摘要:

ABSTRACTIt seems likely, and indeed inevitable, that medical device usage will continue its rapid increase over the next 10 to 20 years and beyond. For surgeons, these new inventions will come in many forms but should take into account biocompatibility and resistance to encrustations and to microorganisms. This review focuses on research under way at presentin vitroandin vivoon materials and coatings, use of bioelectrics, use of artificial organs and tissues, application of indigenous bacteria, and other alternative device management techniques, which could well become part of clinical practice in the future. By necessity, some of these citations are speculative, but supporting documentation for their inclusion is presented.

ISSN:0892-7790    

DOI:10.1089/end.1999.13.1

年代:1999

数据来源: MAL

摘要:

ABSTRACTThe introduction of hand-assisted laparoscopy should benefit every laparoscopic urologist. Hand assistance will shorten the learning curve for many urologists interested in performing laparoscopic renal procedures, including nephrectomy and nephroureterectomy. Advanced laparoscopists will be able to undertake more challenging procedures, including nephrectomies for inflamed, infected kidneys and live-donor nephrectomies. A step-by-step approach is presented for hand-assisted laparoscopic nephrectomy.

ISSN:0892-7790    

DOI:10.1089/end.1999.13.9

年代:1999

数据来源: MAL

摘要:

ABSTRACTPurpose:In an attempt to determine the visceral risk secondary to a direct percutaneous puncture of the upper renal calix, the anatomic relations of the upper pole of the kidney were studied by magnetic resonance imaging.Methods:Examination was performed on 25 normal volunteers placed successively in the right and left prone oblique position. The kidney axis and minimal distances from the cutaneous plane at the level of the upper and lower poles were measured. Axial and tangential simulated percutaneous approaches to the upper renal calix were compared in term of risk of damage to the pulmonary, splenic, and hepatic parenchyma.Results:The transversal anteversion angle was statistically comparable for right and left kidneys, but the sagittal anteversion angle was significantly higher for right kidneys (p= 0.05). The minimal distance from the cutaneous plane was statistically comparable for the upper and lower poles. The lower pole was significantly deeper for left than right kidneys (p= 0.01). The visceral risk was statistically comparable for left and right kidneys and was significantly higher in case of an approach in the axis of the upper renal calix or through the 10th intercostal space compared to a puncture via the 11th space (p= 0.0001).Conclusion:A percutaneous puncture of the upper pole of the kidney above the 11th rib increases the risk of visceral damage. Preoperative evaluation, with the aid of CT scan or MRI, of the risk of pulmonary, splenic, or hepatic injury could be carried out in these cases.

ISSN:0892-7790    

DOI:10.1089/end.1999.13.17

年代:1999

数据来源: MAL

摘要:

ABSTRACTBackground and Objectives:Ureteral obstruction occurs in 2% to 10% of all renal transplant recipients. Antegrade endourologic intervention has been the gold standard of therapy but carries significant morbidity. This study was designed to investigate the feasibility of retrograde stenting of these difficult ureters and to determine whether it can be performed with minimal morbidity without general or regional anesthesia.Methods:Ninety-seven consecutive patients were found to have renal allograft hydronephrosis by ultrasonography, between August 1993 and March 1997. Of these, 61 (63%) had confirmation of obstruction by MAG-3 imaging, with equivocal results in 25 (26%). The remaining 11 patients had a rising creatinine concentration despite Foley catheter drainage. All patients had retrograde stenting attempted under local anesthesia followed by intravenous sedation if necessary. If stent placement was unsuccessful, the procedure was repeated under regional or general anesthesia.Results:A total of 85 patients (88%) were managed successfully with retrograde stenting. Of these procedures, 24 (28%) were performed under local anesthesia alone, while 57 (67%) required both local anesthesia and intravenous sedation. Only 4 patients (5%) required general anesthesia. No patient suffered any morbidity associated with retrograde stenting. Of the 12 patients in whom retrograde stenting failed, 2 had renal allograft rupture and 10 had ureteral necrosis at surgical exploration.Conclusions:Retrograde stenting of the hydronephrotic renal allograft can be achieved with a high success rate and minimal morbidity, usually without general or regional anesthesia. If the ureter cannot be managed in a retrograde fashion, a high index of suspicion for a serious allograft complication should exist.

ISSN:0892-7790    

DOI:10.1089/end.1999.13.21

年代:1999

数据来源: MAL

摘要:

ABSTRACTRenal angiomyolipomas (AML) are vascular tumors associated with a risk of spontaneous bleeding. Renal trauma may also initiate such hemorrhage. We present a case in which we initially avoided direct puncture and the possible risk of bleeding through extensive renal AMLs and then subsequently performed a direct puncture through the tumors. A 21-year-old obese male patient with tuberous sclerosis and mental retardation presented to our institution with left renal colic and was found to have a staghorn calculus. A CT scan revealed extensive bilateral renal AMLs. The patient had previously undergone renal angioinfarction for an enlarging right-sided AML, and nuclear renography demonstrated 70% function from the left side. The patient had a nephrostomy access created on the morning of a scheduled percutaneous nephrolithotomy under three-dimensional CT guidance. There was no clinically significant bleeding. Intraoperatively, a second access site was required in order to render the patient stone free. This was done using standard biplanar fluoroscopic technique and traversed an AML. Both tracts were balloon dilated prior to placement of a 34F Amplatz sheath. Postoperatively, the patient had an uneventful recovery. A CT scan performed 1 day postoperatively revealed no retroperitoneal collection. This case demonstrates that renal access can be achieved with remarkable accuracy using 3D CT imaging. Furthermore, although this approach seems most prudent in the case of extensive renal AMLs, fluoroscopically guided renal access and dilation to 34F was not associated with bleeding in this patient.

ISSN:0892-7790    

DOI:10.1089/end.1999.13.27

年代:1999

数据来源: MAL

摘要:

ABSTRACTPercutaneous access and antegrade intervention remains the gold standard in the management of renal and ureteral complications in the renal transplant recipient. Current techniques with large nephrostomy sheaths and instrumentation carry significant morbidity in this patient population. We present our experience with a modification of the standard nephroscopic approach using a smaller (16F) O'Brien suprapubic peel-away introducer and sheath to access the allograft renal pelvis and allow manipulation with a smaller-caliber endoscope, with the purpose of attaining similar treatment outcomes with less morbidity in this subset of patients. Fourteen renal transplant patients with indications for antegrade management of renal or proximal ureteral complications had successful endoscopic intervention through the smaller sheaths without suffering any intraoperative or postoperative complications at a mean follow-up of 22 months (range 8–37 months). The mean operative time was 140 minutes (33–190 minutes), which is not significantly different from our operative time using standard instrumentat

ISSN:0892-7790    

DOI:10.1089/end.1999.13.31

年代:1999

数据来源: MAL

摘要:

ABSTRACTBackground:Further advances in endoscope technology have allowed the development of a new generation of tightly packed fiberoptics encased within a rigid ureteroscope. The tips of these semirigid ureteroscopes measure between 5.0F and 11.9F, and their working channels measure between 1.8F and 5.5F, which allows passage of routine endoscopc instruments. Additionally, several manufacturers have recently produced straight-channel fiberoptic semirigid endoscopes with an offset lens which allow usage of rigid lithotripsy devices. New fiber-packing techniques provide numerous pixels within the image bundle. These ureteroscopes have varied distal lens systems, but all have excellent vision in the field of view.Methods:Over the past 28 months, we have performed transurethral ureteroscopy in 187 patients, having utilized semirigid ureteroscopes in 158 patients for diagnostic procedures (8.7%), stone manipulation (78.7%), removal of migrated stents (4.4%), and surgery of stricture, tumor, or foreign bodies (8.2%). In more than 50% of our cases, ureteral dilation was not necessary, and the semirigid ureteroscope was passed to the area of interest without difficulty.Results:We accessed the site of pathology in 96.2% of patients. Overall, complications occurred in 6.9% of patients. However, of these problems, 93.6% were small ureteral perforations (only three of which were caused by the semirigid ureteroscope itself), and all cases but one were managed successfully by a ureteral stent. No postoperative strictures were noted.Conclusion:This new generation of semirigid fiberoptic ureteroscopes represents another significant advance in the endourologic management of ureteral disease.

ISSN:0892-7790    

DOI:10.1089/end.1999.13.35

年代:1999

数据来源: MAL

摘要:

ABSTRACTBackground and Objectives:The aim of minimally invasive approaches to vesicoureteral reflux, such as endoscopic trigonoplasty, is to lower the morbidity of open procedures without compromising the results. Initial successes have not been sustained, mainly because of trigonal splitting, which results in the ureteral orifices returning to their preoperative positions. This study was designed to address trigonal splitting by mobilizing the ureters before repositioning them and to evaluate the feasibility of accomplishing this intravesically with 2- to 3-mm endoscopic mini-instruments.Methods:Bilateral vesicoureteral reflux was surgically created in 10 minipigs. After radiologic confirmation of success 4 weeks later, modified trigonoplasty was performed by endoscopic intravesical mobilization of both ureters and incision of the trigonal mucosa using 2-mm instruments. The ureteral orifices were then advanced toward the midline and sutured in place. The initial surgical techniques were modified to permit the entire procedure to be performed endoscopically in the last four minipigs. Cystograms and intravenous urograms were obtained 4 weeks later.Results:Two minipigs died postoperatively. Six of the remaining eight had persistent reflux, including three of the four in the group treated completely by endoscopic means. None of the dissected ureters showed evidence of stricture or necrosis.Conclusions:Although the procedure was not successful in correcting reflux in this model, this study demonstrates the feasibility of endoscopic ureteral mobilization. With current instrumentation, there is no significant technical obstacle to complete intravesical endoscopic surgery, including ureteral reimplantation.

ISSN:0892-7790    

DOI:10.1089/end.1999.13.41

年代:1999

数据来源: MAL

摘要:

ABSTRACTPurpose:To introduce the use of the 20F rigid hysteroscope in urologic procedures.Materials and Methods:The 20F hysteroscope was used to remove deeply embedded foreign bodies from the lower urinary tract of three patients in whom previous attempts with standard cystoscopic equipment were unsuccessful.Results:In all three cases, the hysteroscope easily passed into the urethra and with the use of rigid instruments was able to remove the foreign bodies without complication.Conclusion:Situations may arise when the removal of embedded foreign bodies is not possible with standard cystoscopic equipment. The hysteroscope, which is available in most operating rooms, was able to extirpate even deeply embedded foreign bodies.

ISSN:0892-7790    

DOI:10.1089/end.1999.13.47

年代:1999

数据来源: MAL

摘要:

ABSTRACTBackground and Objective:Current treatment technique for laser prostatectomy involve Nd:YAG wavelength at 60 to 80 W. Use of the KTP wavelength in addition to Nd:YAG allows for vaporization of more tissue, decreasing the amount undergoing coagulation necrosis. In this study, we compared 20 W and 40 W of KTP laser energy in conjunction with the Nd:YAG wavelength for the treatment of benign prostatic hyperplasia (BPH).Patients and Materials:A total of 50 consecutive patients underwent laser ablation of the prostate, with 38 patients (Group I) receiving treatment with 20 W of the KTP and 60 W of the Nd:YAG wavelengths. The other 12 patients (Group II) underwent treatment with 40 W of KTP and 60 W of Nd:YAG laser energy. The patients had an initial evaluation consisting of American Urological Association (AUA) Symptom Score, uroflowmetry, transrectal ultrasonography for prostate volume measurement, and assay of prostate specific antigen (PSA) serum level. The patients were seen in follow-up at 1, 3, and 6 months.Results:The mean symptom score decreased from 23.4 to 8.9 from Group I and from 18.2 to 3.5 for Group II at the 6-month follow-up. The mean peak urinary flow rate increased from 8.4 to 15.4 mL/sec Group I and from 8.3 to 16.5 mL/sec in Group II at the 6-month follow-up.Conclusions:The patients treated with the 40 W of KTP laser energy experienced a more rapid and sustained improvement in symptom score than those treated at 20 W. The improvement in peak urinary flow rate was approximately the same in the two groups.

ISSN:0892-7790    

DOI:10.1089/end.1999.13.49

年代:1999

数据来源: MAL