Comparison of the outcomes of laparoscopic pyeloplasty with and without concomitant pyelolithotomy

Objective

We aimed to evaluate the results of laparoscopic pyeloplasty with concomitant pyelolithotomy and compare results with a cohort of patients undergoing laparoscopic pyeloplasty without pyelolithotomy.

Materials and Methods

We retrospectively reviewed records of 43 patients undergoing transperitoneal laparoscopic Anderson-Hynes dismembered pyeloplasty between December 2012 and July 2018 at our department. Eighteen patients (42%) underwent laparoscopic pyeloplasty with concomitant pyelolithotomy. The results of patients with renal stones were compared with 25 matched patients undergoing laparoscopic pyeloplasty without concomitant renal stones. Demographic data, operative and stone parameters were compared between the groups.

Results

The groups were similar regarding to demographic characteristics. All operations were completed laparoscopically with no conversions to open surgery. In 3 cases without renal stones and 15 cases with renal stones, transposition of the ureter due to crossing vessels was performed. The mean stone size was 13±5.24 mm, and the median number of stones was 1 (1-18). The success of laparoscopic pyeloplasty with and without pyelolithotomy was 93.3% and 92.9%, respectively, as confirmed by negative diuretic renogram at postoperative 3rd months. Overall stone-free rate after laparoscopic pyelolithotomy was 93.3%. Mean operative time was 222.6765.71 minutes vs. 219.11±75.63 minutes for the pyeloplasty with concomitant pyelolithotomy vs. pyeloplasty, respectively (p=0.88).

Conclusions

Laparoscopic pyeloplasty with concomitant pyelolithotomy is a safe and effective intervention with associated good cosmetic results and high stone-free rates without significant increase in operative time or complications.

Partial penectomy after debridement of a Fournier's gangrene progressing with an isolated penile necrosis

Fournier's gangrene (FG) is a rare and often fulminant necrotizing fasciitis of the perineum and genital region frequently due to polymicrobial infection. This truly emergent condition is typically seen in elderly, diabetic and immune compromised patients. Here, we report an unusual case of FG with isolated glans penis necrosis in a diabetic 77-year-old male patient presented to the emergency department complaining 5 days of pain and darkening of the glans penis. Examination of the patient's glans penis was consistent with FG and included significant erythema and infectious discharge. He was given intravenous antibiotics and emergency debridement was done. On following days, the necrotic area spread to distal parts of both cavernosal areas. Partial penectomy was performed. Isolated penile involvement in FG is very rare. Performing partial penectomy in appropriate cases can save penile length, stop the progression of disease, and increase the quality of life.

Comparison of efficacy of laser lithotripter with ultrasonic lithotripter in mini percutaneous nephrolithotomy

OBJECTIVE

The aim of the study was to compare the efficacy of the laser lithotripter with the ultrasonic lithotripter in mini percutaneous nephrolithotomy (miniperc).

MATERIAL AND METHODS

From June 2013 to January 2014; medical records of 77 consecutive patients who underwent miniperc operation were retrospectively evaluated. Ultrasonic lithotripter was used in 22 patients (Group 1), while laser was used in 55 patients. In the laser group, 22 patients were randomly selected who had same characteristics compared to group 1 (Group 2). Success rate, total operative time, complications according to modified Clavien classification, fluoroscopy time, haemoglobin drop, hospital stays and cost analysis were assessed. Success rates were evaluated on the second postoperative day and after the first month.

RESULTS

Total operative time (p = 0.635) and fluoroscopy time (p = 0.248) were not significantly different between the two groups. In the laser group, the success rate (81.8%) was notably more than in the ultrasonic lithotripter group (68.2%) but there was no statistically significance (p = 0.296). Ten reusable ultrasonic probe were used for 22 patients, due to thinness and sensitiveness of the probe. Conversely, one single laser fiber (550 micron) was used for 22 patients. When the cost analysis of lithotripsy was considered, the cost per case was 190 dollar in group 1 and 124 dollar in group 2. (p = 0.154) Complication rate, hospital stay and haemoglobin drop were similar in both groups.

CONCLUSION

Laser lithotripsy seems to be more cost effective than ultrasonic lithotripsy for miniperc but larger number of patients are required to confirm this estimation.

Abdominal wall haemorrhage after robotic-assisted radical prostatectomy: is it a complication of robotic surgery?

OBJECTIVE

Robotic-assisted radical prostatectomy (RARP) is the minimally invasive surgical treatment for patients with localized prostate cancer. Perioperative or postoperative complications following RARP have been reported in some studies and severe postoperative bleeding after RARP is rare, but hemodynamic instability may necessitate open surgical exploration and be associated with considerable morbidity. We reported postoperative bleeding cases, which is a kind of complication associated with robotic surgery and requiring massive transfusion after RARP.

PATIENTS AND METHODS

From August 2009 to May 2012, 317 consecutive patients who underwent RARP performed at our institution were analyzed. Patients with serious postoperative bleeding that caused hemodynamic instability after surgery were enrolled.

RESULTS

A total of 5 among 317 (1.6%) patients had bleeding requiring postoperative transfusion. In these cases, mean operative time was 114 min. The mean estimated blood loss was 110 ml during operation. In these patients, hematocrit (Hct) levels gradually fell after surgery and ecchymosis was detected on the side and posterior walls of the abdomen on the second day. The mean preoperative Hct was 44.3% and mean lowest Hct was 23.1%. All patients were successfully treatment without surgical exploration.

CONCLUSIONS

Robotic radical prostatectomy has proven to be a safe surgical treatment with low morbidity. However, postoperative bleeding can reach serious problems. This is the first study to explain haemorrhage, associated with possible risk of robotic surgery.

Laparoendoscopic single-site pyeloplasty: outcomes of an international multi-institutional study of 140 patients

OBJECTIVE

To report an international, multi-institutional series of laparoendoscopic single-site pyeloplasty (LESS-P) with analysis of functional outcomes.

MATERIALS AND METHODS

LESS-P cases performed between October 2007 and June 2012 at 7 institutions worldwide per individual institutional protocols, entry criteria, and techniques were included. Patient characteristics, operative indications, perioperative outcomes, and postoperative follow-up were retrospectively collected and analyzed.

RESULTS

The study included 140 adult patients (age 39.9 ± 15.7 years; body mass index 24.8 ± 4.2 kg/m(2); 15% with previous abdominal surgery) who underwent unilateral LESS-P, most of whom (94.3%) had dismembered reconstructions. Mean operative time was 202.1 ± 47 minutes with an estimated blood loss of 61.2 ± 44.6 mL. Robotic laparoendoscopic single-site surgery was applied in 31 patients (22.1%). A single 2-3 mm accessory port was used in 44 patients (31.4%) and a single 5-12 mm accessory port was added in 9 patients (6.4%), whereas 10 patients (7.1%) were converted to conventional multiport laparoscopy. No patients required conversion to open surgery, nor were any intraoperative complications reported. Length of hospitalization was 2.4 ± 1.6 days. The overall 90-day postoperative complication rate was 18.6%, mostly low-grade complications (Clavien I-II). With a mean follow-up of 14.0 ± 10.8 months, 93.4% had resolution of symptoms and 94.4% had radiographic evidence demonstrating resolution of ureteropelvic junction obstruction. Assessment of drainage with diuretic nuclear renal scan provided evidence of improvement in 86.5% of patients on their first postoperative renal scan.

CONCLUSION

This study highlights the most comprehensive experience with LESS-P reported to date. Outcome measures parallel those of large published series of conventional laparoscopic pyeloplasty. Despite these encouraging findings, longer follow-up is needed to determine the efficacy and durability of this approach for the treatment of ureteropelvic junction obstruction.

Laparoendoscopic single-site versus conventional transperitoneal laparoscopic pyeloplasty: a prospective randomized study

OBJECTIVES

To evaluate the potential benefits of laparoendoscopic single-site pyeloplasty over conventional laparoscopic pyeloplasty.

METHODS

Between October 2009 and January 2012, 39 patients were enrolled in a prospective study and randomized to undergo a laparoendoscopic single-site pyeloplasty (n = 19) or conventional laparoscopic pyeloplasty (n = 20). The outcomes in the two groups were compared by using Mann-Whitney U-test and χ(2) -test, and considering a P-value less than 0.05 as statistically significant.

RESULTS

There was no difference in blood loss (55.67 ± 6.71 vs 45.84 ± 5.22 mL, P = 0.60), transfusion rates (0% for both) and hospitalization time (2.12 ± 0.23 vs 2.06 ± 0.34 days, P = 0.72) between the laparoendoscopic single-site pyeloplasty and conventional laparoscopic pyeloplasty groups. The time to return to normal activities was shorter (8.65 ± 1.25 vs 11.53 ± 1.28 days, P = 0.01), and median operative time (195.21 ± 12.15 vs 145.62 ± 15.34 min, P = 0.001) was longer in the laparoendoscopic single-site pyeloplasty group compared with the conventional laparoscopic pyeloplasty group. No significant intraoperative or postoperative complications occurred in either group. Compared with conventional laparoscopic pyeloplasty, laparoendoscopic single-site pyeloplasty yielded better cosmetic results and patient satisfaction. The mean follow-up period was 19.7 months (4-28 months). The success rate was 95% in both the groups. Both the visual analog scale and the postoperative use of analgesics were significantly lower in patients who underwent laparoendoscopic single-site pyeloplasty.

CONCLUSIONS

Our findings suggest that laparoendoscopic single-site pyeloplasty can offer faster recovery and higher patient satisfaction than conventional laparoscopic pyeloplasty. Thus, this novel technique promises to become the treatment of choice in minimally-invasive management of ureteropelvic junction obstruction.

Robotic malfunction during live robotic urologic surgery: live surprise in a robotic surgery congress

BACKGROUND

Robotic-assisted laparoscopic radical prostatectomy (RARP) has increasingly become a preferred treatment of choice. Since it is a device dependant surgery, robotic surgery may be a challenging procedure due to failure.

METHODS

We report how we managed to complete successfully a case of RARP with laparoscopic approach in spite of right robotic arm failure during live surgery.

RESULTS

A 56-year-old male patient diagnosed with localized prostate cancer (PCa) (Gleason score 3 + 3 = 6) with a serum prostate specific antigen (PSA) level of 7.6 ng/mL was elected for a live RARP case during the 1st Turkish National Robotic Surgery Congress in 2011. Following 120 minutes from starting the RARP procedure, the right robotic arm failed surprisingly with a "recoverable fault" message appeared on the screen. Pressing "recover fault" button did not work and the right arm operated for few seconds more but the fault repeated again. We replaced the robotic instruments, shut down and restarted the system again that were all useless. Finally, all of the arms were out of order and we were not able to use the robot anymore. Therefore, we laparoscopically completed the procedure successfully without converting to open surgery.

CONCLUSIONS

Although da Vinci surgical system failure rarely occurs, surgical team should be prepared to convert to open or complete the procedure laparoscopically. Having previous laparoscopic experience seems to be an advantage in order to complete the procedure without converting to open. Patients should be informed about the possibility of robotic failure and about its consequences before the surgery.

Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: initial experience

OBJECTIVE

We present the transperitoneal and retroperitoneal approaches to laparoscopic partial nephrectomy and compare the outcomes of each technique.

METHODS

Between December 2006 and March 2010, retroperitoneal laparoscopic partial nephrectomy (RLPN) was performed in 23 patients and transperitoneal laparoscopic partial nephrectomy (TLPN) in 26 patients. They were compared regarding surgical technique, operative parameters, postoperative recovery and follow-up data. The 2 approaches used similar operative techniques to control parenchymal bleeding.

RESULTS

The patient demographics were similar in both groups. The mean tumour size was 3.1 cm in the retroperitoneal group and 3.4 cm in the transperitoneal group. The difference was not statistically significant (p: 0.095). The mean operative time was significantly longer in the transperitoneal group (215 vs 185 minutes, p: 0.031). The mean warm ischemia time difference was not statistically significant (25 vs 28 minutes, p: 0.102). The mean estimated blood loss (EBL) was greater in the transperitoneal group (254 vs 204 cc, p: 0.003). Moreover, the mean hospital stay was 4.1 days in the RLPN and 4.3 days in the TLPN group (p: 0.303) The difference was not statistically significant. The median follow-up was 11 months (range: 2 to 35) in the retroperitoneal group and 13 months (range 1 to 36) in the transperitoneal group.

CONCLUSIONS

Our experience has shown that laparoscopic partial nephrectomy is a safe, feasible technique for patients with small exophytic renal tumours. We believe that the decision regarding the approach should be based on the tumor location on the kidney surface.