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This is an important step to enlarge the much more limited surface area for retroperitoneal port insertion. The initial audible "pop" is the puncturing of the fascia, whereas the second represents entry in to the peritoneal cavity. As the lower pole and pelvis are more anteriorly facing than is usual, a standard lower pole lateral entry may damage the large anterior division arteries or accessory branches from the iliac artery [18]. A novel doubleendoloop technique for natural orifice transluminal endoscopic surgery gastric access site closure. Using a grasper to hold the free end of the suture, the length of the suture is brought between the jaws of the device. Multiple studies have reported significant advantages with the laparoscopic approach when compared with the traditional open approach. If there is any increase in the thickness or in the irregularity of the wall or septa, surgical exploration is indicated. However, the diagnostic accuracy of gray-scale and Doppler ultrasound for malignant processes of the kidney, bladder, and prostate is low. This condition does, however, require minor modifications in port placement due to the thickness and mobility of the large abdominal pannus. Sonography can be quite useful for assessing the presence of renal vein thrombus with 75% sensitivity and 96% specificity, and 100% accuracy for detecting thrombus in the inferior vena cava [30, 31]. Although 83% of the men had effective cancer control, only 60% attained the perfect trifecta after 2 years following surgery as most were affected by erectile dysfunction [12]. Alternative methods, although not practiced by us, are used and should be familiar to the reader. Patients with a history of nephrolithiasis or those found to have bilateral, multiple unilateral, or large renal stones are generally not considered candidates for donor nephrectomy. A series of 60 patients treated with focal cryoablation reported 72% potency rates after the procedure [42]. These early experiences demonstrate that laparoscopic pyelolithotomy is feasible, safe, and efficacious as an alternative to open pyelolithotomy in children, and warrants further study. Extent of pelvic lymphadenectomy and its impact on outcome in patients diagnosed with bladder cancer: analysis of data from the Surveillance, Epidemiology and End Results Program data base. If a collecting system injury occurs, a 15F round Davol drain with the spike removed can be inserted via the 5-mm lateral port site. In this scenario, ultrasound guidance is necessary to locate the kidney for initial access. Lorenzo1 & Cheol Kyu Oh2 1 2 Department of Urology, Urological Science Institute, Yonsei University, Seoul, Korea Department of Urology, Inje University College of Medicine, Haeundae-gu, Busan, Korea Introduction In the early 1990s, attempts were made by urologists to conduct extirpative and reconstructive procedures using laparoscopy. Multiple trocar configuration this trocar configuration consists of a single skin incision with several ports placed through separate fascial sites. The patient is secured on the table with tape and special belts in case lateral flexion is needed. The patient is then carefully placed in a modified lateral decubitus position, angled at approximately 30o from the ground. The dissection should be carried cephalad to release all lateral attachments of the spleen while gently lifting it up using the shaft of an instrument inserted through the upper port. The 10-year survival rate was 49% in the treatment arm versus 39% in the delayed arm (P =. With the placement of the Veress needle the surgeon should appreciate two separate layers that represent the needle traversing the rectus sheath and peritoneum. Generally, in the absence of hemodynamic or respiratory compromise, small pneumothoraces may be managed conservatively. In a study of patients with distal ureteral stones in which all patients were hospitalized for at least one night, Kapoor et al. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: A systematic review and cumulative analysis of comparative studies. The proximal end of the stent is pulled from the pelvis after the anterior incision in the renal pelvis is completed. The potential disadvantages of this are the proximity of the camera to the urachal lesion.

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They concluded that apoptotic pathways are more important in the peripheral zone of ablation where temperatures do not meet necrotic thresholds. The external stent is removed and an indwelling double pigtail stent can be passed over the wire. The authors stated that stones diagnosed prior to or during 720 Section 5 Stone Management in Urology: Management of Stones in Abnormal Situations was successfully treated and/or removed, and all kidneys were rendered stone free. Calcification Absent Few Multiple Extensive with nodularity Enhancement Absent Absent Absent Present Malignant Potential <0. With further improvements in surgical technique, nerve-sparing techniques have been employed. Alternatively on the left, the line of Toldt can be incised around the splenic flexure, leaving the pancreas and spleen in situ. One has precious seconds to determine whether initial laparoscopic attempts at control are feasible or futile. With more precise treatments, the dose to a target structure can be increased while reducing the dose to a neighboring critical structure. Surgical margin status of open versus laparoscopic radical prostatectomy specimens. Further, in locally invasive disease it is important for therapeutic planning and prognostication to distinguish those tumors penetrating the prostate capsule but sparing the seminal vesicles (T3a) from those invading the seminal vesicles (T3b). The 15/18F Miniature Nephroscope is ideal for "mini-perc" procedures, as it can be used with access sheaths as small as 13F. The thorny issue of statistical analyses should be explored early through consultations with an expert statistician. Suture ligation or repair may be necessary in some instances, such as laceration injuries to larger vascular structures. Transurethral resection during the follow-up period was required in 12% due to urinary obstruction. This underscores the importance of obtaining accurate histopathologic staging information prior to developing a treatment plan. Laparoscopic bilateral hand assisted nephrectomy for autosomal dominant polycystic kidney disease: initial experience. The rate of nondiagnostic biopsies varied from 2% to 20% with a trend to be higher than in the modern percutaneous biopsy studies [22]. Transvescicoscopic reimplanatation Technical aspects the port placement is preceded by transurethral cystoscopy to allow placement of the first camera port under cystoscopic guidance. In cases where a bilateral simple nephrectomy is being performed, a total of five trocars are utilized in an "X" configuration [68, 69]. Stratification of pathologic features in radical prostatectomy specimens that are predictive of elevated initial postoperative serum prostate-specific antigen levels. However, in contrast, all but the most basic therapeutic interventions typically require more than one instrument simultaneously. Despite the use of the kidney-shaped dissecting balloon, we find it necessary to use a 10-mm laparoscope and some gentle abdominal pressure to sweep the peritoneum in a cephalad and lateral direction. Retroperitoneal laparoendoscopic single site surgery in urology: initial experience. Transrectal high-intensity focused ultrasound ablation of prostate cancer: effective treatment requiring accurate imaging. In addition, computer technology has made it easier to incorporate an increasing number of customized beams, which allow the radiation dose to be further concentrated in the area of interest.

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Minor complications can occur in up to 25% of patients with most not requiring specific treatment other than observation. These instruments allow for a minimal bleeding during transection of the adrenal parenchyma. Also, use of an additional transumbilical access, albeit a needlescopic port for visualization of entry in to the peritoneal cavity via the viscus, makes the procedure much safer. Also, be aware that in obese patients, reliable surface landmarks, such as the association between the umbilicus and aortic bifurcation, are lost. Five patients had nonfunctioning hydronephrotic lower poles secondary to reflux nephropathy and two a nonfunctioning upper pole due to an obstructing ureterocele. Humility is important; the first step in recognizing complications Chapter 101 Complications in Urologic Laparoscopy 1239 is being open to their occurrence. Rigid ureteroscopy for diagnosis and treatment of ureteral calculi during pregnancy. A preoperative discussion about the need for extubation when fully awake and in a sitting position may minimize patient anxiety and improve cooperation during recovery. In three patients, the initial stent was exchanged after 6 months and after 12 months in one patient. Active surgical drains are closed system drains that exert a negative low pressure, which removes fluid gradually. This results in the ureter exiting the renal pelvis ventrally and more superiorly, and the longitudinal renal axis converges medially [5]. Despite the small number of patients involved, a significant advantage was noted for postoperative recovery after laparoscopic compared to open ileal interposition. Validation of this system is currently underway at a number of institutions [103]. Segura described a technique to incise the skin and fat, with incision extending down to the muscular fascia, reducing the length required to reach the stone [49]. In most transvesical animal experiments, bladder closure was not attempted and the catheter was simply left in place. Absolute contraindications are abdominal wall infection, generalized peritonitis, bowel obstruction, and uncorrected coagulopathy. The increased external pressure on the abdomen compresses the abdominal contents, causing increased venous pressure. This observation is especially relevant in residency training environments 850 Table 73. Core biopsies clearly improve on the accuracy of percutaneous biopsy, as demonstrated by two recent series. This can be determined by puncture and aspiration using a laparoscopic needle inserted via the 5-mm port when indigo carmine was administered prior to insufflation or following a retrograde injection of methylene blue if a preoperative ureteral catheter was placed. Obesity is likewise a relative contraindication as some report success even in these patients. Robotic assistance makes intracorporeal suturing much easier, thereby facilitating reconstructive procedures like vesicovaginal fistula repair. The predominant venous drainage system consists of the anterior spermatic or pampiniform plexus, responsible for draining the testis and anterior epididymis, and the testicular vein, which drains in to the inferior vena cava on the right and the left renal vein on the contralateral side. When a patient is set-up with skin tattoos and verified with the Calypso system, most of the corrections are within 1. Ablative techniques (radiofrequency/cryo/chemical) Ablative techniques represent the new frontier of minimally invasive approaches and offer the benefits of low invasiveness and less technical challenges compared to conventional surgery. All robotic working ports are 8 mm in diameter and are three- or four-arm, based on the da Vinci robotic model. Under transgastric visual guidance, needle-knife electrocautery was used to create a transvaginal port for a 5. As such, in the event of significant venous injury during laparoscopy, intravascular volume should be maintained and the site of bleeding should be occluded directly. It should be emphasized that donors require lifetime follow-up to assess blood pressure, creatinine, and perhaps proteinuria, so abnormalities can be diagnosed early to prevent further complications.

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The recurrence rate associated with laparoscopic repair when performed by surgeons who reported having performed more than 250 laparoscopic repairs was less than half that of surgeons who had performed 250 or fewer. Gasless laparoscopy has become easier with the development of commercial abdominal retractors/ elevators secured to the side of the operating table. Preoperative investigation should be directed by history and examination findings of the patient. Doses of 1 mg/kg should be adequate to bring relief to a patient with renal colic. Rapid symmetric uptake of intravenous contrast, combined with prompt excretion and drainage, documents the relative renal function and can obviate the need for routine renal scans. While children have been shown to have a greater capacity to clear fragments then adults [54], the presence of residual fragments has been correlated with adverse clinical outcome [28]. Passive drains provide an exit port for fluid, blood, purulent material, and debris, and act via gravity and capillary action. Generally speaking, physiologic effects of pneumoperitoneum are attributable to two independent variables: (1) increased intraabdominal pressure; and (2) absorption of the gaseous medium used for insufflation. Following division of the renal vessels, the dissection continues along the superior medial aspect of the kidney. The scrub nurse or technician stands on the opposite side of the table from the primary surgeon, which facilitates passage of equipment directly across the operating table. Positioning Robotic renal surgery can be performed both transperitoneally and retroperitoneally. Two methods can be utilized to identify entry in to the collecting system; one requires cystoscopic placement of a ureteral catheter at the beginning of the operation and repositioning, the other involves simple administration of indigo carmine prior to insufflation. Randomised trial of the efficacy of tamsulosin, nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi. This is typically achieved using a cholinesterase inhibitor such as neostigmine or edrophonium. Effects of intravenous Dexmedetomidine in humans, sedation, ventilation and metabolic rate. A biopsy needle or cryoprobe is inserted percutaneously and advanced on the same trajectory half the distance to the tumor. It must, however, be noted that use of this type of laparoscope does have a learning curve for the assistant holding the scope. With the Harmonic scalpel, energy is delivered using a laparoscopic hand-piece with a shaft tuned to conduct the ultrasonic vibration at a rate of 55 000 cycles/s. The limitation of performing a physical examination in a child is highlighted by Cisek et al. The pelvic extraperitoneal space where the lower ureter will be found is the preperitoneal space caudal to the pelvic brim and between the parietal peritoneum and the fascia transversalis. The second robotic 8-mm port is then "telescoped" in to the 12-mm port in the midline below the xiphoid process. In animal studies using vasopressin antagonist, renal function improved in comparison to control groups. The cyst is aspirated if necessary and decortication is performed by freeing the cyst from the posterior wall of the bladder, the anterior wall of the rectum, and the seminal vesicles laterally. Despite significant advances in laparoscopic technique and technologies, laparoscopic urologic surgery remains technically demanding. Attention to these details will facilitate successful visualization of the ureter and minimize complications. All testis cancer surgeons are aware of the complication of retrograde ejaculation due to an incompetent bladder neck, which occurs when these nerves are resected. The tortuous ureter often associated with a pelvic kidney hinders deflection of the flexible ureteroscope, potentially limiting access. The triangular space created by the iliopubic tract and aponeurotic arch inferior (distal) to the inferior epigastric vessels and internal inguinal ring is the weak point in the medial fossa through which direct herniation occurs. Oncologic outcome of 132 cases of laparoscopic radical nephrectomy with intact specimen removal for t1-2n0m0 renal cell carcinoma. Histories of prior retroperitoneal surgery or infectious process are considered relative contraindications for the retroperitoneal approach as the dense adhesions encountered in these situations hinder dilation of the retroperitoneal space. In selected patients, a cosmetic advantage may be obtained by concealing the single incision below the waistline.

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Therefore, the lack of hematuria does not exclude the possibility of acute renal colic. However, in all recent series (from 1994 onwards) of renal tumor biopsy, no cases of tract seeding have been reported. An additional 5-mm assistant trocar is placed superior to the umbilical port if needed for organ retraction. Normally the obturator vessels are preserved as their course is medial and slightly posterior to the obturator nerve. Using the curved side of the fine scissors with the tips pointed down will help in the dissection and decrease the chance of creating a skin hole during this part of the procedure. A kV unit is mounted 90o from the gantry of the linear accelerator and opposite an X-ray detector. Laparoscopic complications associated with a pyeloplasty are those that might affect any laparoscopic procedure, including bowel injury, adjacent organ injury, and port-site infection. Following this, the authors placed the transvaginal port under laparoscopic visualization. Urology surgical team members also need to be able to troubleshoot unexpected occurrences during a case. Renal cell carcinoma: risk assessment and prognostic factors for newly diagnosed patients. Single-port transvesical enucleation of the prostate: a clinical report of 34 cases. Minor upward adjustments to the location of the ipsilateral lower quadrant port may be required when a transplant kidney is present. Weight loss and dietary modifications, such as increasing fluid and fiber intake, restricting intake of red meat, salt, and oxalate, and only moderate calcium intake, may alleviate urinary electrolyte changes in some patients [12]. There are few reported series of patients who undergo the extraperitoneal approach. Management of renal tumors by image-guided radiofrequency ablation: experience in 105 tumors. An arteriovenous fistula should be considered in cases of persistent bleeding [49]. Open versus laparoscopy-assisted radical cystectomy: results of a prospective study. Suturing in the closed environment is often a time-consuming task and getting things right the first time often gives the best chance for success. The soft collar on the inside of the incision helps maintain insufflation as well as prevent subcutaneous emphysema. In 60 patients, one study reported loss of one beacon via the urethra and one to the venous plexus [54]. Experience among various authors and instrumentation between institutions may vary significantly, influencing final outcomes. In the salvage setting, the outcomes are competitive with salvage prostatectomy and, combined with a favorable morbidity profile, suggest that cryoablation is a first-line treatment option for radiorecurrent prostate cancer in appropriately selected patients. Unilateral templates avoid dissection below the level of the inferior mesenteric artery, minimizing sympathetic nerve fiber damage in this region. Hemiacidrin irrigation of renal pelvic calculi in patients with ileal conduit urinary diversion. The anterior branch divides in to four segmental arteries (apical, upper, middle, and lower). Working together, we combined different techniques from traditional laparoscopy, subcutaneous endoscopic brow lift, and subcutaneous saphenous vein harvest to formulate an approach using laparoscopic instruments for inguinal node dissection in staging penile cancer. If easy separation of the gonadal vein and ureter cannot be performed, we divide the ureter, gonadal vein, and per- Chapter 81 Renal Surgery for Benign Disease 955 on large branch veins and Endoshears are used to divide between the third and fourth clips. An increase in cardiac filling pressure as a consequence of an increase in intrathoracic pressure is also seen during laparoscopy. Of importance is the way the posterior peritoneum and the lateral peritoneal reflexion behave when the patient changes position.


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Urinary tract infections acquired postoperatively can present with fever on the second or third day. We recommend placing the nodes in an extraction sac to decrease the chance of inadvertent skin contamination. Because of the need both for closure of access points and to allow performance of many surgical procedures, tissue approximation has been one of the most intense areas of focus for development. Although these anomalies are seen in half of fetal specimens and persist in 2% of adults, they seldom become symptomatic [29]. Identification of patients with positive lymph nodes provides prognostic information that is useful in counseling and monitoring patients. It also helps assess the accessibility of the fistula for reconstruction through the vagina, extent of fibrosis and associated scarring, and quality of vaginal tissue. The risk of hematoma directly correlates with increasing size of the tumor and number of probes [58, 59]. This has led to increased focus and attention on functional outcomes after radical prostatectomy. A horizontal mattress suture of 3-0 polyglactin is placed in to the fascia at this point, which facilitates closure. This arrangement eliminates the need for the operating surgeon to remove their eyes from the primary monitor to reach behind or to their side to receive instruments. Laparoscopy has been utilized to mobilize the peritoneum and capping the neovagina with bowel serosa. Bladder carcinoma and other second malignancies after radiotherapy for prostate carcinoma. Surgeons have complained of dizziness because of disparities in focus, zoom, and alignment between the two separate images of the two cameras [3]. Indications for renal embolization varied from refractory bleeding and recurring infections to nonoperative candidates for definitive therapy. The key point in technique is slow and careful sharp dissection of the fistulous edges, because the trigone and ureteral orifices invariably lie in close proximity. Gas embolism: a comparative study of air and carbon dioxide as embolic agents in the systemic venous system. The lymphadenectomy is best started using the superior three ports with the camera port in the middle. An injury can occur while dilating the ureteral orifice, introducing the uretero- scope, or during antegrade/retrograde passage of guidewires or baskets, and it is imperative that these injuries be recognized promptly to minimize long-term sequelae. In cases with previous multiple intra-abdominal surgeries or with previous intra-abdominal infections, where the presence of extensive adhesions may make the insertion of the Veress needle potentially dangerous, we use the open technique for establishing pneumoperitoneum. Complications were not reported and stones were removed in all but two cases, including a complete staghorn stone [80, 81]. A subdartos pouch is then created over the point of the dissector, which then is passed through the scrotal fat. In these cases, the operating table is prepared in a similar fashion to that for unilateral cases with the exception that the arm boards are opened on either side at almost 90o to the table. The adult patient is placed in a lithotomy position with the hips hyperextended and the table in a moderate Trendelenburg. Experience with gadolinium is limited, but to date no adverse effects on a fetus have been reported. Clinical implications of clinically insignificant stone fragments after extracorporeal shockwave lithotripsy. The effects of tidal volume and respiratory rate on oxygenation and respiratory mechanics during laparoscopy in morbidly obese patients. It should be noted that comparisons with laparoscopic pyeloplasty by those performing conventional laparoscopic pyeloplasty showed no major advantage to the robotic technology [5]. Ultrasound imaging cannot differentiate perfectly between complex cysts that need surgery and those that can be observed. These are caused by ischemic insult as well as direct surgical injury or contusion. Hormonal regulation of testicular descent: Experimental and clinical observations.

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The primary reason proposed in the mid 1990s was that laparoscopic nephrectomy was too difficult for the average urologist to develop and to maintain the necessary operative skills, given the relative infrequency of nephrectomy in a typical urology practice. Rarely, when more significant bleeding is anticipated, a type and cross or autologous blood donation should be considered. Furthermore, tumors in complex locations, such as adjacent to neighboring bowel, are not suited for ultrasound guidance as the proximity of the adjacent structures is not readily evident sonographically. The dissection usually starts on the right side, as the exposure and dissection are more difficult on the left due to the presence of the sigmoid colon. This approach reportedly permitted excellent exposure of the anomalous renal anatomy and avoided the need to mobilize and translocate the sigmoid colon. Chapter 98 Minimally Invasive Techniques in Lower Urinary Tract Reconstruction 1207 40. Often, there is a perforating tributary of the obturator vein to the pelvic side wall inferolateral to the obturator nerve. Survival benefit of radical prostatectomy in lymph node-positive patients with prostate cancer. Other pelvic structures in this space are the vas deferens, external iliac vessels, the deep circumflex iliac vessels, and pubic or accessory branches of the inferior epigastric vessels. The rate of secondary malignancies after radical prostatectomy versus external beam radiation therapy for localized prostate cancer: a population-based study on 17,845 patients. Effects of intermittent pneumatic leg compression for prevention of postoperative deep venous thrombosis with special reference to fibrinolytic activity. It is our preference to approach the bladder neck laterally, entering the space between the posterior bladder wall and the seminal vesicles. Despite a limited number of patients, narrowed ureteral segment greater than 10 mm, and age younger than 4 years were associated with a poor outcome with an endoscopic approach [119]. Limitations and concerns In children there is currently no consensus regarding the maximum size of residual stone fragments that are considered clinically significant [5, 42] and as a result there is no clear definition as to what constitutes "stone-free" status. During robotic procedures the surgeon console can be positioned in a corner of the operating room, depending on room configuration. In inexperienced hands, relative contraindications to pneumoperitoneum are prior abdominal surgery, nonreversible coagulopathy, and severe cardiopulmonary disease. Monotherapy extracorporeal shock wave lithotripsy for the treatment of staghorn calculi in children. Like fiducials, transponders are implanted in to the left lobe, right lobe, and apex of the prostate gland via 14G introducer needles. The specimen was removed via the vaginal opening after being placed in to a retrieval bag. Further clinical investigations will elucidate the true efficacy and indications for these stent [82]. The articulating instruments can be used through conventional straight trocars, which were passed through a single site (usually the umbilicus) to give a sense of triangulation (see below) [32, 47]. A double-blind, placebo controlled comparison of the morphine sparing effect of oral rofecoxib and diclofenac for acute renal colic. An attempt at suture closure should be performed for all substantial collecting system lacerations utilizing a 4-0 Vicryl or Polydioxanone suture. The fascial tacking sutures are wrapped around the guides on the inverted conical sleeve of the Hasson cannula, which is then seated down in to the incision prior to locking it on the port sleeve to help prevent leakage of the pneumo-retroperitoneum. Seminal vesicles appear as paired organs caudal to the bladder with attenuation similar to that of soft tissue. Since the landmark autopsy study of the pelvic plexus by Walsh and Donker in 1982 [38], the technique of anatomic, nerve-sparing radical prostatectomy has resulted in significant improvements in sexual function outcomes.

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Traditionally, patients were aggressively hydrated intravenously or were told to increase their oral hydration in order to promote stone passage [33]. Additionally, a prostate grasper or atraumatic grasper can be used by the assitant for additional traction. Pathology revealed Fuhrman grade 4 chromophil and sarcomatoid renal carcinoma [16]. Single trocar laparoscopic nephrectomy using magnetic anchoring and guidance system in the porcine model. Special attention should be given to the trocar placed at the initial site of access as this is the only trocar that is not placed under direct vision. The technique of retrograde nephroscopy being utilized along with laparoscopy to assist percutaneous access permits continuous visual control and facilitates displacement of overlying bowel. Therefore, early diagnosis and proper management are essential for a successful outcome. Because of differences in healthcare systems, there is significant disparity in the cost of stone management worldwide. Finally, several studies have emphasized that postoperative pulmonary status following laparoscopy is favorable compared to an open surgical approach. The standard gastric endoscopes have a number of advantages over other traditional scopes, including ability to maneuver both up/down and right/left separately, ability to selfclean the lens by depressing a button, and good illumination of the abdominal cavity. They recommended establishing the border of the bladder by modulating the volume of fluid in the bladder via a urethral catheter; careful perivesical dissection, particularly in boys with prior inguinal surgery; and maintaining a high index of suspicion, particularly in the presence of hematuria. Physiologic effect of nifedipine and tamsulosin on contractility of distal rreter. The peritoneum is incised transversely across the anterior margin of the hernia defect(s) from the medial umbilical ligament to the anterior superior iliac spine. Care should be taken during resection in close proximity to the ureters as inadvertent injury may occur. Using fluoroscopic guidance, the tract can be dilated and the kidney stones removed through a combination of ultrasonic lithotripsy and mechanical extraction. Complications and limitations the risks of fibrin products include viral transmission, anaphylaxis, and coagulopathy due to the use of homologous and bovine products. For this reason also, adequate hemostasis should be instituted prior to opening the vaginal wall. Percutaneous placement of permanent metal stents for treatment of ureteroenteric anastomotic strictures. Ten ureters (10 patients) with malignant obstruction were treated with this combination. Additionally, there are instruments made specifically for use by the intra-abdominal hand. To avoid inadvertently traumatizing a blood vessel or other structure, most clip appliers are equipped with a safety mechanism preventing closure of the jaws unless a clip has been loaded in to place. Bacteriology the majority of patients with urinary diversions are colonized with bacteria. Germ cell counts in semithin sections of biopsies of 115 unilaterally cryptorchid testicles. Increased risk of calcium oxalate formation is not expected secondary to a urinary diversion; therefore, these groups of patients were already predisposed to stone formation unrelated to urinary diversion [3]. It has been suggested that residual gas in the abdomen may contribute to pain or ileus in the postoperative period. Results Several large series of laparoscopic pyeloplasties demonstrate success rates equivalent to open surgery (Table 86. The mean operative time may be as low as 30 min in experienced hands, but over twice as long for those still learning the procedure. Finally, the anastomosis is checked by instilling 300 mL of saline in to the bladder, and any additional interrupted sutures are placed as necessary. The most superior port should be placed approximately 2 cm below the xiphoid process. Step 7: Diverticulum ablation and closure of collecting system the diverticulum is inspected to find its communication with the collecting system.

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Although rarely used when the retroperitoneal approach is selected, the robot is docked from the abdominal side. Third-generation cholecystectomy by natural orifices: transgastric and transvesical combined approach (with video). Results A few large series on laparoscopic herniorrhaphy have been published (Table 95. A recent analysis of urinary function after primary and salvage cryoablation using validated instruments has shown excellent functional outcomes [29]. This technique, however, is only applicable to the most basic surgery, especially gynecologic surgery where the uterus can be manipulated from below, obviating the need for retraction. The access sheath offers the additional benefit of keeping the ureteroscope straight, which improves deflectability within the renal pelvis. Although not routinely performed at all institutions, we believe that this maneuver facilitates the apical dissection and reduces the risk of anterior apical positive margins. Since treatment to the whole pelvis increases the morbidity of treatment, the answer is of the utmost importance. Our own study consists of four patients who have all done well with the 1164 Section 6 Laparoscopy and Robotic Surgery: Laparoscopy and Robotics in Adults more patients who have undergone such repairs. Assuming a euvolemic status, and is suspected to be secondary to loss of the normal lordotic curve and decreased tone of the paraspinous muscles [74]. Two 12-mm standard laparoscopic ports (Ethicon Endo-Surgery Inc) were placed through the vagina and colon, with robotic ports telescoped through these ports upon docking of the robot. The contact region between the edge of the kidney and the retroperitoneal fat is noted and the Harmonic shears are utilized to remove all of the fat overlying this region, so the broad fascial surface of the quadratus musculature is available for suturing (see Video 81. Consequently, cost from the patient perspective is highly variable and must be individualized. Risk factors for the formation of a steinstrasse after extracorporeal shock wave lithotripsy: a statistical model. Postoperative convalescence after inguinal hernia surgery: prospective randomized multicenter study of laparoscopic versus Shouldice inguinal hernia repair in 1042 patients. Insufflation Pneumoperitoneum or pneumoretroperitoneum creates and maintains the working space for laparoscopic procedures, although many reports suggest that pneumoperitoneum is not necessary for safe access using an optical trocar [11]. Erythema, tenderness, and fluctuation should prompt the consideration of infection. Other animal studies have implicated that increased intra-abdominal pressure during laparoscopy impacts renal hemodynamics. The risk of cyanide toxicity should be negligible, as any cyanide produced during the lithotripsy should be diluted out from the urinary tract with the irrigant. Use of a straight needle to place a stay suture in the target viscera can provide exposure and countertraction. Socially, 45% of the women interviewed felt ostracized and 50% were economically impoverished by job loss consequent to their developing the fistula. In select cases, imaging may be helpful for patients at significantly increased risk of general anesthesia. In our practice, a 26F nephroscope is used to extract stones of less than 1 cm with a rigid stone forceps or an ultrasonic lithotripter may be used to fragment stones of greater than 1 cm. However, there is evidence to suggest fewer wound complications, decreased testicular/ scrotal edema, shorter operative time, and decreased need for postoperative analgesia using the laparoscopic approach. Prior to insufflation, an orogastric tube and Foley catheter should be in place in order to decompress the stomach and bladder to avoid inadvertent injury to these hollow viscera. Trans-appendicular continent cystostomy in the management of the neurogenic bladder. Transoesophageal echocardiographic assessment of haemodynamic function during laparoscopic cholecystectomy. Laparoscopy allows for a decrease in acute-phase reactants normally seen during the surgical stimulus. The drain output is monitored until it is less than 30 mL on two consecutive shifts following removal of the Foley catheter on postoperative day 1.

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Some centers have utilized diluted iodinated contrast for hydrodissection to better visualize the interceding fluid [43]. Recently, published randomized trials comparing the mortality outcomes of a screened group versus a nonscreened group showed conflicting results [3, 4]. The van Velthoven stitch, as it is now referred to , allowed for 10 needle placements through the bladder and urethra in a tension-free fashion; five throws from each of the two 7-inch monofilament absorbable sutures. Although controversial, in select adult patients all stone fragments can be considered clinically significant and can lead to stone recurrence [103]. Postoperative complications developed in three patients, including sepsis, gastrointestinal bleeding, and herpes esophagitis. Randomized controlled trial comparing endoscopic clips and overthe-scope clips for closure of natural orifice transluminal endoscopic surgery gastrotomies. With the patient in a prone or semi-prone position, contrast is infused in to the renal pelvis at a rate of 10 mL/min. As with all surgical operations requiring general anesthesia, the attendant risks of pneumonia, myocardial infarction, stroke, and death should be discussed. Other surgeons have overcome the fluid problem by using a disposable fluid-impervious gown. Based on efficacy demonstrated in the adult population [26], tamsulosin may be offered on an individualized basis as adjunctive therapy to facilitate ureteral expulsion, although there is limited current evidence supporting its effectiveness in children [27]. Postoperative immobilization following open nephropexy procedures has ranged from 1. A recent addition to the armamentarium for artery-sparing varicocelectomy is a variety of Doppler transducers for laparoscopic use. The trocar design must not create false reassurance, as even shielded trocars have not been shown to decrease access injuries. If the patient has a history of voiding abnormalities, we often wait to remove the Foley catheter until the second postoperative day. To gain access to the deep nodes, the fascia lata is opened to the edge of the adductor longus medially and the sartorius muscle laterally. This has important implications in relation to the management of stones in horseshoe kidneys. Further studies are needed, however, to determine the optimal dosing and duration of use, as well as the patient population that would benefit from these adjuvant analgesics. Multiple trocars of varying size can be introduced through the GelSeal cap and the specimen can be extracted once the GelSeal cap has been removed. Another potential finding is the presence of a gonad distal to the internal inguinal ring that was not found on physical examination and requires further exploration and management. A posterior lumbar approach for retroperitoneoscopic adrenalectomy: assessment of surgical efficacy. Instead, a more tangential resection is required in such cases so as to ensure complete excision of the posterior prostatic apical tissue. Initial data have supported the use of endopyelotomy for this indication in children, but current recommendations support its use only when the ureteral lumen is recognizable for cannulation [116]. Long-term incidence and risks for recurrent stones following contemporary management of upper tract calculi in patients with a urinary diversion. Field borders were designated on the films and generally corresponded to bone landmarks. With these modifications the mean delivered fetal radiation Management When to intervene The rate of spontaneous stone passage in pregnancy is between 64% and 84% [17, 21]. In the constant phase, the period of sustained maximal pain, the pain tends to remain constant until it is either treated or allowed to improve spontaneously. Gynecologists were gaining peritoneal access via the vagina to perform culdoscopy in the 1920s [1]. Selfassessment is a continual iterative process, and as the volume of cases increases, a personal database allows the surgeon to quickly measure themselves against published results.