Biomedical subjects

E M McDougall

Publications and source records attributed to E M McDougall.

At least 19 recordsLinked to original sources

PubMed2001

Laparoscopic management of female urinary incontinence.

Recent technologic developments in laparoscopic reconstructive surgery have generated an interest in the laparoscopic approach to bladder neck suspension. There have been numerous descriptions of a variety of techniques for the laparoscopic approach to bladder neck suspension. Initial reports seemed to suggest satisfactory rates of improvement in the stress urinary incontinence of these patients. Long-term follow-up has shown that although this minimally invasive approach to the management of stress urinary incontinence is associated with a short duration of urinary diversion, minimal postoperative discomfort, and a quick return to a productive life, the durability of the cure has failed the test of time. The laparoscopic bladder neck suspension in 3 and 4 years follow-up has achieved a success rate of only 30%, with a mean time to failure of 18 months. Any new surgical technique applied to the management of stress urinary incontinence must have a minimum of 2 years mean follow-up to determine its true clinical efficacy and durability.

Female↗

PubMed2001

Comparison of real-time instruments used to monitor airborne particulate matter.

Measurements collected using five real-time continuous airborne particle monitors were compared to measurements made using reference filter-based samplers at Bakersfield, CA, between December 2, 1998, and January 31, 1999. The purpose of this analysis was to evaluate the suitability of each instrument for use in a real-time continuous monitoring network designed to measure the mass of airborne particles with an aerodynamic diam less than 2.5 microns (PM2.5) under wintertime conditions in the southern San Joaquin Valley. Measurements of airborne particulate mass made with a beta attenuation monitor (BAM), an integrating nephelometer, and a continuous aerosol mass monitor (CAMM) were found to correlate well with reference measurements made with a filter-based sampler. A Dusttrak aerosol sampler overestimated airborne particle concentrations by a factor of approximately 3 throughout the study. Measurements of airborne particulate matter made with a tapered element oscillating microbalance (TEOM) were found to be lower than the reference filter-based measurements by an amount approximately equal to the concentration of NH4NO3 observed to be present in the airborne particles. The performance of the Dusttrak sampler and the integrating nephelometer was affected by the size distribution of airborne particulate matter. The performance of the BAM, the integrating nephelometer, the CAMM, the Dusttrak sampler, and the TEOM was not strongly affected by temperature, relative humidity, wind speed, or wind direction within the range of conditions encountered in the current study. Based on instrument performance, the BAM, the integrating nephelometer, and the CAMM appear to be suitable candidates for deployment in a real-time continuous PM2.5 monitoring network in central California for the range of winter conditions and aerosol composition encountered during the study.

Air Pollution↗

PubMed2001

Does the cleaning technique influence the durability of the <9F flexible ureteroscope?

BACKGROUND AND PURPOSE: The fragility of the <9F flexible ureteroscope limits its availability to general urology practice. The purpose of this study was to determine whether the technique used to clean the flexible ureteroscope or the number of persons handling the instrument during the cleaning process influenced endoscope breakage or deterioration during regular endourologic use. PATIENTS AND METHODS: A new Olympus URF/P3 flexible 7.5F ureteroscope was used for each of two 30-day study periods during which a single surgeon used the endoscope for a variety of upper urinary tract procedures. During the first 30-day period (Group 1), the endoscope was leak-proof-pressure tested and cleaned by the endourology support team using the Steris 20 (peroxyacetic acid 35%) technique. During the second 30-day period (Group 2), the endoscope was leak-proof tested and cleaned only by the surgeon using the Cidex (glutaraldehyde 2.4%) technique. A record was kept for each ureteroscopic case to document the patient position, access technique, time the endoscope was in the urinary tract, instruments passed through the ureteroscope, and the maximum irrigant pressure used. In addition, a record was made of the number of broken fibers, the degree of flexion and deflexion of the endoscope, and the problems encountered with the endoscope during the case. RESULTS: The two study groups were similar in terms of the total number of cases performed, the mean time the endoscope was in the urinary tract per case, the access approach used, and the use of the ureteral access sheath and ancillary equipment. In Group 2, the endoscope was used for a longer total time (618 minutes v 457 minutes), and access to a lower pole calix was more than twice as common as in Group 1. This may explain why more broken fibers were noted in the instrument used in Group 2 over the study period (eight v four broken fibers) than in Group 1. The only breakage occurred as a result of the surgeon accidentally activating the laser probe inside the working channel of the endoscope in Group 2. CONCLUSION: The technique and number of personnel involved in the maintenance and cleaning of the flexible ureteroscope does not have a significant effect on the durability and function of these instruments. It is the arduous demands of the endourologic procedure that influence the durability of these fragile endoscopes.

Disinfectants↗

PubMed2001

Laparoscopic management of retrovesical cystic disease: Washington University experience and review of the literature.

BACKGROUND AND PURPOSE: Recently, the laparoscopic approach to the management of seminal vesicle cysts has been described. This report outlines the Washington University experience and reviews the present literature to evaluate the results of the laparoscopic approach to the excision of retrovesical cysts of seminal vesicle and Müllerian origin. PATIENTS AND METHODS: The hospital and office records of three patients undergoing laparoscopic excision of seminal vesicle and Müllerian duct cyst disease between April 1993 and March 1999 were reviewed for the operative time, the estimated blood loss, total hospital stay, total analgesia required postoperatively, the time to resumption of oral intake, and the postoperative recovery. A literature search revealed two additional reports of laparoscopic management of cystic disease of the seminal vesicle, comprising only one and two patients. An additional review of the literature was performed to compare the laparoscopic procedure with the transvesical, transurethral, open transvesical, and open retrovesical approach for the management of the disease. RESULTS: For the three patients at Washington University, the operative time averaged 4 hours (range 1.8-6.1 hours), and the mean estimated blood loss was 150 mL (range 50-200 nL). The patients required a mean of 43 mg of morphine sulfate for postoperative pain control, had a mean hospital stay of 2.6 days, and resumed oral intake 5.8 hours postoperatively. In combination with the three other cases reported in the literature, the average operative time for laparoscopic retrovesical cyst excision was 2.9 hours, and the average hospital stay was 2.2 days. With an average follow-up of 17 months, all six patients had excellent resolution of their preoperative symptoms. There have been no major or minor complications or any need for further operative therapy. CONCLUSION: Laparoscopic excision of retrovesical cystic disease is an effective surgical procedure, associated with minimal postoperative morbidity, short hospitalization, and a rapid recovery for the patient.

Adult↗

PubMed2001

Assessment of optimal balloon size for rupture of the ureteropelvic junction and mid-ureter in a porcine model.

PURPOSE: Balloon dilation potentially represents a safer and simpler technique for the treatment of ureteropelvic junction (UPJ) obstruction and ureteral strictures. Using a porcine model, we sought to establish the optimal balloon size for endoballoon rupture of the UPJ and ureter. MATERIALS AND METHODS: The efficacy of endoballoon rupture of the proximal and middle ureter with 24F, 30F, and 36F balloon catheters was compared in 19 female minipigs. At the proximal ureter, the effect of the rate of dilation also was evaluated for each balloon size. Extravasation of methylene blue-stained contrast material was assessed with retrograde pyelograms and direct laparoscopic vision. After acute sacrifice, the dilated segments were evaluated histologically with hematoxylin and eosin and Masson's trichrome staining. RESULTS: At the proximal ureter, free extravasation of contrast was observed in 61% of the rapid inflation and 72% of the slow inflation trials; contained extravasation was noted in 28% of the rapid inflation and 17% of the slow inflation trials. Except for two of the 24F slow inflation trials, all of the proximal ureteral trials produced at least one full-thickness tear into the periureteral fat. Grossly, the tears appeared linear with various lengths and no consistent orientation. Rapid inflation and increasing balloon size tended to produce a ureterotomy with less damage to the ureter surrounding the tear. At the mid-ureter, none of the balloon sizes consistently produced a transmural tear. CONCLUSIONS: Rapid dilation and use of a 36F balloon capable of maintaining a low profile after inflation may result in a cleaner proximal ureterotomy with less distortion of the untorn neighboring proximal ureter. Both 36F and 30F balloons consistently produced a full-thickness proximal ureterotomy in normal porcine tissue. For mid-ureteral strictures, balloon dilation to even 36F may fail to create a suitable ureterotomy. However, it must be noted that dysplastic or scarred tissue may respond differently to dilation than the more elastic normal porcine tissues used in this study.

Animals↗

PubMed2001

Laparoscopic cyst marsupialization in patients with autosomal dominant polycystic kidney disease.

PURPOSE: Autosomal dominant polycystic kidney disease is characterized by progressively enlarging renal cysts associated with hypertension, renal failure, pain, hematuria and infection. We explored the role of laparoscopic cyst marsupialization for managing cyst related problems. MATERIALS AND METHODS: In 4 male and 11 female adults with autosomal dominant polycystic kidney disease who had preserved renal function laparoscopic cyst marsupialization was done for pain unilaterally and bilaterally in 9 and 6, respectively. An average of 204 cysts per kidney (range 11 to 635) were decorticated or drained. RESULTS: Average operative time was 5.5 hours. Patients were discharged from the hospital after an average of 3.2 days. At a mean followup of 2.2 years (range 0.5 to 5) pain was decreased an average of 62% (range 30% to 90%) in 11 cases (73%). One patient had no improvement and 1 had subsequent worsening of pain postoperatively. Two patients with initial improvement had pain recurrence 4 and 36 months postoperatively, respectively. Hypertension resolved in 1 patient (7%), improved in 20% and did not change in 40%. In 33% of the cases hypertension worsened, requiring additional antihypertensive medication. Renal function remained stable in 13 patients (87%), improved in 1 (6.5%) and worsened in 1 (6.5%). Overall patients who underwent a bilateral procedure had better long-term pain relief and more improvement in hypertension. CONCLUSIONS: Laparoscopic cyst marsupialization may effectively decrease cyst associated pain. In some cases hypertension may be improved. Renal function remained stable in all except 1 patient. At a mean followup of 2.2 years the benefits of aggressive laparoscopic cyst decortication appear to be relatively long lasting when bilateral decortication is indicated. The benefits of unilateral cyst decortication are less predictable and of shorter duration.

Adult↗

PubMed2001

Laparoscopic bilateral hand assisted nephrectomy for autosomal dominant polycystic kidney disease: initial experience.

PURPOSE: The laparoscopic technique for bilateral nephrectomy in patients with autosomal dominant polycystic kidney disease is technically difficult. The procedure may be more acceptable if alterations to the technique made it safer and easier to perform. We describe our initial experience with, and the feasibility and potential benefits of hand assisted laparoscopic nephrectomy for approaching these large kidneys in patients with autosomal dominant polycystic kidney disease. MATERIALS AND METHODS: This approach was successfully applied in 3 patients with end stage renal disease due to autosomal dominant polycystic kidney disease. After obtaining transumbilical pneumoperitoneum ports were placed in the umbilicus (12 mm.), sub-xiphoid in the midline (12 mm.) and subcostal in the midclavicular line on each side (12 mm.). The table was tilted 40 degrees away from the planned side of initial nephrectomy with the patient in the half lateral position. A 7 cm. midline incision was made that incorporated the umbilical port and a commercially available hand assistance device was positioned. One surgeon hand was inserted into the abdomen to serve as a retractor/blunt dissector, while the other operated the electrosurgical instruments. The right hand was inserted for left nephrectomy and the left hand was inserted for right nephrectomy. The laparoscope was passed via the sub-xiphoid port and the instruments were placed through the ipsilateral subcostal laparoscopic port. Nephrectomy was completed and the specimen was removed through the hand port incision by draining the cysts as they were exposed to view via the midline incision. When dissection was difficult, an additional port was placed in the anterior axillary line at the umbilical level. Some cysts were ruptured or aspirated to decrease overall kidney size and make extraction possible via the 6 to 7 cm. midline incision. RESULTS: All procedures were successfully completed. Mean operative time for bilateral hand assisted laparoscopic nephrectomy was 5.5 hours (range 4.5 to 6.6). Estimated blood loss was 200 cc or less. Patients resumed oral intake on postoperative day 1. The mean amount of parenteral analgesics required postoperatively was decreased. Mean hospital stay was 4.3 days but it was 3 days when considering nephrectomy only. Patients returned to normal activity after an average of 2 weeks. There was sustained resolution of preoperative discomfort based on pain analog scales. At 1 month or less all patients recorded absent pain. They uniformly noticed improved preoperative pulmonary and gastrointestinal symptoms CONCLUSIONS: Hand assisted laparoscopic nephrectomy in patients with autosomal dominant polycystic kidney disease makes bilateral nephrectomy a reasonable option. The bilateral procedure may be performed as rapidly as laparoscopic only, unilateral nephrectomy in these cases. The advantages of the hand assisted approach include using tactile sensation to facilitate dissection, rapid blunt finger dissection, hand retraction and the application of immediate tamponade when needed. This procedure provides the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay and rapid convalescence in this group of patients at high risk.

Adult↗

PubMed2001

Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi.

PURPOSE: We compared the efficacy of shock wave lithotripsy and ureteroscopy for treatment of distal ureteral calculi. MATERIALS AND METHODS: A total of 64 patients with solitary, radiopaque distal ureteral calculi 15 mm. or less in largest diameter were randomized to treatment with shock wave lithotripsy (32) using an HM3 lithotriptor (Dornier MedTech, Kennesaw, Georgia) or ureteroscopy (32). Patient and stone characteristics, treatment parameters, clinical outcomes, patient satisfaction and cost were assessed for each group. RESULTS: The 2 groups were comparable in regard to patient age, sex, body mass index, stone size, degree of hydronephrosis and time to treatment. Procedural and operating room times were statistically significantly shorter for the shock wave lithotripsy compared to the ureteroscopy group (34 and 72 versus 65 and 97 minutes, respectively). In addition, 94% of patients who underwent shock wave lithotripsy versus 75% who underwent ureteroscopy were discharged home the day of procedure. At a mean followup of 21 and 24 days for shock wave lithotripsy and ureteroscopy, respectively, 91% of patients in each group had undergone imaging with a plain abdominal radiograph, and all studies showed resolution of the target stone. Minor complications occurred in 9% and 25% of the shock wave lithotripsy and ureteroscopy groups, respectively (p value was not significant). No ureteral perforation or stricture occurred in the ureteroscopy group. Postoperative flank pain and dysuria were more severe in the ureteroscopy than shock wave lithotripsy group, although the differences were not statistically significant. Patient satisfaction was high, including 94% for shock wave lithotripsy and 87% for ureteroscopy (p value not significant). Cost favored ureteroscopy by $1,255 if outpatient treatment for both modalities was assumed. CONCLUSIONS: Ureteroscopy and shock wave lithotripsy were associated with high success and low complication rates. However, shock wave lithotripsy required significantly less operating time, was more often performed on an outpatient basis, and showed a trend towards less flank pain and dysuria, fewer complications and quicker convalescence. Patient satisfaction was uniformly high in both groups. Although ureteroscopy and shock wave lithotripsy are highly effective for treatment of distal ureteral stones, we believe that HM3 shock wave lithotripsy, albeit slightly more costly, is preferable to manipulation with ureteroscopy since it is equally efficacious, more efficient and less morbid.

Adult↗

PubMed2000

Evaluation of a chronic indwelling prototype mesh ureteral stent in a porcine model.

OBJECTIVES: Ureteral stents all share one general goal, drainage, and one major drawback, irritative symptoms in the kidney and bladder. In an effort to preserve drainage while minimizing irritation, a lightweight, self-expanding mesh stent was designed. Herein, we compare the in vivo tissue reaction and flow characteristics of the mesh stent to a standard 7F double-pigtail polyurethane stent. METHODS: Eight female Yucatan minipigs had bilateral stents placed: a mesh stent on one side and a standard 7F stent on the opposite side. Imaging and flow measurements were obtained in 4 pigs at 1 week and in another 4 pigs at 6 weeks. Following this procedure, the stents were removed, and the kidneys, ureters, and bladder were harvested en bloc for a blinded histopathologic analysis. RESULTS: The degree of stent-related tissue reactivity was low for both stents and appeared similar for the ureter and bladder. Overall, the mesh stent resulted in a decrease in inflammation along the urinary tract at 1 week, but this result was statistically insignificant (P = 0.55). Flow rate through the mesh stent tended to be greater than for the polyurethane stent both at 1 week and at 6 weeks. CONCLUSIONS: Overall, the mesh stent appeared to be well tolerated and provided for excellent flow.

Animals↗

PubMed2000

Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery.

OBJECTIVES: Laparoscopy may be complicated by neuromuscular injuries, both to the patient and to the surgeon. We used a survey to estimate the incidence of these injuries during urologic laparoscopic surgery, to assess risk factors for these injuries, and to determine preventive measures. METHODS: A survey of neuromuscular injuries associated with laparoscopy submitted to 18 institutions in the United States was completed by 18 attending urologists from 15 institutions. RESULTS: From among a total of 1651 procedures, there were 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2). Neuromuscular injuries were twice as common with upper retroperitoneal as with pelvic laparoscopy (3. 1% versus 1.5%). Among patients with neuromuscular injuries, those with rhabdomyolysis were heavier (means 91 versus 80 kg) and underwent longer procedures (means 379 versus 300 minutes), and those with motor deficits were older (means 51 versus 42 years of age). Of the surgeons, 28% and 17% reported frequent neck and shoulder pain, respectively. CONCLUSIONS: Although not common, neuromuscular injuries during laparoscopy do contribute to morbidity. Abdominal wall neuralgias, injuries to peripheral nerves, and joint or back injuries likely occur no more frequently than during open surgery, but risk of rhabdomyolysis may be increased. Positioning in a partial rather than full flank position may reduce the incidence of some injuries. Measures to reduce neuromuscular strain on the surgeon during laparoscopy should be considered.

Abdominal Muscles↗

PubMed2000

Renal physiology. Laparoscopic considerations.

Oliguria is a recognized component of the physiologic effect of increased intra-abdominal or retroperitoneal pressure. The cause is multifactorial, emanating from vascular and parenchymal compression, and is associated with systemic hormonal effects. Ureteral obstruction does not play a significant role. These changes are pressure-dependent and are usually not apparent until pressures reach 15 mm Hg or more. This effect is not associated with any histologic pathology or evidence of renal tubular damage. After the release of the pneumoperitoneum or pneumoretroperitoneum, the renal function and urine output return to normal with no long-term sequelae, even in patients with pre-existing renal disease. The entire operative team must understand the physiologic effects of CO2 insufflation, which allows appropriate intraoperative monitoring and management and minimizes intraoperative and postoperative complications.

Animals↗

PubMed2000

Laparoscopic nephroureterectomy. A new standard for the surgical management of upper tract transitional cell cancer.

Laparoscopic nephroureterectomy for upper tract TCC still remains somewhat controversial. Unlike laparoscopic radical nephrectomy, which has become widely accepted, LNU is still in its earliest stages. Although there are obvious benefits for the patient who has LNU--less pulmonary complications, less postoperative discomfort, a shorter hospital stay, a better cosmetic result, and a brief convalescence--there are significant concerns. The longer operative time creates a negative financial and professional inducement to learn this technique. Operative times need to fall into the 4-hour range or less to make the procedure cost-effective. Analysis of the efficacy of laparoscopic nephroureterectomy as a curative treatment modality is important. In the short-run, LNU seems to provide similar results to open nephroureterectomy for upper TCC. Although concerns over port site seeding, bladder recurrence, and intraperitoneal seeding have been voiced, these problems have not occurred. The higher incidence of local recurrence noted in the authors' series, however, is of concern and remains an unsettled issue. Despite these local recurrences, the overall cancer survival for a given grade and stage of upper tract TCC seem to be similar to survivals recorded after open nephroureterectomy. Still, the number of LNU cases remains small, and follow-up is brief. These patients need to be monitored closely, with follow-up CT scans over the next decade. The authors believe that there are still several significant hurdles standing in the path of LNU before it can become a widely accepted procedure. Issues of cost, training, and long-term efficacy must be answered definitively. To obtain these types of data, it will be necessary to create a multi-institutional, cooperative study to obtain sufficient numbers of patients with a more than 5-year follow-up on which to base future recommendations.

Carcinoma, Transitional Cell↗

PubMed2000

Laparoscopic nephrectomy in patients with end-stage renal disease and autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is often characterized by end-stage renal disease (ESRD) and problems including pain, hematuria, and infection. Open nephrectomy is curative; however, the morbidity of the procedure is considerable. Between 1995 and 1998, 11 laparoscopic nephrectomies were performed on nine symptomatic patients (five men and four women) with ESRD and ADPKD. Two patients underwent a staged bilateral laparoscopic nephrectomy. All patients presented with abdominal or flank pain and an abdominal mass. Other clinical problems included hypertension in eight patients, urinary tract infections in two patients, and gross hematuria in one patient. Seven patients were receiving long-term dialysis treatment, and two patients had undergone prior renal transplantation. Patients were evaluated for preoperative and postoperative pain, analgesic use, hospital course, and convalescence. The overall average operative time was 6.3 hours, with an average estimated blood loss of 153 mL. Eight nephrectomy specimens were removed by morcellation, and three specimens were removed intact through a 7- to 12-cm incision. The average hospital stay was 3 days, and the average time to normal activity was 5 weeks. With a mean follow-up of 31 months, all nine patients reported elimination of their preoperative pain based on a pain analogue score. Six major and two minor complications occurred, including blood transfusion, a vena cavotomy, splenic cyanosis, pulmonary embolism, clotted arteriovenous fistula, and brachial plexus injury. Incisional hernias occurred in two of the three patients who underwent open removal. One patient noted improvement, and two patients noted resolution of their hypertension postoperatively. Laparoscopic nephrectomy in patients with ADPKD and ESRD offers an effective alternative to open nephrectomy to manage renal-related pain. This procedure provides the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay, and rapid convalescence.

Aged↗

PubMed2000

Clinical effectiveness of new stent design: randomized single-blind comparison of tail and double-pigtail stents.

BACKGROUND AND PURPOSE: Stent morbidity appears to be secondary to lower urinary tract irritation. In an effort to decrease stent morbidity, a "one size fits all" Tail stent (Microvasive [Boston Scientific] Natick, MA) was developed with a 7F proximal pigtail and 7F shaft which tapers to a lumenless straight 3F tail. PATIENTS AND METHODS: We randomized 60 patients in a single-blind fashion to a 7F tail stent or 7F double-pigtail Percuflex stent. Patients were evaluated at the time of stent removal and 2 weeks later with a standardized questionnaire assessing: irritative lower tract symptoms individually and on a total scale of 0 (no symptoms) to 30 (worst symptoms), obstructive lower tract symptoms (on a total scale of 0-20), and upper tract irritative symptoms (on a total scale of 0-10). RESULTS: Patient age, weight, and height were similar in the two groups. Complications, including fever, urinary tract infections, emergency room visits, and the need for antispasmodics and pain medication, also demonstrated no significant difference. At the time of stent removal, patients who received a tail stent had significantly less urinary frequency and a statistically significant (21%) decrease in overall irritative voiding symptoms (12.2 v 15.4; p = 0.048). Two weeks after stent removal, the total irritative voiding symptoms was markedly decreased in both groups (7.1 in the Tail v 5.3 in the double-pigtail group; p = 0.15). Obstructive bladder and flank symptoms were not significantly different in the two stent groups, either at the time of stent removal or at 2 weeks after removal. CONCLUSION: In this randomized, single-blind study, the 7F Tail stent produced significantly less irritative symptoms than did the standard 7F double-pigtail stent. Obstructive symptoms tended to be less with the new stent, while flank symptoms were similar.

Adult↗

PubMed2000

Laparoscopic midsagittal hemicystectomy and replacement of bladder wall with small intestinal submucosa and reimplantation of ureter into graft.

BACKGROUND AND PURPOSE: A variety of biodegradable organic materials have been used for bladder wall replacement. In some instances, partial replacement has been done using laparoscopic reconstructive techniques. However, to date, this activity has been limited to small patches. Herein, we present the initial experience with laparoscopic sagittal hemicystectomy and the use of laparoscopic reconstructive techniques to replace half of the bladder with small-intestinal submucosa (SIS) and to reimplant the ureter into SIS. MATERIALS AND METHODS: Six female minipigs (20-25 kg) underwent transperitoneal laparoscopic sagittal hemicystectomy; the excised bladder wall was replaced with a 5 x 15-cm patch of SIS (Cook Biotechnology, Spencer, IN). The ipsilateral ureter was reimplanted through a small incision in the graft and secured with two sutures. Cystoscopy and cystometrograms were performed under general anesthesia preoperatively and at 6 and 12 weeks postoperatively. Tissues were harvested at 12 weeks. RESULTS: The procedure was successful in six animals (left three, right three). During cystoscopy at 12 weeks, the area of the graft was not distinguishable from normal mucosa. Cystometrograms revealed maintenance of volume and compliance, with volumes of 338, 343, and 369 mL and intravesical leak-point pressures of 37, 59, and 39 cm H2O at 0, 6, and 12 weeks, respectively. Antegrade ureterograms demonstrated extrinsic obstruction, minimal (two), moderate (three), or complete (one), at the ureterovesical junction. The kidney associated with the completely obstructed ureter was grossly hydronephrotic at sacrifice. Histologically, patchy epithelialization of the graft with a mixture of squamoid and mature transitional-cell epithelium was found. CONCLUSIONS: Laparoscopic hemicystectomy with replacement of the bladder wall and implantation of the ureter into the SIS graft is a feasible procedure. Clinical application awaits improvements in the method of ureteral reimplantation and longer follow-up to assess for ingrowth of muscle and nerve fibers.

Anastomosis, Surgical↗

PubMed2000

Laparoscopic nephropexy: long-term follow-up--Washington University experience.

BACKGROUND AND PURPOSE: Recently, laparoscopy has been reported as a minimally invasive approach for performing nephropexy in patients with symptomatic nephroptosis. Herein, we report our long-term follow-up of patients undergoing laparoscopic nephropexy for this indication. PATIENTS AND METHODS: Fourteen women presenting with right flank pain and radiologically documented nephroptosis underwent transperitoneal laparoscopic nephropexy. The hospital data were evaluated for operative time, time to oral intake, time to ambulation, amount of parenteral analgesics, and hospital stay. Pain analog scores and postoperative questionnaires were used to assess the long-term postoperative recovery of the patients. RESULTS: The average operative time was 4.1 hours (range 2.5-6.5 hours). The patients resumed oral intake an average of 16.5 hours (range 15-48 hours) postoperatively. Analgesic requirements averaged 37 mg of morphine sulfate equivalent (range 15-80 mg of morphine equivalent). The average hospital stay was 2.6 days (range 2-5 days). The average follow-up time for the 14 patients was 3.3 years, with an average 80% improvement in their pain (range 56%-100%). On average, the patients resumed their usual activities 6 weeks postoperatively (range 1-12 weeks). CONCLUSION: Nephropexy can be safely and effectively accomplished laparoscopically, with durable radiographic and clinical resolution of the signs and symptoms.

Adult↗

PubMed2000

Approach to decortication of simple cysts and polycystic kidneys.

Laparoscopic excision and marsupialization of symptomatic of recurrent simple renal cysts is an alternative to open or percutaneous surgery. Such surgery may also be useful for pain relief in patients with autosomal dominant polycystic kidney disease (ADPKD). An occlusion balloon catheter is placed in the renal pelvis at the start of the procedure. Cysts are punctured, and the outer wall of the larger cysts is excised with care not to incise the renal parenchyma. In patients with ADPKD, it is important to mobilize the kidney completely, particularly the upper pole, to treat every visible cyst. A laparoscopic ultrasound probe is used to guide the unroofing of any large cysts within 5 to 10 mm of the renal surface. At the end of the procedure, the integrity of the collecting system is confirmed. Strict criteria must be used in selecting patients with simple cysts for laparoscopic marsupialization to minimize the incidence of unsuspected malignancy, and the cyst wall should be examined by frozen and permanent section. Long-term follow-up is needed to evaluate the effect of laparoscopic decompression in ADPKD.

Adult↗

PubMed2000

Laparoscopic radical nephrectomy.

Although open nephrectomy is the standard of care for localized renal-cell carcinoma, the significant postoperative pain and lengthy convalescence have encouraged the use of laparoscopy, which can yield similar 2- to 5-year survival rates. Either a transperitoneal or a retroperitoneal approach may be used, and sometimes, they are combined. Generally, the technique is limited to tumors <10 cm, but larger tumors can be removed. Nitrous oxide is avoided as an anesthetic agent. The dissection follows accepted oncologic principles: in situ renal dissection within Gerota's fascia, early ligation of the renal vessels, and careful removal of the specimen to prevent tumor spillage. Dissection of the hilum is facilitated by a PEER retractor and an Endoholder. On average, patients having laparoscopic radical nephrectomy return to normal activities approximately 4.5 weeks sooner than those having open surgery, a fact not taken into account in cost analyses. Laparoscopic nephrectomy may offer a special benefit in patients with known metastatic disease, as interleukin-2 administration can be started a month earlier than after open surgery. There may also be immunologic benefits of minimally invasive v open surgery. The technique and instruments continue to evolve, and cost-effectiveness should continue to improve.

Biopsy↗