摘要:

Abdominal insufflation during laparoscopy has been associated with transient oliguria, which abates after desufflation. Direct renal compression evoking a Page kidney effect was proposed as a mechanism. In an effort to confirm this theory, the left kidney was subjected to 15 mm Hg compression in six anesthetized mongrel dogs. For this, a pressure cuff was placed around the kidney excluding the renal hilar structures. The contralateral kidney was left untouched to serve as a control. After a steady-state period, the pressure cuff was inflated to 15 mm Hg for 2 hours. Cuff desufflation was followed by a 1-hour recovery period. Urine output, glomerular filtration rate (GFR), and effective renal blood flow (ERBF) were measured for both kidneys during each clearance period. For the treated kidneys, the mean urine output decreased 63% (P<0.05) during compression and increased 109% (P<0.05) after cuff desufflation. The GFR decreased 21% (P<0.01) during compression and increased 25% (P<0.05) during recovery. The ERBF decreased 26% (P<0.05) during compression, and during the 1-hour recovery period, ERBF did not recover to baseline values. For the control kidneys, there were no significant changes in urine output or GFR during the experimental and recovery periods. These data support the view that direct renal parenchymal compression is an important factor in the development of insufflation-induced oliguria. The clinical implications of insufflation-induced oliguria during laparoscopy deserve further investigation.

ISSN:0892-7790    

DOI:10.1089/end.1996.10.1

年代:1996

数据来源: MAL

摘要:

Conventional radiofrequency (RF) ablative techniques have shown promise for the treatment of symptomatic benign prostatic hyperplasia (BPH); however, present RF technology is limited by the small lesion size, necessitating several probe placements and heating cycles to achieve sizable lesions. This limitation is attributable primarily to a rapid increase in electrical impedance secondary to tissue desiccation and charring at the electrode tip. We devised a hollow screw-tip needle electrode that permits fixation to tissue, recording of temperature and impedance, infusion of fluid, and delivery of RF energy. Infusion of electrolyte solution (i.e., saline) into tissue prevents impedance rise by conducting RF energy away from the metal electrode and permits the creation of large lesions. By varying the conductivity of the perfusate (concentration and temperature), lesions of large diameter can be created in a controlled manner. To determine the long-term tissue effects, we applied this new modified RF technique to the prostates of five mongrel dogs in a chronic (0.5 to 8-week) study. The screw-tip electrode was serially embedded into each lobe of the perineally exposed glands with 1 -minute infusion of 0.9% saline (2 mL/min) followed by application of RF energy (500 KHz, 50 W, 2-18 minutes) along with continuous saline infusion. Thermocouples were embedded 5 mm below and at the gland capsule, and RF application was discontinued when the temperature reached 50°C at the periphery. Postoperatively, the animals were examined daily for clinical status and weekly for glandular changes using transrectal ultrasonography. At predetermined intervals, the animals were sacrificed and the prostates excised, measured, sectioned, and examined for histologic changes. Ablative tissue temperatures of 50 to 100°C were produced while impedance remained stable. Four animals required a single catheterization for relief of urinary retention between days 2 and 3; otherwise, all animals demonstrated a quick and uneventful recovery with no edema detectable on day 7 ultrasound examination. The outside dimensions of the gland remained relatively constant throughout the study (±0.39 cm L + W + H). Histologic examination revealed coagulation necrosis (ablation) in both lobes of all prostates (69.94% ± 16.62% of the gland) with tissueless cavities forming from the ablation area (28.71% ± 8.24% of the gland) contained within the capsule surrounded by healthy tissue at the periphery. Intraprostatic lesions were obtained without any gross damage to surrounding tissue, including the bladder and rectal wall. Utilizing a liquid conductor in prostate tissue allows a single electrode-placement heating cycle for controlled ablation for the potential treatment of BPH. This new technique produces more extensive and uniform lesions than conventional RF procedures, and lesion size is limited only by the duration of RF energy applica

ISSN:0892-7790    

DOI:10.1089/end.1996.10.5

年代:1996

数据来源: MAL

摘要:

Although extracorporeal Shockwave lithotripsy (SWL) has dramatically changed the management of urinary tract stone disease, the anatomic abnormalities of horseshoe kidneys cause some difficulties in the use of SWL in this disorder. In this study, 18 patients with stone-bearing horseshoe kidneys were investigated retrospectively in order to determine the effectiveness of SWL. Patients received an average of 11,437 ± 3062 shocks at an average of 18.8 kV with the Siemens Lithostar. Ten patients were treated in the supine position; stones could be localized in the prone position in eight. Catheterization with a double-J stent was the only adjuncts e procedure; it was used in four patients prior to SWL. Adequate stone fragmentation (smaller than 5 mm) was achieved in 14 of the 18 patients (78%). Although 5 of them (28%) became stone free within 6 months after the treatment, residual fragments persisted in 9 patients (50%) during the mean follow-up of 55 months. Stones of 4 patients (22%) were not fragmented adequately. We concluded that although adequate fragmentation can be achieved in stone-bearing horseshoe kidneys, the anatomic abnormalities prevent fragment passage in a substantial number of patients

ISSN:0892-7790    

DOI:10.1089/end.1996.10.13

年代:1996

数据来源: MAL

摘要:

A controversy has arisen as to whether the initial form of therapy for lower pole nephrolithiasis should be extracorporeal Shockwave lithotripsy (SWL) or percutaneous nephrolithotomy (PCNL). We reviewed our results with 968 single lower pole stones treated by SWL and reviewed publications comparing SWL and PCNL for lower pole nephrolithiasis. In our cases, the stone-free rate was 71.2%, the rate of repeat treatment and post-treatment secondary procedures was 6.4%, the complication rate was 0.5%, and the hospital stay was less than 24 hours in 99.3% of patients. In published series of PCNL for lower pole nephrolithiasis, the stone-$ free rate was 70.5% to 100%, repeat treatment rates were 4% to 62.5%, the complication rates were 13% to 38%, and the hospital stay was 3.1 to 6.1 days. The rates of recurrent stone disease with PCNL were 11% to 22%, similar to the rates after SWL. The percentage of renal urolithiasis patients with lower pole calculi since we started our unit in late 1986 has remained essentially constant at 38%. Although the stone-free rate with PCNL is higher than with SWL, the lower complication rate, lower repeat treatment/secondary procedure rate, the shorter hospital stay, and the similar recurrent stone rate with SWL make SWL more clinically effective as the primary therapy for lower pole calculi less than 2 cm in diameter.

ISSN:0892-7790    

DOI:10.1089/end.1996.10.17

年代:1996

数据来源: MAL

摘要:

Calculi in a noncommunicating or excluded calix may be associated with infection, pain, and focal renal damage. Some authors have recommended removal of these calculi and reestablishment of the pelvicaliceal communication, either by dilation of the infundibulum or creation of a neoinfundibulum, in order to prevent recurrent stone formation and infection. Herein, we report two patients with stones in a completely excluded calix, one after repeated courses of Shockwave lithotripsy for a staghorn calculus and the other after recurrent pyelonephritis. The combined approach is especially helpful if the examiner is in doubt about the anatomy (true calixvcaliceal diverticulum) or if a natural infundibulum cannot be identified by antegrade endoscopy.

ISSN:0892-7790    

DOI:10.1089/end.1996.10.21

年代:1996

数据来源: MAL

摘要:

Forty-three patients with single ureteral calculi located above the pelvic brim were treated by electrohydraulic lithotripsy (EHL) using a semirigid mini-ureteroscope. Of the 43 calculi, 36 (84%) were fragmented in one procedure. Six calculi (14%) were pushed back to the renal pelvis and treated successfully by complementary extracorporeal Shockwave lithotripsy (SWL). The total success rate of ureteroscopic manipulation thus was 98%. The operation time (mean 26.4 minutes) and postoperative hospital stay (mean 2.53 days) were relatively short. Complications were limited to four (9%) minor perforations of the ureter managed by internal stenting. Among these patients with complications, there were no significant ureteral strictures noted on excretory urography or ureteroscopic examination 1 to 3 months after ureterolithotripsy. The costs of ureteroscopy with EHL are lower than that of SWL or ureteroscopic lasertripsy. The total fees for ureteroscopy with EHL are about two thirds those for SWL in Taiwan. Despite the longer learning curve required for ureteroscopy, ureteroscopy associated with EHL is a cost-effective alternative for the treatment of upper ureteral calculi, especially when SWL is not readily available.

ISSN:0892-7790    

DOI:10.1089/end.1996.10.27

年代:1996

数据来源: MAL

摘要:

We report the formation of a staghorn calculus in a transplanted kidney caused by infection with a urea-splittingCorynebacteriumgroup D2organism. The stone was debulked percutaneously followed by intravenous vancomycin administration and urinary acidification with oral acetohydroxamic acid, leading to clearance of nearly all of the stone.

ISSN:0892-7790    

DOI:10.1089/end.1996.10.31

年代:1996

数据来源: MAL

摘要:

We have managed 164 bilharzial ureteral strictures endourologically. The site was at the pelviureteral junction in 4, at the pelvic inlet in 22, juxtavesical in 78, and intramural in 60. These lesions were categorized according to the line of management. Type I or simple stricture, present in 116 cases, was managed by retrograde bougie dilation to 16F. Dilation was preceded by transurethral ureterotomy in 54 cases. Type II or difficult strictures (24 cases) were managed by percutaneous antegrade dilation. Type III or complicated strictures (24 cases) were managed by antegrade placement of a guidewire down to the bladder followed by transureteral meatotomy and bougie dilation in one sitting under C-arm fluoroscopy. Three types of stenting procedures and diversion were used according to the length of the stricture and the quality of renal function. After 6 to 72 months, an overall successful clinical outcome with decompression of the upper urinary system and improved drainage pattern was achieved in 87.8% (144 cases)vonly 50% in patients with strictures longer than 2 cm. Postoperative reflux was seen in 21 cases (18%) of Type I strictures compared with 4 (17%) of Type II and 13 (54%) of Type III strictures. We concluded that this scheme of combined endourologic management for ureteral strictures is safe, simple, and less traumatic and produces excellent results. It should be the approach of choice, although it needs special equipment and operator experience. Open surgery should be restricted to the lesions that prove undilatable on both retrograde and antegrade procedures.

ISSN:0892-7790    

DOI:10.1089/end.1996.10.35

年代:1996

数据来源: MAL

摘要:

We report our experience with the transperitoneal (TP) and retroperitoneal (RP) approaches for performing laparoscopic nephrectomy for benign disease. Thirty-three patients with benign renal disease underwent laparoscopic nephrectomy, 23 by the TP and 10 by the RP approach. The average age of the patient, ASA score, and specimen weight were similar for the two groups. The average operating time for the TP approach was 5.6 hoursv5 hours for the RP approach. The average hospital stay was 2.8 and 3 days for TP and RP groups, respectively. The use of postoperative analgesics was similar in the two groups (37 mg of morphine sulfate equivalentv39 mg of morphine sulfate equivalent for the TP and RP groups, respectively). However, the RP group required less time to resume normal oral intake than the TP group (0.3v0.6 days). When assessed according to specimen weight of 100 or less, there was a significant reduction in the postoperative analgesia requirements for the RP group of patients (11 mg of morphine sulfate equivalentv28 mg of morphine sulfate equivalent for the TP group). In this subgroup of patients, the resumption of oral intake also occurred more quickly in the RP than the TP group (0.4v0.5 days). The hospital stay and total convalescence time were similar for the two groups. Four complications occurred in the 33 patients: 2 patients (1 TP and 1 RP), required conversion to open surgery, 1 asthenic patient developed a vastus lateralis bruise undergoing a TP approach, and a brachial nerve palsy occurred in a morbidly obese patient who failed a TP approach. The RP approach to laparoscopic nephrectomy reduces the time to resuming normal oral intake for patients postoperatively and, in those patients with a small specimen, may significantly reduce their postoperative analgesia requirements. However, the RP approach for laparoscopic nephrectomy for benign disease does not significantly improve the length of hospital stay or the patient's ultimate postoperative return to normal activity in comparison to the TP approach. There does appear to be a trend toward a shorter operative time for the RP approach. The RP laparoscopic approach is our method of choice for patients with benign renal disease.

ISSN:0892-7790    

DOI:10.1089/end.1996.10.45

年代:1996

数据来源: MAL

摘要:

Laparoscopic suturing is still difficult and time-consuming. The aim of this study, using the porcine model, was to evaluate the feasibility, safety, and efficacy of laparoscopic fibrin glue ureteral anastomosis without stay sutures for approximating the ureteral ends. In five pigs, after bilateral cystoscopic insertion of a 7F ureteral catheter, each upper ureter was laparoscopically dissected free and transected with scissors. The ureteral ends were then approximated with two atraumatic grasping forceps, and the fibrin glue was applied over the anastomotic site using a specially designed catheter (Duplocath). After waiting 5 minutes for the sealant to adhere, the forceps were removed, and the anastomotic site was examined for any early disruption. The ureteral stents were then pulled back to the distal ureter, and retrograde ureteropyelography was accomplished bilaterally in order to assess the immediate patency of the anastomoses. The animals were sacrificed and the ureteral anastomoses surgically removed for histologic examination. The operative time after insertion of the trocars averaged 15 minutes for each anastomosis, and no early disruption was observed after withdrawal of the grasping forceps. Immediate ureteral fluoroscopic patency was achieved in all 10 ureteral anastomoses, without leakage in 8 and with minimal leakage in 2. Histologic examination revealed a mild inflammatory reaction in the serosa with no modifications of the mucosa or the muscularis. Subsequently, two pigs were subjected to the same procedure bilaterally and not sacrificed. These two animals died with enormous urinomas on postoperative days 6 and 8. In each case, the anastomotic site was completely disrupted on one side, while the other side remained grossly patent. However, histologic examination of these latter anastomoses revealed no real coaptation of the ureteral ends, while demonstrating complete eversion of the mucosa. In conclusion, fibrin glue ureteroureterostomies, although easy to accomplish, are not safe enough to be used without stay sutures in laparoscopic surgery.

ISSN:0892-7790    

DOI:10.1089/end.1996.10.51

年代:1996

数据来源: MAL