80% of patients with followupimaging were stone free at an average of 6 weeks postop (2 patients failed to return).The average residual stone burden was 2.6 x 2 mm. The diverticulumwas absent oncontrast imaging in 10/16 patients (63%). Two intrathoracic complications occurredafter supra-11th rib access, both successfully managed with chest tubes.
Vol. 169, No.4, Supplement, Wednesday, April 30, 2003 THE JOURNAL OF UROLOGY® 499
CONCLUSIONS: Neoinfundibulotomy offers a safe, simple and effectivemeans of managing symptomatic calyceal diverticula, while ensuring secure accessto the main collecting system. One should consider this technique when the stenoticinfundibulum cannot be traversed by the safety guidewire.
Source of Funding: None.
V1868THE MINI-PERC: A LESS INVASIVE ALTERNATIVE TOSTANDARD PERCUTANEOUS NEPHROLITHOTOMY ?Francesco Francesca*, Renato Felipetto, Pisa, Italy; Pier Francesco Buli,Roberto Bordini, Bologna, Italy
INTRODUCTION AND OBJECTIVE: The concept of Mini-Perc evolvedfrom the use of smaller working sheaths to reduce trauma during pediatricpercutaneous nepholithotomy. Using a working nephrostomy tract less than 16 Fr,the goal is to maintain the effectiveness of standard PCNL while significantlyreducing the morbility of the procedure.
METHODS: The video shows two PCNL performed using a prototype 12 Frmini-nephroscope (Direction of View: 12°; Shealth: 15 Fr; Working Length: 225mm; Working Channel: 6 Fr). After positioning an ureteral catheter the patient isplaced in the prone position with supportive bolsters in place. Two differentprocedures to positioning the safe guide-wire are shown in the video. The tract isdilated until 14 Fr using coaxial Aiken dilatators. To improve the out-flow of theirrigant solution, a 14 Fr Amplatz sheath is used to establish the working access,instead of the specific metallic outer sheath of the endoscope. Stones were removedwith a combination of lithotripsy and extraction using graspers. The small pieceseasily passed around the scope and out the sheath. At the end of the procedure a 8Fr nephrostomy pig tail catheter was positioned for drainage and left in place for12 hours.
RESULTS: The patient was discharged stone free without drainage the dayafter.
CONCLUSIONS: The Mini-Perc technique has been facilitated by advanced inendoscopic equipment and potentially provides a less invasive alternative tostandard PCNL for low volume renal calculi. As compared with standard PCNL,the Mini-Perc technique seems to have similar early success rates in selectedpatients and may offer advantages with respect to hemorrhage, postoperative painand shorter hospital stays.
Source of Funding: None.
V1869PERCUTANEOUS VASECTOMY J Stephen Jones", Cleveland, OH
INTRODUCTION AND OBJECTIVE: We report a simplified method to avoidthe most difficult step of no-scalpel vasectomy while maintaining its minimallyinvasive advantages.
METHODS: Using the no-scalpel vasectomy instruments in percutaneousfashion, we perform vasectomy in the office setting without fixation of thevas to skin using the ring clamp. The sharp no-scalpel hemostat punctures theskin. The vas is then grasped with the ringed instrument instead of piercing thevas and performing the supination maneuver as described for no-scalpelvasectomy.
RESULTS: Percutaneous vasectomy has been performed on over 600 men bya single surgeon. Among 35 consecutive cases recently reviewed, operative timesaveraged 9.3 minutes, with an additional 67 seconds added when a residentperformed the procedure on one side in 15 of those cases. Incisional length,determined by the "knuckle" of vas pulled through a puncture, averages 8.4 mm.Patients report complete recovery averaging 8.9 days. No major complicationshave occurred. One case of recanalization has been noted (0.17%), successfullycorrected with repeat percutaneous vasectomy.
CONCLUSIONS: Percutaneous vasectomy is a minimally invasive option forpermanent male sterilization that avoids the difficult aspects of no-scalpelvasectomy. We have found it easier to teach to residents than the other alternatives.
Source of Funding: None.
V1870ROBOT ASSISTED KIDNEY TRANSPLANTATION AndrasHoznek*, Matthew Gettman, Patrick Antiphon, Alexandre De La Taille,Laurent Salomon, Fabien Saint, Adrian Lobontiu, Clement-Claude Abbou,CRETEIL, France
INTRODUCTIONAND OBJECTIVE:Robotic technologyhas a long establishedrole in several fields of industry. One advantage of robots is their ability to placehumans at a safe distance from hazardous material. In urology, in addition to dexterityenhancement and motion scaling, this new technology opens the horizon of remotesurgery.This latter advancementhas potentialuse during surgery involvinga high risk
of patient-to-professional or professional-to-patient virus transmission. This filmpresents the first case of robotic assisted kidney transplantation.
METHODS: A right cadaveric kidney was transplanted into a 26-year-old malepatient who has been on hemodialysis for II years. Surgery was done with the helpof the da Vinci robot (Intuitive Surgical, Inc., Mountain View, California) by aremote surgeon, who completely performed vascular dissection and anastomosis aswell as ureterovesical anastomosis. The role of the assistant by the side of thepatient was limited to access creation, exposure, hemostasis and maintainingtraction on the running sutures performed by the robot.
RESULTS: Operative time was 178 minutes. Robotic assistance madeanastomosis possible by its unique ability of stereoscopic magnification andultra-precise suturing techniques due to the flexibility of the robotic wristedinstruments. Renal perfusion was excellent with immediate diuresis.
CONCLUSIONS: This initial experience demonstrates that robotic assistedkidney transplantation is feasible. Currently technical and financial barrierslimit the widespread use of robots. However, with advances in miniaturization,computer technology and high speed data transmission the routine use oftelerobotics will likely be added to the surgical armamentarium within the nextdecades.
Source of Funding: None.
V1871VIDEO-ASSISTED MINILAPAROTOMY SURGERY (VAMS)SINGLE-SURGEON LIVE DONOR NEPHRECTOMY Seung CYang*, Seoul, South Korea; Koon H Rha, Baltimore, MD; Joong S Lee, SeungH Lee, Duk H Kwon, Dong] Kim, Seoul, South Korea
INTRODUCTION AND OBJECTIVE: Recently, a great interest inminimally invasive procedures in kidney transplant has been taking place.Laparoscopic donor nephrectomy requires a surgeon and an assistant duringretrieval process. Based on the experience with minilaparotomynephrectomies(J Urol 165(4): 1099-1102, 2001) and recent improvements insurgical equipments, video-assisted minilpaprotomy (VAMS) live donornephrectomies performed by a single surgeon has been standard in our centerusing a newly developed retractor system.
METHODS: Operations were performed by single surgeon and an assistant,with the help of specially designed piercing abdominal and peritoneal retractors(Thompson Surgical Instruments Inc, USA). With improvement in retractors, thelast 31 cases were performed by single surgeon without an assistant. A 5 to 7 em.transverse pararectal skin incision is made at the level of l Oth rib and theabdominal muscles are split without division. A 10 mm. port is placed at the lowerabdomen to allow for the telescope. The procedure is performed extraperitoneally,combining open and laparoscopic instruments under direct vision. Renal pediclesand ureters are ligated using laparoscopic clips and sutures. The kidney is removedvia laparotomy and the wound is closed.
RESULTS: Average operating time for the 157 live donor nephrectomies was130 (85-210) minutes, and there was no case of kidney loss, open surgicalconversion or blood transfusion. Mean warm ischemia time was 2.3±1.2 minutesand average incision length was 6.5 em. (range 5.1 to 7.0). Oral intake, return toambulation and postoperative analgesic requirements for video assisted andconventional open donor nephrectomies were 16 vs 31 hours, 1.5 vs 3.1 days and21 vs 43 mg morphine equivalent, respectively (p<0.05).
CONCLUSIONS: Live donor nephrectomy via minilaparotomy can be safelyperformed using video-assistance and retractor system has been successfullyperformed. We believe this minimally invasive technique with the elimination ofsurgical assistant and minimal use of laparoscopic instruments has broadimplications.
Source of Fundiug: None.
V1872
WITHDRAWN
500 THE JOURNAL OF UROLOGY® Vol. 169, No.4, Supplement, Wednesday, April 30,2003
V1873COMBINED ROBOTIC-ASSISTED AND MANUAL LAPAROSCOPIC LEFT RETROPERITONEAL LYMPH NODES DISSECTION FOR NONSEMINOMATOUS TESTICULAR CANCERPaulos Yohann es*, Yaoming Gu, Omaha, NE
INTRODUCTION AND OBJECTIVE: The use of minimally invasive surgeryis becoming increasingly common . The use of the da Vinci robot (IntuitiveSurgical , Mountain View , CAl has inherent advantages of a three-d imensionalconsole that allows for a lOX magn ification of the operative field, that translatesinto better visualization of vital structures such as the sympathetic chain , that needto be preser ved. From this regard, the da Vinci can be a vital tool duringlaparos copic retroperit oneal lymph node dissection.
METHODS : The use of minimally invasive surgery is becoming increasinglycommon. The use of the da Vinci robot (Intuitive Surgical, Mountain View, CAl hasinherent advantages of a three-dimensional console that allows for a lOX magnificationof the operative field, that translates into better visualization of vital structures such asthe sympathetic chain, that need to be preserved. From this regard, the da Vinci can bea vital tool during laparoscopic retroperitoneal lymph node dissection.
RESULTS : The operative time was 7 hours (3 hrs for robotic, 4 hrs for manu allaparoscopy). Estimated blood loss was 100cc. Hosp ital stay was four days.Postoperative analgesic use was 33 mg of Morphine sulfate. With return of bowelfunction on POD 2, patient was tolerating a regular diet on POD3. The return tonormal activity was in 2 weeks. The pathological analysis of the specimen showed32 lymph nodes, with no evidenc e of malignancy. The case was converted fromrobotic to manual laparoscopy due to mechanical interference between the cameraand working robotic arms of the da Vinci.
CONCLUSIONS : Robotic dissection during retroperitoneal lymph node dissectionfacilitates preservation of vital structures. Multiple ports for the working arm of therobot and repositioning of the surgical working cart during the case is critical tocomplete dissection of the nodes within the template using solely the robot.
Source of Funding: None .
V1874LAPAROSCOPIC SPLENORENAL BYPASS: SURVIVAL STUDYGyung Tak Sung *, Sidney C Abreu, lnderbir S Gill, Anup Ramani, AmgadFarouk , Andrew Steinb erg, Chia-Hsiang Lin, Kevin Banks, Mahesh Gael,Wilson Molina , Jihad Kaouk, Cleveland, OH
INTRODUCTIO N AND OBJECTIVE: Splen orenal bypass is a major surgicalprocedure for the management of renal artery stenosis. In this video, we evaluatethe feasibilit y and efficacy of performin g a laparoscopic splenorenal bypass in achronic canine model (6 male dogs/ 25 - 30Kg / 1- 2 moths follow-up).
METHODS : A 5 to 6 port transperitoneal approach was employed. The renalartery was identified and dissected. The distal splenic artery was mobilized, itsproximal end was clamped, and its distal end was clipped and transected. Afterproximal clamping, the renal artery was transected and cannulated with a 3 Fr. ballooncatheter. Intracorporeal renal hypothermia was achieved in situ by intra-arterialperfusion of ice-cold solution. Manitol (12.5 mg) and heparin 2000 ill (N) were givenat this time. An end-to-end anastomosis was performed using laparoscopic free-handsuturing (6-0 Prolene / RB-2 needle) exclusively. Due to the disparaty in the caliber ofthe splenic and renal arteries in thecanine model, complete dissection and adequatespatulation of the tip of both arteries were critical to the success of the anastomosis.During the performance of the anterior wall anastomosis the catheter was kept withinthe renal artery, thus maintaining the kidney in cold ischemia conditions. Aftercompleting the anterior wall anastomosis, the arterial catheter was removed and theposterior wall anastomosis was completed.
RESULTS: Total operative time was 297 minut es (SD= 36) . Mean time toreestablish renal perfusion was 7 1 (SD= 8). At euth anasia, IVP showed earlyvisualization of the left kidney with prompt drainage in 5 of 6 surviving animals.In one animal with two left renal arteries, a distal thrombosis was found despitepatent anastom otic site.
CONCLUSIONS : Lapa roscopic splenorenal bypass can be performed utilizingintracorporeal techn iques exclu sively. Despite of techn ical challenges, this studymay for the basis for perform ance of complex urologic vascular procedureslaparoscopically.
Source of Funding: None.
V1875LAPAROSCOPIC MANAGEMENT OF INTRA-PARENCHYMALRENAL ARTERY ANEURYSM Christopher S Ng*, Sidney C Ab reu,Andrew P Steinberg, Mihir M Desai, Wilson Molina, Surena F Matin, JihadKaouk, Inderbir S Gill, Cleveland, OH
INTRODUCTION AND OBJECTIVE: Renal artery aneurysms are rare lesionsthat may cause deterioration of renal function and arc prone to rupture as theyenlarge. In this video, we describe a laparoscopic approach of management of alarge intra-renal aneurysm.
· Presenting author.
METHODS: A 51-year-old gentleman presented with microscopic hematuri a.Thre e-dimensional CT scan revealed a multi-lobulated intrarenal aneurysm arisingfrom the upper pole branch. Selective renal angiography confirmed these findings.The patient consented to a laparoscopic right upper pole partial nephrectomy. A4-port transperitoneal approach was employed. Gerota's fascia was incised,exposing the upper pole of the kidney and the surface of the aneurysm , The renalhilum was dissected, and the renal artery branches were identified. Laparo scopicultrasonography identified the parenchymal margin of excision. Color flowDoppler was employed to identify the feeding vessel to the aneury sm, which wascircumferent ially mobilized. clipped and divided . Doppler ultrasonograph y thenconfirmed the lack of blood flow within the aneurysm. A Satin sky clamp was usedto control the renal hilum en bloc. Cold-cut scissors were used to excise theaneurysm from the remaining normal kidney. Injection of diluted methylene bluethrou gh the pre-placed ureteral catheter revealed a pelvicaliceal entry, which wassuture-repaired in a water-tight manner. Parenchymal hemo stasis was achievedwith placement of figure-of-eight sutures over Surg icel bolsters. The hilum wasthen unclamped and the kidney returned to a normal color without bleeding fromthe dissection bed.
RESULTS: Total warm ischemia time was 39 minutes. Operative time was 4hours. Blood loss was 400 cc. The patient resumed ambulation and oral intake thefollow ing day.
CONCLUSIONS : Laparosc opic managemen t of intra-parenchymal renal arteryaneurysm is feasible and safety. Intraoperative Doppler ultrasonography was usefulin precisely localiz ing the feedin g branch to the aneurysm.
Source of Funding: None.
V1876LAPAROSCOPIC RIGHT AND LEFT RETROPERITONEALLYMPH NODE DISSECTION Wilson R Molinar, Andrew Steinberg,Sidney Abreu, Jihad Kaouk, Mihir Desai, Anup Ramani, Inderbir Gill,Cleveland , OH
INTRODUCTION AND OBJECTIVE: Retroperitoneal lymph nodesdissecti on is indicated in patients with clinical stage I testicula r neoplasm.Lapar oscopic RPLND has been proposed as an effective minimally invasivealternative. In this video. our techniques for laparo scopic right and left RPLND aredemonstrated .
METHODS: Right RPLND : 20 year old patient with right clinical stage Inon-semin omatou s germ cell carcinoma with 95% of embryonal tumor . AFP andbeta-HCG normalized after orchiectomy. Chest x-ray and abdomin al-pelvic CTscan were normal. Laparo scopic Right RPLND was performed by a live porttransperitoneal approach: ( I) port placement, (2) mobilization of the right colon,(3) exposure of the aorta and complete mobili zation of the inferior venacava, (4)excision of the inter aorto-c aval-lymph nodes , (5) exc ision of the retrocaval lymphnodes , (6) excision of the right spermatic vein and (7) excision of para-caval lymphnodes. Left RPLND: 25 year old patient with clinical stage I non-seminomatousgerm cell carcinoma with 40 % of embryonal tumor. AFP and beta -HCGnormalized after orchiectomy. Chest x-ray and abdominal-pelvic CT scan werenorma l. Laparoscopic left RPLND has perform ed by a five port transperitonealapproach : ( I) port placement, (2) mobilization of left colon,(3) dissection andclipping of the left spermatic vein, (4) dissection of the para-aortic lymph nodes .(5) dissection of the inter aorto-caval and retroaort ic lymph nodes, (6) enblocklymph nodes extraction.
RES ULTS; Case I: OR time = 4 hrs, estimated blood loss = 5Occ, hospitalstay less than 24 hrs, convalesce nce =2 weeks, pathology revealed 13 negati velymph nodes and patient reported normal antegrade ej aculation. Case 2: ORtim e =6 .5 hrs , estimated blo od loss = 100cc. hospital stay=48 hrs ,convalescence = 3 weeks, pathology revealed II negative lymph nodes and patientreported non antegrade ejaculation.
CONCLUSIONS: Laparo scopic RPLND is a feasible and oncologi c surgicaloption for patients with clinical stage I NSGCTT. Right and left RPLND can beperformed respecting open surgical templates.
Source of Funding: None.
V1877LAPAROSCOPIC PYELOPLASTY WITH CONCOMITANTPYELOLITHOTOMY (138 CALCULD Christopher S Ng*, Sidney CAbreu, Wilson Molina, Surm a F Matin, Jihad Kaouk; Inderbi r S Gill, StevanB Streem, Cleveland, OH
INTRODUCTION AND OBJECTIVE: Minimally-invas ive treatment optionsfor concomitant ureteropelvic j unction obstruction (UPJO) and renal calculiinclude antegrade endopyelotomy with pe rcutaneous stone removal orureteroscopic endopyelotomy with intracorporeal lithotripsy. Thi s videodocuments our laparoscopic approa ch to UPJO with concomitant stones.
METHODS: A 51- year-old gentleman with a long-standing history ofUPJO and renal calculi had fail ed a retrograde endop yelotomy. Radiographic
Vol. 169, No.4, Supplement, Wednesday, April 30, 2003 THE JOURNAL OF UROLOGY® SOl
evaluation confirmed recurrent UPJO with innumerable renal calculi.Laparoscopic pyeloplasty with pyelolithotomy was performed as follows. Aftercystoscopic insertion of a double pigtail ureteral stent, the patient was placedin sixty-degree left flank position. A 4-port transperitoneal approach wasemployed. The descending colon and spleen were reflected, and the renal pelvisand proximal ureter were completely mobilized. Flexible nephroscopy wasperformed through a I-cm pyelotomy, which was well away from the UP] soas not to compromise the repair. Using a 5.5 French flat wire basket, the stoneswere extracted onto a gauze sponge, then placed in an Endocatch bag,introduced through an additional port site. The collecting system was exploredwith the laparoscope, and remaining stones were flushed out with the suction-
irrigator device. The pye!otomy was closed with a running suture, and anAnderson-Hynes dismembered pyeloplasty was performed using intracorporealfree-hand suturing exclusively.
RESULTS: Total operative time was 6 hours. Estimated blood loss was 200 cc.A total of 138 stones were removed. The patient resumed oral intake andarnbulation the following day. Initial postoperative x-ray revealed two residualcalculi, which were treated with ESWL. Follow-up x-ray showed no stones. He iscurrently asymptomatic.
CONCLUSIONS: Although technically demanding, laparoscopic pyeloplastywith pyelolithotomy can be performed safely and efficaciously.
