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PubMed1997

Anterior, posterior, or laparoscopic approach for the management of adrenal diseases?

BACKGROUND: At the advent of laparoscopic adrenalectomy it seemed timely to us to assess the advantages and the overall results of the different techniques that are currently used in an approach to adrenalectomy. PATIENTS AND METHODS: Between 1984 and 1995, 165 patients underwent adrenalectomy. Eighty-six patients (37 men and 49 women with a mean age of 46.4 years) underwent adrenalectomy via the anterior approach, 61 patients (18 men and 43 women with a mean age of 43.8 years) underwent posterior extraperitoneal adrenalectomy, and 18 patients (8 men and 10 women with a mean age of 48.7 years) underwent anterior laparoscopic adrenalectomy. For statistical analysis of the different comparisons between the groups we used the t test for independent samples, the Wilcoxon test, chi-square, and one way analysis of variance. RESULTS: There was no operative mortality. The morbidity was 13.9% in the anterior approach, 9.8% in the posterior approach, and 0% in the laparoscopic approach. The mean operating time for unilateral adrenalectomy was 155.3 min (range 75 to 315) for the anterior approach, 108.6 min (range 60 to 195) for the posterior approach and 116.1 min (range 75 to 180) for the laparoscopic approach. For bilateral adrenalectomy the mean operating time was 165 min for the anterior and 178 min for the posterior approach. The average diameter of tumors resected anteriorly was 8.07 cm (range 2.5 to 20), posteriorly was 5.25 cm (range 0.5 to 14), and laparoscopically was 4.03 cm (range 2 to 6.5). The mean length of postoperative hospitalization for patients undergoing unilateral adrenalectomy was 8 days (range 2 to 25) for the anterior approach, 4.5 days (range 1 to 11) for the posterior approach, and 2.2 days (range 1 to 5) for the laparoscopic approach. Patient controlled analgesia lasted 3.4 days for those operated anteriorly, 2.3 days for those operated posteriorly, and 1.08 days for those that underwent laparoscopic adrenalectomy. CONCLUSIONS: The laparoscopic approach to the adrenal promises the safest and least painful operation with shorter in-hospital stay and the best cosmetic and long-term results. The posterior approach is the fastest of all and a better overall operation than the anterior approach that should only be reserved for removing very large adrenal tumors and when concomitant intra-abdominal procedures, that can't be handled laparoscopically, are anticipated.

Adolescent↗
PubMed1998

The accuracy of laparoscopic ultrasound in the detection of colorectal cancer liver metastases.

BACKGROUND: The most sensitive and specific method of detecting colorectal cancer hepatic metastases has been shown to be a combination of careful intraoperative palpation and intraoperative ultrasound. Although there has been growing interest in laparoscopic surgical therapy for colorectal cancer, the ability of this technique to adequately evaluate the liver for small metastases has been unknown. This study was undertaken to compare laparoscopic liver ultrasound to the gold standard of open palpation and intraoperative ultrasound in detecting hepatic metastases from colorectal cancer. METHODS: A preliminary animal model was first performed in adult pigs. Eighteen liver "lesions" were created with chlorhexidine gluconate under laparoscopic guidance. A blinded surgeon then performed laparoscopic liver ultrasound followed by open ultrasound and palpation, comparing the accuracy of these techniques in detecting the lesions. In a second study, 15 patients undergoing laparotomy for colorectal cancer underwent preliminary laparoscopic liver ultrasound followed by open palpation and intraoperative ultrasound to compare these methods of liver evaluation. RESULTS: Laparoscopic liver ultrasound detected 17 of 18 lesions created in the pig livers, for a sensitivity of 94.4%. There were two false negatives, for a specificity of 77.7%. Laparoscopic liver ultrasound detected 4 of the 5 liver metastases in the human study, for a sensitivity of 80%. There was a single false negative, for a specificity of 90.9%. Several technical difficulties and their solutions are discussed. CONCLUSIONS: With several technical modifications guided by our initial experience, we believe laparoscopic liver ultrasound can be an effective way of evaluating the liver for metastases during laparoscopic colorectal resection for cancer.

Animals↗
PubMed1995

Preliminary results of a prospective randomized trial of laparoscopic onlay versus conventional inguinal herniorrhaphy.

BACKGROUND: To compare laparoscopic onlay hernia repair with conventional surgery, 61 patients were randomized to either open or laparoscopic surgery. METHODS: Traditional repairs were done according to the surgeons' preference. Laparoscopic repairs utilized a modified onlay technique with a meshed prototype prosthesis. RESULTS: Mean operative time was 62.5 minutes for the laparoscopic group and 80.9 minutes for the open group. Each group had five complications. There were two conversions from laparoscopic to open surgery. Individuals undergoing laparoscopic surgery reported a mean intake of 5 doses of an oral narcotic analgesic versus 16 doses in the open group. Return to normal activity (nonstrenuous) was 7.5 days in the laparoscopic group and 18.5 days in the open group. After a mean follow-up of 8 months (range 1 to 14), there have been two recurrences in the open group and one in the laparoscopic group. CONCLUSION: Laparoscopic onlay inguinal herniorrhaphy is a viable alternative for those who prefer a minimally invasive treatment for this disease.

Female↗
PubMed1994

Laparoscopic versus subinguinal varicocelectomy: a comparative study.

OBJECTIVE: To determine the relative advantages of the laparoscopic approach to varicocelectomy, postoperative morbidity and pain in patients undergoing subinguinal varicocelectomies were compared with that of patients undergoing laparoscopic varicocele repairs. DESIGN: Retrospective study of concurrent groups of patients undergoing laparoscopic or open subinguinal varicocele repairs. SETTING: Tertiary teaching hospital. PATIENTS: Forty-seven patients with primary or secondary infertility. INTERVENTIONS: Patients were offered a choice between a laparoscopic or open subinguinal varicocele repair. MAIN OUTCOME MEASURES: The total number of pain pills used, the number of days of analgesics, and the number of days off from work after surgery were recorded. RESULTS: Fourteen patients underwent laparoscopic varicocelectomies, and 33 patients underwent subinguinal varicocelectomies. Analgesic use by the laparoscopic patients was no different from that of the subinguinal patients. The length of time off from work was significantly longer for the laparoscopic patients (6.4 days) as compared with the time off from work for the patients who underwent subinguinal varicocele repairs (2.6 days). CONCLUSION: The subinguinal varicocele repair performed with local anesthesia is a safe, low morbid technique offering a quicker recovery period than laparoscopic approaches. Although laparoscopic repairs may offer a shorter recovery period when compared with standard inguinal varicocelectomies, this is not the case when compared with subinguinal approaches.

Adult↗
PubMed1997

Should laparoscopic appendectomy be avoided for complicated appendicitis in children?

BACKGROUND/PURPOSE: Laparoscopic appendectomy is becoming the preferred technique for treating acute appendicitis. However, recent literature on adults suggests that laparoscopic appendectomy may increase the risk for postoperative infectious complications in complicated (gangrenous or perforated) cases. This study was undertaken to compare the results of open versus laparoscopic appendectomy for complicated appendicitis in children. METHODS: A retrospective review from two institutions was performed for all children treated operatively for complicated appendicitis from January 1994 through November 1996. RESULTS: Fifty-six cases were identified. Twenty-seven children underwent laparoscopic appendectomy, whereas 22 underwent open appendectomy. Seven children underwent conversion from laparoscopic to open surgery. Operating times and length of hospital stay did not differ significantly between the laparoscopic and open groups. Postoperative complications developed in 24 children (42.8%). Complications were more frequent after laparoscopic appendectomy compared with open appendectomy (56% v 18%, P = .002). A postoperative intraabdominal abscess (IAA) developed in 14 children (25%). An IAA occurred in two children after open appendectomy compared with 11 children after laparoscopic appendectomy (9% v 41%, P = .01). CONCLUSION: The findings suggest that laparoscopic appendectomy should be avoided in children who have complicated appendicitis because of the increased risk for postoperative intraabdominal abscesses. The authors propose a prospective, randomized trial to verify this finding.

Abdominal Abscess↗
PubMed1998

Laparoscopic gastric antroplasty in children with delayed gastric emptying and gastroesophageal reflux.

BACKGROUND/PURPOSE: A significant number of children (50%) with gastroesophageal reflux (GER) have delayed gastric emptying (DGE). Although controversial, many pediatric surgeons use a gastric outlet procedure in conjunction with fundoplication for gastroesophageal reflux in these patients. This paper describes the technique and clinical outcome of 61 patients undergoing a laparoscopic gastric antroplasty at the time of the laparoscopic fundoplication. METHODS: The charts of 61 patients who underwent laparoscopic gastric antroplasty in conjunction with laparoscopic fundoplication between May 26, 1992 and October 17, 1996 were reviewed retrospectively. All patients had a documented DGE confirmed by a liquid isotope meal being retained in the stomach. After completion of the fundoplication, a laparoscopic antroplasty was performed by incising a 2 to 3.5-cm linear incision in the pylorus and distal gastric antrum. The seromuscular wall was divided to the level of the mucosa allowing the mucosa to bulge through the defect. The wound was closed transversely using interrupted 2-0 silk sutures. RESULTS: Four of the 61 patients underwent conversion to open antroplasty for technical reasons. The remaining 57 patients recovered uneventfully from the laparoscopic antroplasty with clinical resolution of both GER and DGE. Two of 57 patients had intermittent episodes of retching and were unable to tolerate large bolus feedings because of dumping. They were treated by dividing the feedings into two smaller portions. These symptoms cleared within 6 months. The remaining 55 patients have tolerated feedings well. Evaluation of the gastric emptying was performed randomly in selected patients with documented improvement of the emptying after antroplasty. An evisceration of omentum through the umbilical incision developed in one patient on the third postoperative day. CONCLUSIONS: Patients with delayed gastric emptying who need fundoplication can be treated with laparoscopic gastric antroplasty in conjunction with laparoscopic fundoplication. Laparoscopic antroplasty appears to be clinically efficacious in improving delayed gastric emptying.

Child↗
PubMed1998

Laparoscopic adrenalectomy: the preferred choice? A comparison to open adrenalectomy.

PURPOSE: We compare the effectiveness and efficiency of laparoscopic adrenalectomy to open surgical management of adrenal disorders. MATERIALS AND METHODS: A retrospective comparison was undertaken of 21 patients who underwent transperitoneal laparoscopic adrenalectomy between April 1996 and May 1997 with 17 patients who underwent open adrenalectomy between October 1994 and January 1996. Any patient suspected of having primary adrenal carcinoma and/or an adrenal lesion larger than 6 cm. was excluded from the study. RESULTS: Patient demographics were matched well. Mean laparoscopic surgical time was 79 minutes longer than for open surgery. After overcoming the learning curve, the surgical time decreased by 59 minutes in the last 10 laparoscopic adrenalectomies. All laparoscopic intraoperative complications were managed without the need for open surgical conversion. Postoperative characteristics demonstrated significant benefits in the laparoscopic group (p=0.001) with respect to days to return to full diet (1.7 versus 4.6), analgesic pain requirements and days of hospitalization (2.7 versus 6.2). CONCLUSIONS: Laparoscopic adrenalectomy offers significant postoperative benefits to patients with benign adrenal disease requiring surgical intervention. The surgical time is longer than that for open adrenalectomy but there was an encouraging reduction in time after overcoming the laparoscopic learning curve. Laparoscopic adrenalectomy is an excellent choice for tumors smaller than 6 cm. Its role for larger lesions and/or primary adrenal carcinoma is currently under investigation.

Adrenal Gland Neoplasms↗
PubMed2002

Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes.

PURPOSE: The technique of laparoscopic radical prostatectomy is difficult to master and is associated with a steep learning curve. We hypothesized that a structured approach to establishing a laparoscopic prostatectomy program would diminish complications during the learning process and that robotic technology would be useful in learning the operation. MATERIALS AND METHODS: A structured laparoscopic radical prostatectomy program was introduced at the Vattikuti Urology Institute on October 23, 2000. One of 2 surgeons with a combined experience of more than 500 laparoscopic radical prostatectomies performed or supervised the first prostatectomies, training a third surgeon with extensive "open" surgical skills but no laparoscopic experience. The "trained" surgeon then started performing the operation independently with robotic assistance. The results of this approach were analyzed at the end of 12 months. RESULTS: We performed 48 laparoscopic radical prostatectomies and 50 robot assisted prostatectomies within the 12-month period. The preoperative and intraoperative demographical variables were comparable in both groups as were the operative times, changes in hemoglobin concentrations, durations of hospitalization, positive margin rates and overall complication rates. All measured parameters were comparable to the "best-in-class" values for laparoscopic radical prostatectomy reported in the literature. CONCLUSIONS: A structured approach minimizes complications during the establishment of laparoscopic radical prostatectomy program. Robotic assistance helps skilled "open" surgeons learn the technique of laparoscopic radical prostatectomy.

Humans↗
PubMed1994

Comparative financial analysis of laparoscopic versus open pelvic lymph node dissection for men with cancer of the prostate.

Laparoscopic pelvic lymph node dissection has been applied as a minimally invasive staging technique for men with prostate cancer. This procedure has been shown to shorten markedly postoperative hospitalization, decrease analgesic requirements and shorten convalescence period compared to open pelvic node dissection. However, the laparoscopic procedure takes longer to perform and many disposable instruments are used, thus increasing the cost. We determine the overall cost of laparoscopic versus open pelvic lymph node dissection. Between January 1989 and April 1992, 61 men underwent only staging pelvic lymph node dissection for cancer of the prostate at a single university teaching hospital. Of these patients 11 and 50 underwent open and laparoscopic pelvic lymph node dissection, respectively. Information from the hospital business office was reorganized into preoperative, intraoperative and postoperative expenses. All individual charges were transformed up or down to the dollar amounts of the 1990 to 1991 fiscal year so as to correct for inflationary changes. Preoperative costs were not significantly different between the 2 operative approaches. Intraoperative expenses were 52% greater if laparoscopic pelvic lymph node dissection was performed and can be explained by the longer operative times and use of disposable instrumentation. However, the postoperative period lasted an average of 1.61 days following laparoscopic pelvic lymph node dissection. Postoperative nursing and analgesic requirements were significantly more for patients undergoing open pelvic lymph node dissection. The overall postoperative costs following open pelvic lymph node dissection were 280% more expensive than for the laparoscopic procedure. The overall total costs were approximately $1,250 more for laparoscopic pelvic lymph node dissection. Wages lost or earned during this period and rapid return to normal activity following laparoscopic pelvic lymph node dissection would, in our opinion, justify this additional cost.

Aged↗
PubMed1994

Urological laparoscopic practice patterns 1 year after formal training.

The long-term impact of laparoscopic training on urological surgical practice patterns is unclear. We assessed urologist practice patterns 1 year subsequent to a formal training course in urological laparoscopic surgery. Results were compared to findings from an identical study performed 3 months following training. On 5 dates between January and October 1991, a total of 163 urologists participated in a 2-day, university sponsored, laparoscopic surgery training seminar. At 3 months and 1 year following the course, participants were mailed a 20-question survey inquiring as to the interval laparoscopic experience. Multiple questions were designed for later correlation with participant use of laparoscopic surgery. Totals of 105 and 128 course participants (64% and 78.5%) responded to the questionnaire at 3 and 12 months, respectively. No significant differences in 3-month and 12-month demographics were demonstrated with respect to practice setting, practice focus or percentage undergoing additional training. Significant increases were noted between 3 and 12 months in the number of candidates identified per month (1.5 versus 2.4), proportion of surgical case load taken by laparoscopy (2.6% versus 4.1%), number of laparoscopic patient inquiries per month (0.25 versus 1.0) and number of laparoscopies performed per month (0.55 versus 0.78). Additional post-course training was significantly correlated with clinical use at 3 and 12 months. Of the 105 and 108 respondents 64 (61%) and 83 (65%) had engaged in some form of additional training by 3 months and 1 year after the course, respectively. Additional training as well as performance of laparoscopy proved to be independent of practice setting or practice focus at 3 and 12 months. Those who attended the course with a partner were significantly more likely to have performed laparoscopy at 1 year than those who attended alone. At 12 months following course completion 66% of the respondents believed that the year of laparoscopic experience was sufficient to maintain skills. This survey suggests that laparoscopic techniques are being used consistently by urologists subsequent to formal laparoscopic training courses.

Education, Medical, Continuing↗
PubMed1997

Open compared with laparoscopic approach to Burch colposuspension: a cost analysis.

OBJECTIVE: To compare postoperative course and hospital charges of an open versus laparoscopic approach to Burch colposuspension for the treatment of genuine stress urinary incontinence. METHODS: A retrospective chart review was performed to identify all patients undergoing open or laparoscopic Burch colposuspension by the same surgeon over a 2-year period. Patients undergoing additional surgical procedures at the time of colposuspension were excluded from the study. Twenty-one patients underwent open Burch colposuspension and 17 patients underwent laparoscopic colposuspension. Demographic data including age, parity, height, and weight were collected for each group. Both groups also were compared with regard to operative time, operating room charges, estimated blood loss, intraoperative complications, change in postoperative hematocrit, time required to resume normal voiding, length of hospital stay, and total hospital charges. RESULTS: The laparoscopic colposuspension group had significantly longer operative times (110 versus 66 minutes, P < .01) and increased operating room charges ($3479 versus $2138, P < .001). There was no statistical difference in estimated blood loss or change in postoperative hematocrit between the two groups. No major intraoperative complications occurred in either group. Mean length of hospital stay was 1.3 days for the laparoscopic group and 2.1 days for the open group (P < .005). However, total hospital charges for the laparoscopic group were significantly higher ($4960 versus $4079, P < .01). CONCLUSION: Laparoscopic colposuspension has been described as a minimally invasive, cost-effective technique for the surgical correction of stress urinary incontinence. Although the laparoscopic approach was found to be associated with a reduction in length of hospital stay, it had significantly higher total hospital charges than the traditional open approach because of expenses associated with increased operative time and use of laparoscopic equipment.

Adult↗
PubMed1997

Analysis of the effectiveness of an endoscopy education program in improving residents' laparoscopic skills.

OBJECTIVE: To evaluate the effectiveness of a gynecologic endoscopy education program in enhancing residents' proficiency in laparoscopic surgery. METHODS: The program was designed to provide residents with the knowledge and skills necessary for laparoscopic surgery, before entering the operating room, in a cost-effective manner that honored the principles of adult education. The 7-week program included didactic sessions to provide conceptual learning but focused on practical skills enhancement through practice in both pelvic trainer and animal laboratory settings. The program design included dominant, nondominant, and two-handed skills as well as models for laparoscopic dissection, hemostasis, and suturing. The evaluation of the program is based on timing of laparoscopic skills as well as resident and faculty evaluation of laparoscopic proficiency at the beginning and end of the program. RESULTS: Prior to the program, 48% of residents and 75% of faculty were satisfied with laparoscopic training. All residents improved operating times in pelvic trainer skills after the program, with first-year residents improving by 68%, third-year residents by 58%, and fourth-year residents by 72%. The residents self-assessment of competence in 14 laparoscopic skills revealed an increase in all skills following the program. The faculty assessment showed an upward trend in skills competence. At the conclusion of the program, 100% of residents and 92% of faculty were satisfied with the laparoscopic training. CONCLUSION: A structured program emphasizing skills enhancement is an effective approach to improve residents' performance in laparoscopic surgery.

Clinical Competence↗
PubMed2000

Advanced laparoscopic gynecologic surgery.

What is the future for laparoscopy? Any procedure thought to be impossible to perform by laparoscopy or procedures that, based on conventional wisdom, should not be done laparoscopically are being performed or developed as the reader peruses this article. Technical advances in the endoscopic equipment and development of laparoscopic instruments have allowed for performance of sophisticated procedures with laparoscopic assistance. Appropriate laparoscopic skills allow surgeons to perform these procedures in a fashion nearly identical to an open procedure; however, modifications of historically proven techniques are controversial regarding the expenses generated, equipment necessary to perform the procedure, training necessary, and potential for complications. Has the obituary of laparotomy been written? The benefits of laparoscopically assisted or performed procedures are continuing to be analyzed. LAVH has been touted as a way to reduce the number of abdominal hysterectomies while increasing the number of vaginal hysterectomies. Therefore, indications for LAVH would ideally more resemble indications for abdominal hysterectomy than vaginal hysterectomy; however, LAVH does not seem to have increased the total number of vaginal hysterectomies. Conversely, the number of abdominal hysterectomies seems to be roughly the same, whereas the number of vaginal hysterectomies has decreased and the number of LAVHs has increased. Therefore, surgeons seem to be substituting LAVH for vaginal hysterectomy. Studies comparing laparoscopic Burch procedures and open Burch procedures are just now being reported. Many early reports described procedures that are not classic Burch colposuspensions. These changes make it impossible to assume that overall success and rate of complications are the same. The same can be said for techniques for correction of pelvic organ prolapse. Although laparoscopic performance and laparoscopic assistance are increasing in popularity, most cases are not handled in this way. Clearly, not every surgeon has embraced using the laparoscope to treat patients who would otherwise have undergone abdominal or vaginal surgery.

Female↗
PubMed2000

Laparoscopic paravaginal repair plus burch colposuspension: review and descriptive technique.

The objective of this article was to review the available literature on laparoscopic Burch urethropexy cure rates and describe the authors' laparoscopic technique and experience with Burch urethropexy and paravaginal repair. A MEDLINE search (1991 to 1999) was performed for articles describing the laparoscopic Burch urethropexy using suture to elevate and stabilize the paraurethral tissue. Also a retrospective chart review of the authors' 171 consecutive patients between January 1997 and December 1999 was done. The laparoscopic Burch urethropexy and paravaginal repair is described using an open laparoscopic technique with 3 accessory ports for access. A transperitoneal approach is taken to gain access to the space of Retzius. The anterior vaginal wall and its paravaginal defects, if present, are identified. Nonabsorbable sutures are placed in a conventional fashion. The paravaginal repair is used for support of the anterior vaginal wall proximal to the urethral vesical junction and the Burch urethropexy distal to the vesical neck. An average of 6 sutures are used for the paravaginal repair and 4 sutures for the Burch urethropexy. Cystoscopy is performed to ensure no breech of lower urinary tract integrity. In all, 20 articles describing a laparoscopic Burch urethropexy and postoperative cure rate were identified. Cure rates ranged from 69% to 100%. A review of our experience revealed 130 of 171 patients had a Burch urethropexy and paravaginal repair, 23 of 171 patients a Burch urethropexy alone, and 18 of 171 patients a paravaginal repair alone. Of the authors' 171 patients, 4 (2.3%) had injury to the lower urinary tract during laparoscopic Burch urethropexy or paravaginal repair. All 4 injuries were cystotomies, 2 in patients with previous open retropubic urethropexies. No ureteral ligations or intravesical placement of suture was diagnosed. Other surgical parameters for the laparoscopic Burch uethropexy and paravaginal repair include an estimated blood loss of 50 mL, average hospital stay of less than 23 hours, and an average operative time of 70 minutes. All patients had their surgery completed via laparoscopy. The literature review and our personal experience suggests that the laparoscopic Burch urethropexy and paravaginal repair are safe and effective alternatives to traditional laparotomy for the treatment of genuine anatomic stress urine incontinence and cystourethrocele resulting from lateral vaginal wall defects.

Female↗
PubMed2001

Prospective comparison between hand-assisted laparoscopic and open surgical nephroureterectomy for urothelial cell carcinoma.

OBJECTIVES: To prospectively compare open surgical and the new hand-assisted approach to laparoscopic nephroureterectomy for urothelial cell carcinoma. Previous retrospective studies have suggested that standard laparoscopic nephroureterectomy provides a briefer convalescence than open surgical nephroureterectomy. METHODS: Between March 1997 and September 1999, 16 hand-assisted laparoscopic and 11 open surgical nephroureterectomies were performed, without randomization. Validated questionnaires were prospectively administered preoperatively and 2 and 6 weeks postoperatively. RESULTS: The operative time was longer with the laparoscopic approach (320 versus 199 minutes, P <0.001), but the hospital stay was shorter (3.9 versus 5.2 days, P = 0.03). Patient recovery favored the laparoscopic group with regard to time to drive (17.1 versus 37.7 days), time to normal, nonstrenuous activity (18.2 versus 38.1 days), and the mental component score of the SF-12 survey at 6 weeks (57.1 versus 43.0) (P <0.05 for all). Minor complications occurred in 19% of the laparoscopic and 45% of the open surgical procedures; major complications occurred in 19% of laparoscopic and 27% of open surgical procedures (P >0.1 for both). Cancer control was similar between both groups. The mean operating room cost was 56% more for the laparoscopic group (P <0.001), but the overall hospital cost was only 8% greater (P >0.3). CONCLUSIONS: Hand-assisted laparoscopic nephroureterectomy is a safe and effective alternative to an open surgical approach. Indexes of patient recovery suggest that patient convalescence is less than after an open surgical nephroureterectomy. Increased operative costs may be offset by a shorter hospital stay and fewer complications, resulting in similar overall hospital costs.

Aged↗
PubMed2001

Laparoscopic nephroureterectomy for the treatment of transitional cell carcinoma of the upper urinary tract.

OBJECTIVES: To establish the safety and efficacy of laparoscopic and laparoscopic-assisted nephroureterectomy. METHODS: Since 1993, 25 patients with a minimum of 12 months of follow-up underwent nephroureterectomy using a total laparoscopic or laparoscopic-assisted technique. Four patients had specimen morcellation for tissue removal. All patients had regular follow-up with physical examinations, interval cystoscopy, and radiographs, depending on the metastatic potential of the tumor. Retrospective chart review was performed and assessed for operative time, blood loss, tumor pathologic stage, complications, and outcome. One patient was excluded because of an open conversion due to multiple previous abdominal surgeries and failure to progress. RESULTS: The mean operating time was 329 minutes but decreased with experience. The median hospital stay was 4 days. Tumor stage was directly related to tumor grade. Associated bladder tumors (prior history or recurrent tumors) occurred in 50% of the patients. Ipsilateral ureteral stump site recurrence occurred in 1 patient. Although no port site seeding occurred, 1 patient, whose tumor was discovered histologically after laparoscopic pyeloplasty for presumed benign disease, developed recurrence in the renal fossa and metastatic disease. Two patients developed liver metastasis. CONCLUSIONS: Total laparoscopic and laparoscopic-assisted nephroureterectomy are acceptable alternatives to open surgery in the treatment of transitional cell carcinoma of the upper urinary tract. Tumor morcellation did not appear to adversely affect patient outcome. As with open nephroureterectomy, tumor grade is the most important prognostic indicator of local, bladder, and metastatic recurrence. No port site seeding was observed in either the total laparoscopic or laparoscopic-assisted groups.

Adolescent↗
PubMed2001

Transperitoneal laparoscopic nephrectomy for giant polycystic kidneys: a case control study.

OBJECTIVES: To describe the technique and compare the surgical outcomes of patients with autosomal dominant polycystic kidney disease (ADPKD) undergoing laparoscopic or open nephrectomy for giant kidneys. METHODS: The surgical outcome of our first 10 consecutive patients with ADPKD who underwent laparoscopic nephrectomy was analyzed from a large prospective computer database. The results were compared with the 10 most recent open nephrectomy procedures performed for ADPKD at the same institution. To facilitate safe laparoscopic hilar dissection, the kidneys were made manageable by volume reduction, accomplished through diligent cyst puncture and aspiration using a novel prototype suction device with a beveled tip. RESULTS: No statistically significant differences were found between the laparoscopic and open surgical groups relative to patient sex, age, or median preoperative kidney size (24.0 versus 21.5 cm, respectively). The laparoscopic patients were significantly heavier than their open counterparts (94 versus 78 kg, P = 0.0095) and had a longer operative time (247 versus 205 minutes, P = 0.04). One conversion to open surgery occurred in the laparoscopic group because cysts were adherent to the spleen and colonic mesentery. No intraoperative complications or deaths occurred in either group and the postoperative complications were similar. The mean length of the postoperative hospitalization was markedly reduced with the laparoscopic compared with the open approach (2.6 versus 6.6 days, P = 0.00002). At a median of 12 months after surgery, none of the laparoscopic patients had recurrent pain, bleeding, or infection. CONCLUSIONS: Laparoscopic nephrectomy is technically safe and feasible in patients with ADPKD. Progressive cyst aspiration is a critical step, facilitating the identification of vital structures and the creation of enough abdominal cavity space to operate. The advantages of this minimally invasive technique include a short hospital stay, minimal pain, low morbidity, and superior cosmesis.

Adult↗
PubMed2003

Surgical treatment of renal neoplasia: evolving toward a laparoscopic standard of care.

OBJECTIVES: To determine the extent to which laparoscopy has replaced open surgery for renal malignancy. METHODS: The records of all 537 patients at Washington University who underwent surgery for localized renal malignancies from January 1997 to December 2001 were examined for clinical and pathologic information. RESULTS: The total procedures per year increased from 1997 to 2001, but the distribution of pathologic stages throughout the 5 years was similar. In 1997, laparoscopic approaches were used in 15% of cases; this increased to 65% by 2001. Nephron-sparing surgery (NSS) was used in 31% to 42% of patients yearly, but laparoscopic NSS increased in frequency. By 2001, only 3.3% of T1 tumors were removed by open radical nephrectomy compared with 55% treated by laparoscopic nephrectomy. The rest of the T1 tumors in 2001 were treated by open partial nephrectomy (20.2%) or laparoscopic NSS (21.3%). In 2001, 61% of T2 lesions were treated laparoscopically, an increase from 37% in 1997. Most open radical nephrectomies in 2001 were performed for T3 disease. The number of surgeons performing laparoscopic renal surgery has increased at our institution, from two in 1997, both endourologists, to eight in 2001, representing the entire urology faculty that treats renal cancer. CONCLUSIONS: Laparoscopic radical nephrectomy has replaced open radical nephrectomy for low-stage renal neoplasia. Although laparoscopic NSS is increasing in frequency, it has not yet replaced open partial nephrectomy. At our institution, the laparoscopic approach has become the standard of care when radical nephrectomy is needed for T1 or T2 renal cancer.

Carcinoma, Renal Cell↗