Abdominal Colpopexy: Comparison of Endoscopic Surgical Strategies (ACCESS)

INTRODUCTION

Robotic assistance during laparoscopic surgery for pelvic organ prolapse rapidly disseminated across the United States without level I data to support its benefit over traditional open and laparoscopic approaches [1]. This manuscript describes design and methodology of the Abdominal Colpopexy: Comparison of Endoscopic Surgical Strategies (ACCESS) Trial.

METHODS

ACCESS is a randomized comparative effectiveness trial enrolling patients at two academic teaching facilities, UCLA (Los Angeles, CA) and Loyola University (Chicago, IL). The primary aim is to compare costs of robotic assisted versus pure laparoscopic abdominal sacrocolpopexy (RASC vs LASC). Following a clinical decision for minimally-invasive abdominal sacrocolpopexy (ASC) and research consent, participants with symptomatic stage≥II pelvic organ prolapse are randomized to LASC or RASC on the day of surgery. Costs of care are based on each patient's billing record and equipment costs at each hospital. All costs associated with surgical procedure including costs for robot and initial hospitalization and any re-hospitalization in the first 6weeks are compared between groups. Secondary outcomes include post-operative pain, anatomic outcomes, symptom severity and quality of life, and adverse events. Power calculation determined that 32 women in each arm would provide 95% power to detect a $2500 difference in total charges, using a two-sided two sample t-test with a significance level of 0.05.

RESULTS

Enrollment was completed in May 2011. The 12-month follow-up was completed in May 2012.

CONCLUSIONS

This is a multi-center study to assess cost as a primary outcome in a comparative effectiveness trial of LASC versus RASC.

Asynchronous, out-of-sequence, transcontinental chain kidney transplantation: a novel concept

The organ donor shortage has been the most important hindrance in getting listed patients transplanted. Living kidney donors who are incompatible with their intended recipients are an untapped resource for expanding the donor pool through participation in transplant exchanges. Chain transplantation takes this concept further, with the potential to benefit even more recipients. We describe the first asynchronous, out of sequence transplant chain that was initiated by transcontinental shipment of an altruistic donor kidney 1 week after that recipient's incompatible donor had already donated his kidney to the next recipient in the chain. The altruistic donor kidney was transported from New York to Los Angeles and functioned immediately after transplantation. Our modified-sequence asynchronous transplant chain (MATCH) enabled eight recipients, at four different institutions, to benefit from the generosity of one altruistic donor and warrants further exploration as a promising step toward addressing the organ donor shortage.

Orchiopexy using 2 mm. laparoscopic instruments: 2 techniques for delivering the testis into the scrotum

PURPOSE

We describe modified techniques of laparoscopic orchiopexy using 2 mm. instruments that enable straightforward delivery of the testis into the scrotum.

MATERIALS AND METHODS

The preferred technique involves a radially dilating trocar advanced over the 2 mm. grasper placed antegrade through the new internal ring. The other method is similar but Amplatz dilators are used when a radially dilating trocar system is not available.

RESULTS

We used these techniques with complete success to deliver 18 testes into the scrotum.

CONCLUSIONS

The testis may be safely and effectively delivered to the scrotum using 2 mm. instruments and disposable fascial dilators or a radially dilating trocar system.

Factors involved in gas embolism after laparoscopic injury to inferior vena cava

This study evaluated the incidence and factors involved in the occurrence of gas embolism after laparoscopic injuries. A 5-MHz transesophageal echocardiographic (TEE) probe was placed in 11 anesthetized pigs and used to examine the right cardiac chambers and pulmonary artery. A calibrated carbon dioxide analyzer continuously measured end-tidal carbon dioxide (ETCO2). The ventilatory settings were adjusted to achieve a baseline ETCO2 between 25 and 28 mm Hg. A blinded dose-response curve for TEE and ETCO2 measurements were created by injecting 0.0007 to 1.5 mL/kg of CO2 gas intravenously. Venotomies (N = 22) were created laparoscopically in the inferior vena cava (IVC) of the study animals. All TEE images were videotaped and correlated with laparoscopic events. Embolic episodes were classified by comparison with images recorded during the bolus studies. A variety of methods for obtaining hemostasis and repairing the venotomies were evaluated and their effects on gas embolism were studied. No emboli were noted when the venotomies were bleeding freely, the hole was directly occluded, or the proximal IVC was compressed. Marked embolism was seen with distal IVC occlusion or when there had been significant blood loss. In this situation, manipulation of the hole and higher intraperitoneal pressures led to higher degrees of embolization. No emboli were seen in an open control group except after significant bleeding. The TEE is the most sensitive method of detecting gas emboli; however, the majority of episodes are not clinically significant. Embolism of CO2 occurs when central venous pressure is decreased by blood loss or distal compression. When significant venous bleeding occurs, intravascular volume should be maintained and the bleeding site should be directly occluded.

Laparoscopic renal surgery in patients at high risk for intra-abdominal or retroperitoneal scarring

Prior open abdominal or renal surgery has been considered a relative contraindication to laparoscopic surgery because of the likelihood of adhesion formation and perinephric scarring, which results in difficulty obtaining access to the peritoneal cavity and during surgical dissection. The purpose of this study was to examine the feasibility and morbidity of laparoscopic renal surgery in patients at high risk for intra-abdominal or retroperitoneal scarring. Twenty-four patients who underwent laparoscopic renal surgery at our institution gave a history of significant open abdominal or renal surgery. Seven patients had undergone prior open extraperitoneal (N = 6) or percutaneous (N = 1) renal procedures, 10 patients had undergone prior open laparotomy for various reasons, and 7 patients had undergone open pelvic surgery. The mean interval from the prior operation to laparoscopic renal surgery was 16.5 years (range 0.3-44 years). Operative time, estimated blood loss, incidence of complications, perioperative parenteral narcotic use, length of hospitalization convalescence, and degree of intra-abdominal and retroperitoneal scarring were assessed. Patients who developed complications were compared with patients who did not. No difficulty was encountered while obtaining initial access to the peritoneal cavity or retroperitoneal space. No bowel or visceral injuries occurred during Veress needle or trocar placement. The laparoscopic procedure was completed successfully in all cases. The mean operative time was 4.3 (range 2.0-10.9) hours. The mean estimated blood loss was 266 mL (range 50-1200 mL). There were eight complications (overall complication 33%) including three major and five minor complications. Patients who developed complications had a higher total scarring score that those who did not (p = 0.01). For experienced laparoscopic surgeons, laparoscopic renal surgery in patients who have a history of open abdominal or renal surgery can be successful. Access via the transperitoneal or retroperitoneal route can be obtained safely, and the procedure usually can be performed in a timely fashion. However, a relatively high perioperative complication rate can be expected, particularly for those patients with significant intraperitoneal and retroperitoneal scarring.

International surgical telementoring: our initial experience

INTRODUCTION

Telesurgical laparoscopic telementoring has successfully been implemented between the Johns Hopkins Bayview Medical Center and the Johns Hopkins Hospital in 27 prior operations. In this previously reported series, telerobotic mentoring was achieved between two institutions 3.5 miles away. We report our experience in performing two international surgical telementoring operations.

PURPOSE

To determine the clinical utility of international surgical telementoring during laparoscopic surgical procedures.

METHOD

A laparoscopic adrenalectomy was telementored between Innsbruck, Austria (5,083 miles) and Baltimore, MD. As well, a laparoscopic varicocelectomy was telementored between Bangkok, Thailand and Baltimore, MD (10,880 miles) both over three ISDN lines (384 kbps) with an approximate 1 sec delay.

RESULTS

Both procedures were successfully accomplished with an uneventful postoperative course.

CONCLUSION

International telementoring is a viable method of instructing less experienced laparoscopic surgeons through potentially complex laparoscopic procedures, as well as potentially improving patient access to specialty care.

Effect of laparoscopic pelvic lymph node dissection on the natural history of D1 (T1-3, N1-3, M0) prostate cancer

OBJECTIVES

Reports of abdominal wall tumor implantation after laparoscopic procedures have raised questions regarding the safety of laparoscopic surgery when applied to patients with malignancies. Our objective was to determine if laparoscopic pelvic lymph node dissection (LPLND) had a negative effect on tumor behavior and clinical outcome in men with Stage T1-3, N1-3, M0 (D1) prostate cancer.

METHODS

Fifty-two men were retrospectively identified at four institutions who had pelvic nodes positive for metastatic prostate adenocarcinoma at LPLND and at least 1 year of follow-up. Operative and clinical records were reviewed to determine morbidity, adjuvant treatment, onset of hormone-resistant disease, and survival.

RESULTS

During a mean follow-up of 3.1 years, there were no cases of trocar site tumor implantation. There were four perioperative complications, including enterotomy, epigastric vessel injury, abscess, and symptomatic lymphocele formation. There were three deaths from prostate cancer (5.8%) occurring 3 to 4 years after LPLND. For the 45 men treated with early androgen ablation, the 5-year biochemical prostate-specific antigen and clinical progression free rates were 45% and 55%, respectively.

CONCLUSIONS

Abdominal wall tumor implantation after LPLND for prostate cancer was not demonstrated, even in patients who developed hormone-resistant disease. LPLND in men with Stage D1 disease did not alter short-term disease progression. Longer follow-up in a larger cohort is necessary to determine if LPLND will have an impact on the 5 and 10-year disease progression and survival rates for patients with Stage D1 prostate cancer.

Laparoscopic nephrectomy: present state and future developments

Laparoscopy has been a valuable tool in gynecologic practice for many years but it is only recently that this technology has been applied to urological surgery.1 Initially laparoscopy was used in urology only for di- agnostic purposes; however, following the success of laparoscopic cholecystectomy,' the technique was utilized to perform therapeutic procedures such as varicocelectomy and pelvic lymphadenectomy.v' Open surgery has been the standard for nephrectomy for over 100 years and the techniques, results, and complica- tions have been well documented in surgical texts. Laparoscopic nephrectomy is also a relatively new appli- cation, having only been first described in 1991.5 This article will review the current status of laparoscopic nephrectomy and speculate on its future role. The pros and cons of the laparoscopic technique when com- pared to open nephrectomy will also be discussed.