Sonographic detection of renal and ureteral stones. Value of the twinkling sign

PURPOSE

To compare the detection of urinary stones using standard gray scale ultrasound for diagnostic accuracy using the color Doppler "twinkling sign".

MATERIALS AND METHODS

Our study population consisted of forty-one patients who demonstrated at least one urinary stone on unenhanced CT evaluation of the kidneys or ureters. Each patient was evaluated using gray scale ultrasound and color Doppler imaging by an observer who was blinded to the CT results.

RESULTS

Seventy-seven stones were present in 41 patients, including 47 intrarenal stones, 5 stones in the renal pelvis, 8 stones at the ureteropelvic junction, 5 ureteral stones and 12 stones at the ureterovesical junction. Based upon gray scale sonography the diagnosis of stone was made with confidence in 66% (51/77) of locations. Based upon Doppler sonography using the twinkling sign, the diagnosis of stone was made with confidence in 97% (75/77) of locations. Clustered ROC analysis demonstrated that the Doppler twinkling sign (Az = 0.99) was significantly better than conventional gray scale criteria (Az = 0.95) for the diagnosis of urinary stones (p = 0.005, two-sided test).

CONCLUSIONS

The color Doppler twinkling sign improves the detection, confidence and overall accuracy of diagnosis for renal and ureteral stones with minimal loss of specificity.

Robotic-assisted laparoscopic partial nephrectomy: surgical technique and clinical outcomes at 1 year

OBJECTIVE

To report our surgical technique of robotic-assisted laparoscopic partial nephrectomy (RLPN) for renal tumours of <7 cm and present their clinical outcomes, as minimally invasive PN is an increasingly viable option for small renal tumours.

PATIENTS AND METHODS

From July 2005 to December 2006, 20 consecutive patients (mean age 58.2 years, sd 7.9) had RLPN and a follow-up of > or =1 year, all surgery being undertaken by one surgeon. All cases were elective except in one patient with a solitary kidney. We used the three-arm da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA) in a four-port, transperitoneal approach. Transient vascular occlusion was applied in all cases using a tourniquet technique. The tumour was excised with a 5-mm margin using cold-cut scissors, and the margins were assessed by frozen sections. The specimen was placed in an impervious bag for subsequent removal via the camera port. Under direct vision, we repaired all pelvicalyceal system entries with absorbable sutures. After the entire tumour bed surface was lined with Floseal (Baxter Healthcare, Deerfield, IL, ISA) the capsule/parenchyma was closed with running suture, reinforced by haemostatic clips.

RESULTS

The mean (sd) operative and warm ischaemia times were 82.7 (17.0) and 21.7 (2.4) min, respectively, and the mean estimated blood loss was 189 (32) mL. There were no intraoperative complications or conversion to open surgery. There was also no bleeding after surgery, perinephric haematoma or urinary leakage. The mean (sd) tumour size was 30.2 (2.4) mm, while margins were negative in all cases of malignancy. At the 1-year follow-up there was no local recurrence, renal functional deterioration or late surgical complications.

CONCLUSIONS

Our RLPN technique is a safe and feasible option for small renal tumours. Reproducible technique and good team co-ordination are pivotal for obtaining good oncological and surgical outcomes.

Real-time virtual ultrasonographic radiofrequency ablation of renal cell carcinoma

OBJECTIVE

To evaluate the usefulness of real-time virtual ultrasonography (RVS) as a new navigational tool for percutaneous radiofrequency ablation (RFA) of solid renal cell carcinoma (RCC).

PATIENTS AND METHODS

Ten patients with 13 RCCs were treated with percutaneous RFA using RVS, which displays ultrasonograms and corresponding multiplanar reconstruction images of computed tomography in parallel.

RESULTS

RVS allowed excellent anatomical visualization and precise navigation of RFA for RCC. All patients were treated successfully in one session with percutaneous RVS RFA. There were no significant complications, and none of the patients had a local tumour recurrence during the follow-up.

CONCLUSION

RVS for RFA of solid RCC is a new and promising alternative imaging method.

Sonographic measurement of renal pelvis wall thickness as diagnostic criterion for acute pyelonephritis in adults

PURPOSE

Inflammatory processes may increase the urothelial thickness of the renal pyelon. Purpose of the study was to assess sonographic measurement of pyelon wall thickness (PWT) in adult patients with acute pyelonephritis, chronic urinary tract infection (UTI) and indwelling ureteral stents.

MATERIALS AND METHODS

Four study groups (acute pyelonephritis n=50, chronic UTI n=10, indwelling ureteral stents n=10, controls n=25) underwent renal ultrasonography (Acuson Seqouia, Mountain View, CA; 6 MHz Transducer). The renal pyelon was imaged in transverse and longitudinal planes. PWT measurements of patients with acute pyelonephritis were repeated after successful antibiotic treatment.

RESULTS

Mean PWT in healthy controls was 1.0 mm+/-0.19. In patients with acute pyelonephritis, PWT was significantly increased to 2.9 mm+/-0.89 (p<0.001). PWT decreased significantly after antibiotic treatment to 1.4 mm+/-0.47 (p<0.001). Kidneys with indwelling stents presented with a PWT of 2.7 mm+/-0.68, kidneys with chronic UTI demonstrated a PWT of 2.8 mm+/-0.62. PWT in these patient groups was significantly greater than PWT in healthy volunteers (p<0.001). The interobserver agreement was excellent (p<0.001).

CONCLUSION

PWT is a reproducible diagnostic criterion for acute pyelonephritis. Based upon our experience, we suggest a cut-off value of 2.0 mm to distinguish healthy kidneys from those with urothelium thickened by inflammation. PWT cannot be used to distinguish acute pyelonephritis from chronic inflammation of the urothelium.

Multimodal evaluation of renal perfusional changes due to extracorporeal shock wave lithotripsy

OBJECTIVES

To examine the effect of extracorporeal shock wave lithotripsy (ESWL) on renal perfusion before and after treatment, by assessing renal resistive index (RI) using colour Doppler ultrasonography (CDUS), magnetic resonance perfusion imaging (MRPI), radionuclide renography and big-endothelin-1 values (Big-ET-1).

PATIENTS AND METHODS

In 69 normotensive patients the RI was measured before, 1, 3, 6 and 24 h after ESWL using CDUS. The RI values, measured in interlobar/arcuate arteries, were correlated with the findings on MRPI, done before and within 24 h after ESWL. In addition, renal plasma flow (RPF, assessed on radionuclide renography) and Big-ET-1 levels (a potent vasoconstrictor peptide), served as a control for evaluating renal perfusion. The patients were stratified in three age groups, i.e. <or=39, 40-59 and >or=60 years, with 23 patients in each group.

RESULTS

The mean (sd) RI increased significantly in the treated kidneys, from 0.64 (0.05) before to 0.72 (0.08) after ESWL (P = 0.001). Only in patients aged >or=60 years did the RI continue to increase over the 24 h. MRPI showed a decrease of renal blood flow (RBF) in all age groups, but most significantly in those aged >or=60 years. The radionuclide renography and big-ET-1 levels changed significantly only in the oldest group. The best correlation was between RI and RBF changes detected by MRPI.

CONCLUSIONS

ESWL obviously causes disturbances of renal perfusion, particularly in elderly patients (>or=60 years). Measurement of RI with Doppler techniques might provide useful information for the clinical diagnosis of renal damage.

Robotic Anderson-Hynes pyeloplasty: 5-year experience of one centre

OBJECTIVE

To present our 5-year experience with robotically assisted laparoscopic pyeloplasty (RALP), as LP has been shown to have similar success rates as open surgery, but standard LP requires high operative skills and a correspondingly long period of training, limiting its widespread availability, and RALP is easier and quicker to learn due to facilitated intracorporeal suturing.

PATIENTS AND METHODS

In all, 92 patients had transperitoneal RALP for pelvi-ureteric junction obstruction (PUJO) using the daVinci system (Intuitive Surgical, Sunnyvale, CA, USA). A transperitoneal dismembered Anderson-Hynes procedure was used in all cases. Three robotic ports and one assistant port were used in all cases while a JJ stent was left indwelling for 6 weeks. Both primary PUJO (including horseshoe kidneys in 80 cases) and secondary (in 12 cases) were considered eligible. The follow-up included ultrasonography, excretory urography and renal scintigraphy.

RESULTS

The mean follow-up was 39.1 months; PUJO was successfully resolved in 89 patients (96.7%) while three required additional procedures. Haemorrhage into the collecting system and urine extravasation occurring early after surgery were the causes of failure. The mean (range) operative duration, including the set-up of the robot, was 108.34 (72-215) min; the mean duration of docking and surgery significantly decreased with experience (P < 0.001). The mean hospital stay was 4.57 days. Split renal function improved from 37.6% to 41.9%. No cases of secondary PUJO were recorded during extended follow-up.

CONCLUSIONS

RALP using the daVinci system is safe and effective, achieving similar long-term success rates to open surgery. The three-dimensional versatility of the robot enables the surgeon to recapitulate the open procedure. The results were durable with no cases of late complications, corroborating the accuracy of robot-assisted intracorporeal suturing and the subsequent quality of the pelvi-ureteric anastomosis. Moreover, the robotic approach was easy and quick to learn for both the surgical and the technical staff. Therefore, RALP is our preferred technique to treat PUJO.

Plain abdominal radiography with transabdominal native tissue harmonic imaging ultrasonography vs unenhanced computed tomography in renal colic

OBJECTIVE

To compare plain film kidney, ureter and bladder radiography (KUB) with transabdominal native tissue harmonic imaging ultrasonography (NTHI-US) vs unenhanced computed tomography (CT) for the diagnosis of urinary calculi in patients with acute flank pain.

PATIENTS AND METHODS

In all, 112 patients who presented to the urological department with clinical suspicion of ureteric calculi were included. These patients had KUB with NTHI-US and unenhanced CT. Of the 112 patients, 14 were lost to follow-up and therefore excluded. For the remaining 98 patients (53 men, 45 women; mean age 43.3 years, range: 19-74) the KUB with NTHI-US findings were compared with the CT findings, which served as the 'gold standard'.

RESULTS

In all, 75 patients were confirmed to have ureteric calculi. KUB with transabdominal NTHI-US detected 72 of the 75 patients with calculi (sensitivity 96%, specificity 91%, and accuracy 95%). Unenhanced CT detected urolithiasis in all 75 patients (sensitivity, specificity and accuracy of 100%). Both techniques showed further extra-urinary pathologies.

CONCLUSION

This prospective study shows that CT is the most accurate technique for detecting urolithiasis. However, KUB with transabdominal NTHI-US is an alternative to unenhanced CT with comparable results.

Value of 3-dimensional transrectal/transvaginal sonography in diagnosis of distal ureteral calculi

OBJECTIVE

In a prospective study, the feasibility of 3-dimensional (3D) transrectal/transvaginal sonography in comparison with transabdominal sonography and intravenous urography (IVU) in identifying distal ureteral calculi was evaluated.

METHODS

Sixty-two patients in the urologic clinic with clinical suspicion of distal ureteral calculi were included. The patients consisted of 44 men and 18 women with a mean age +/- SD of 44 +/- 17 years. These patients underwent 3D transrectal/transvaginal sonography, transabdominal sonography with IVU, and, finally, ureterorenoscopy.

RESULTS

Fifty-nine patients were confirmed to have distal ureteral calculi on the basis of urologic intervention (ureterorenoscopy). Three patients had a spontaneous stone passage immediately after imaging completion. The median size of the calculi was 3.7 +/- 2.00 mm. Transabdominal sonography detected 34 of the 62 patients with calculi (sensitivity, 55%). The median size of the calculi was calculated as 5.0 +/- 2.4 mm. The examination time was 6.5 +/- 2.7 minutes. Intravenous urography detected 44 of the 62 patients with ureterolithiasis (sensitivity, 71%). Herein, the median stone size was measured as 3.9 +/- 1.9 mm, and the examination time was 38 +/- 17 minutes. The combination of transabdominal sonography and IVU in visualization of ureterolithiasis raised the sensitivity to 81% (50 of 62 patients). Three-dimensional transrectal/transvaginal sonography showed ureterolithiasis in all 62 patients confirmed to have distal ureteral calculi (sensitivity and specificity, 100%). The median size of the calculi was calculated as 4.4 +/- 2.2 mm, and the examination took 1.9 +/- 0.6 minutes.

CONCLUSIONS

The data in our prospective study show that transrectal/transvaginal sonography with 3D image assessment is superior to IVU and abdominal sonography for diagnosing distal ureteral calculi.

Laparoscopic varicocele ligation in children and adolescents using isosulphan blue: a prospective randomized trial

OBJECTIVES

To evaluate, in a randomized prospective trial in children and adolescents, the feasibility of isosulphan blue-based lymphatic vessel preservation during laparoscopic varicocelectomy and its impact on the complication rate, as the operative management of varicoceles remains controversial.

PATIENTS AND METHODS

In all, 50 consecutive patients were randomly assigned to two laparoscopic varicocelectomy groups. The indications for surgery included scrotal pain and a difference in testicular size, as well as severe cosmetic impairment. All the patients had a laparoscopic varicocelectomy using three ports. Patients in group A had standard laparoscopy, while those in group B had additional isosulphan blue administered. After surgery, the patients were assessed at 3, 6 and 12 months for varicocele recurrence, hydrocele formation, atrophy, pain or other complications.

RESULTS

There were no intraoperative complications or conversions to open surgery. There were no adverse reactions, scrotal haematomas or atrophy. At 3 months after surgery, the incidence of hydrocele in group A was 20% whereas in group B no hydroceles were detected (P = 0.025); at 6 months the 20% still had hydroceles. One patient in each group had varicocele recurrence associated with persistent pain. In two patients in group B, blue pigmentation of the left hemiscrotum persisted at the 3-month follow-up but resolved by 6 months.

CONCLUSIONS

Laparoscopic repair of varicoceles using isosulphan blue helps to identify and preserve the lymphatic drainage. It prevents secondary hydrocele formation, the most common complication, with no supplementary risk to the patient. Also, testicular oedema causing impaired spermatogenesis can be avoided.

Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system

OBJECTIVES

To develop and assess the feasibility of laparoscopic partial nephrectomy performed using the daVinci robotic system.

METHODS

Between November 2002 and August 2003, 13 patients with solid or suspicious cystic renal masses underwent robotic-assisted laparoscopic partial nephrectomy. In 8 cases, an intra-arterial catheter was inserted for renal cooling before occlusion of the renal artery. The remaining 5 patients underwent partial nephrectomy after the renal hilum had been clamped. Tumor excision and intracorporeal suturing were performed entirely with telerobotics. The perioperative data and pathologic results were retrospectively reviewed.

RESULTS

The mean lesion diameter was 3.5 cm (range 2.0 to 6.0). The mean operative time was 215 minutes (range 130 to 262), and the mean blood loss was 170 mL (range 50 to 300). The mean warm ischemia was 22 minutes (range 15 to 29), and the mean cold ischemia time was 33 minutes (range 18 to 43). The length of hospital stay averaged 4.3 days (range 2 to 7). The resected lesions included renal cell carcinoma in 10, oncocytoma in 2, and a complex renal cyst in 1. In 1 case, a positive margin occurred despite negative frozen sections; laparoscopic nephrectomy was performed and showed no residual tumor. One patient experienced postoperative ileus. At 2 to 11 months of follow-up, no recurrence had been observed.

CONCLUSIONS

Robotic-assisted partial nephrectomy is feasible. Robotic partial nephrectomy can be safely performed using a transperitoneal or retroperitoneal approach. A second scrubbed assistant is mandatory to provide assistance using conventional laparoscopic instruments with this technique.

Robotic pyeloplasty: technique and results

The da Vinci robotic system can be used to perform dismembered and nondismembered pyeloplasty techniques effectively. Robotics not only seems to improve dexterity and surgical precision but also provides an ergonomic surgical environment for a surgeon performing complex reconstructive procedures such as pyeloplasty. Although performance-enhancing features of the da Vinci robot seem to decrease the difficulty of intracorporeal suturing, a learning curve also exists for telerobotic procedures. This learning curve may decrease as experience with telerobotics increases and as advances in technology are introduced. Presently, the interaction between the primary and assistant surgeon seems crucial to the success of the procedure. Although the early clinical experience with robotic pyeloplasty is favorable, continuing clinical evaluation and careful follow-up are required to determine if the procedure is as efficacious in the long run as open pyeloplasty and laparoscopic pyeloplasty.

Laparoscopic radical nephrectomy in the elderly

OBJECTIVE

To evaluate the efficacy and outcome of laparoscopic radical nephrectomy (LRN) in patients aged >75 years, and to compare the results with those obtained from patients younger than this undergoing laparoscopic surgery for the same indication.

PATIENTS AND METHODS

From a retrospective review of 33 patients aged >75 years undergoing LRN, 28 were for tumour. A group of 28 consecutive patients aged <75 years undergoing laparoscopy for the same indication were used for comparison. The two groups were compared for American Society of Anesthesiology (ASA) physical status score, comorbidity, previous surgical history, operative duration, estimated blood loss, tumour size, complications during and after surgery, conversion rates, time to oral intake and drain removal, perioperative mortality and hospital stay.

RESULTS

Only the initial ASA score was significantly higher for the older patients. All other variables before, during and after surgery were similar for both groups.

CONCLUSIONS

The final outcome of laparoscopic surgery in elderly patients was as promising as in their younger counterparts. Therefore, elderly patients should not be excluded from LRN, even though they usually present with more comorbidities.

Long-Term Outcome of Laparoscopically Managed Nonpalpable Testes

PURPOSE

We evaluated laparoscopic diagnostic findings in 108 impalpable testes, and analyzed the success rate and long-term outcome of either direct laparoscopic orchiopexy or the 2-stage Fowler-Stephens procedure.

MATERIALS AND METHODS

A total of 84 children with 108 impalpable testes and a mean age of 1.9 years underwent laparoscopy between 1992 and September 2000. Long-term outcome with regard to viability and location of the testes was evaluated.

RESULTS

Of the 108 testes 72 were located intra-abdominally, of which 28 were managed by direct laparoscopic orchiopexy, 29 were managed by a 2-stage laparoscopic Fowler-Stephens procedure and 15 were vanishing. The remaining 36 testes were inguinally located during exploration and orchiopexy, except for 5 vanishing testes. In all cases the operation proceeded as planned. After a mean followup of 6.2 years all laparoscopically managed testicles were in a normal scrotal position with normal perfusion as revealed by color flow Doppler sonography. Two testicles became atrophic after a 2-stage Fowler-Stephens procedure. Morbidity was low in all children.

CONCLUSIONS

The laparoscopic approach allows not only diagnosis, but also adequate therapy regardless of whether direct orchiopexy or a 2-stage procedure is performed. Our long-term results clearly demonstrate that even in the patients undergoing the 2-stage procedure the laparoscopic approach is safe and efficient, and leads to excellent results concerning viability of the affected testicles. Progress and experience gained during recent years are encouraging in continuing laparoscopic procedures in children.

Management of Adult Leydig-Cell Testicular Tumors: Assessing the Role of Laparoscopic Retroperitoneal Lymph Node Dissection

BACKGROUND AND PURPOSE

Leydig-cell tumors represent <5% of malignant testicular tumors in adults. Orchiectomy is curative in approximately 90% of cases; however, the remaining men can develop metastases refractory to chemotherapy and radiation. We evaluated the role of laparoscopic retroperitoneal lymph node dissection (RPLND) in adult Leydig-cell tumors.

PATIENTS AND METHODS

Between 1999 and 2001, laparoscopic RPLND was performed with four transperitoneal ports within a unilateral template for six patients with pure Leydig-cell tumors. Presenting signs and symptoms, operative time, blood loss, intraoperative complications, postoperative complications, length of hospitalization, pathology reports, ejaculatory function, and survival were reviewed retrospectively.

RESULTS

Laparoscopic RPLND was successful, without open conversions or reinterventions. Two vascular injuries occurred during dissection; additional intraoperative complications were not observed. Postoperatively, one patient developed erysipelas, but no other postoperative complications were recorded. The mean operative time was 190 minutes, and the mean length of hospitalization was 4.3 days. Pathologic analysis of lymph nodes revealed no evidence of metastatic Leydig-cell tumor. At 12 months' mean follow-up (range 3-29 months), no recurrences have been identified.

CONCLUSIONS

Laparoscopic RPLND is a safe, minimally invasive procedure for Leydig-cell tumors. Additional clinical experience is required to evaluate its effectiveness for pathologic stage II tumors and to determine if a therapeutic advantage can be realized with a protocol employing laparoscopic RPLND for adult Leydig-cell tumors.

Splenosis mimicking local recurrence after laparoscopic radical nephrectomy

We report a case of retroperitoneal splenosis, which presented as a local recurrence after laparoscopic radical nephrectomy. Seeding of splenic tissue can occur after trauma and/or removal of the spleen and must be kept in mind when performing laparoscopic surgery.

A comparison of laparoscopic pyeloplasty performed with the daVinci robotic system versus standard laparoscopic techniques: initial clinical results

PURPOSE

Laparoscopic pyeloplasty is an accepted therapy for primary ureteropelvic junction obstruction (UPJO), however difficulty associated with intracorporeal suturing has limited widespread clinical application. We report our initial experience of laparoscopic pyeloplasty performed with the daVinci robotic system matched to procedures performed with standard laparoscopic techniques.

PATIENTS AND METHODS

From June 2001 until August 2001, six patients underwent definitive management of primary UPJO using the daVinci robotic system. In four patients an Anderson-Hynes pyeloplasty was performed, while in two patients Fengerplasty was performed. Using demographic and preoperative information, each patient in the daVinci-assisted group was matched to a corresponding patient with primary UPJO undergoing laparoscopic pyeloplasty with standard techniques between November 1999 and June 2001. Perioperative results and follow-up data were subsequently compared.

RESULTS

Treatment groups were identical with regard to surgical procedure, gender, and side of UPJO. The length of hospitalization was 4 days for all patients, regardless of treatment group. Estimated blood loss was <50 cc in all cases. For Anderson-Hynes pyeloplasty, the mean overall operative and suturing times were 140 and 70 min using the daVinci system and 235 and 120 min using standard techniques, respectively. For the Fengerplasty, the mean overall operative and suturing times were 78 and 13 minutes using the daVinci system and 100 and 28 minutes using standard techniques, respectively. No complications were observed and there were no open conversions.

CONCLUSION

Anderson-Hynes pyeloplasty and Fengerplasty are feasible using either conventional laparoscopic techniques or the daVinci robotic system. In this initial pilot study, procedures performed with the daVinci robotic system resulted in overall decreased operative time, however factors responsible for the decreased operative time remain to be defined. Long-term prospective follow-up of procedures performed with or without the daVinci robotic system for surgeons with limited experience in laparoscopic management of UPJO is warranted to delineate the true efficacy of the device.

Anderson-Hynes dismembered pyeloplasty performed using the da Vinci robotic system

INTRODUCTION

To evaluate and describe the use of the da Vinci robotic system in performing laparoscopic Anderson-Hynes pyeloplasty.

TECHNICAL CONSIDERATIONS

Between June 2001 and February 2002, 9 patients underwent laparoscopic Anderson-Hynes pyeloplasty with the da Vinci telerobotic surgical system. The diagnosis was based on the presenting symptoms and radiologic imaging findings. The technique for da Vinci-assisted Anderson-Hynes pyeloplasty followed the same steps as for conventional laparoscopy. Three transperitoneal laparoscopic ports were required for the robotic system, and a fourth laparoscopic port was used by the assistant for retraction, suction, and introduction of suture. The operative time, suturing time, perioperative complications, and success rates were prospectively evaluated. The mean operative time was 138.8 minutes (range 80 to 215), and the mean suturing time was 62.4 minutes (range 40 to 115). No intraoperative complications or open conversions were required. The estimated blood loss was less than 50 mL in all cases. The mean length of hospitalization was 4.7 days (range 4 to 11). Postoperatively, 1 (11.1%) of 9 patients required open exploration to repair a defect in the renal pelvis. At a mean follow-up of 4.1 months (range less than 1 to 8), all procedures were successful on the basis of the subjective and radiographic data.

CONCLUSIONS

All aspects of laparoscopic Anderson-Hynes pyeloplasty were performed using the da Vinci robotic system. da Vinci-assisted procedures resulted in favorable overall operative times, suturing times, perioperative complications, and available success rates, but additional clinical experience is required. Ongoing clinical application of robotic technology in a controlled scientific manner is needed to gauge the effectiveness of this method completely.

Laparoscopic retroperitoneal lymph node dissection: description of the nerve-sparing technique

INTRODUCTION

Laparoscopic retroperitoneal lymph node dissection (RPLND) is associated with a more favorable postoperative recovery and decreased morbidity compared with open RPLND. To date, laparoscopic RPLND is used as a diagnostic tool for patients with clinical Stage I nonseminomatous germ cell tumor and as a diagnostic and therapeutic tool for patients with low-volume Stage II nonseminomatous germ cell tumor after chemotherapy. In an effort to further expand the therapeutic implications for laparoscopic RPLND, we describe a nerve-sparing technique for laparoscopic RPLND.

TECHNICAL CONSIDERATIONS

In all cases, a four-port transperitoneal approach was used to perform a unilateral nerve-sparing technique. Laparoscopic nerve-sparing RPLND requires complete exposure of the retroperitoneum, similar to the standard procedure. A stepwise surgical approach is required for prospective identification of the sympathetic trunk and postganglionic nerve fibers. Identification and division of the lumbar veins is required for complete mobilization of the vena cava to facilitate dissection of the postganglionic nerves on the right side as they course dorsal to the vena cava. Meticulous dissection was required for preservation of the postganglionic nerves in the interaortocaval and para-aortic regions.

CONCLUSIONS

Laparoscopic nerve-sparing RPLND is technically feasible. Performance of laparoscopic nerve-sparing RPLND decreases the potential morbidity associated with the standard laparoscopic technique further and may help expand the therapeutic potential for this minimally invasive procedure.