Laparoscopic Left Donor Nephrectomy: Contemporary Technique, Tips and Tricks
Ahmed M. Mansour, MD, MRCS,1,3 Ahmed R. El-Nahas, MD,1 Nasr El-Tabey, MD,1 Ahmed Elshabrawy, MD,3 Ahmed A. Denewar, MD,2 Ibrahim Eraky, MD,1 Ahmed Shoma, MD,1 and Ahmed Shokeir, MD1
1Department of Urology, Urology and Nephrology Center, Mansoura, Egypt.
2Department of Nephrology, Urology and Nephrology Center, Mansoura, Egypt.
3Department of Urology, UT Health San Antonio, Texas, USA.
Background: Laparoscopic donor nephrectomy (LDN) has become the gold standard approach for kidney donation. The procedure has evolved with time and technological advancements. Contemporary LDN underwent multiple technical refinements to decrease operative time, warm ischemia times (WITs), morbidity, and improve safety of the procedure.
Objective: To illustrate contemporary surgical techniques for LDN and provide a step-by-step guide for the procedure.
Design, Setting, and Participants: Our Prospectively maintained donor database was reviewed for donors who underwent left LDN between January 2013 and December 2016.
Surgical Procedure: Pure laparoscopic left donor nephrectomy was performed using contemporary standardized technique, all patients were enrolled in enhanced recovery program for donor nephrectomy.
Outcome Measurements and Statistical Analysis: Clinical data were collected in a prospectively maintained database. Perioperative donor and recipient outcomes were evaluated.
Results and Limitations: A total of 246 donors were included in the study. Mean operative time was 145.2 ± 31.6 minutes. Mean estimated blood loss was 165.6 ± 45.2 mL. Mean WIT was 2.9 ± 1.0 minutes. Complications were reported in 27 patients (10.9%), patients with Clavien grade 1 in 15 patients (6.9%), grade 2 in 11 patients (4.4%), and Clavien grade 3 in 1 patient (0.4%) (inferior epigastric artery-related hematoma and subsequent evacuation). Vascular control in this series was achieved by double Hem-O-Lok application after a policy change in our institute because of a stapler malfunction. The main limitation of this study is the retrospective nature despite prospective maintenance of our database.
Conclusion: With cumulative refinement of the technique, the described approach for laparoscopic left donor nephrectomy may improve the efficiency of the procedure and offer functional advantage of the graft with low complication rates.
Muljibhai Patel Urological Hospital, Nadiad, India.
Introduction and Objective: Ureteropelvic junction (UPJ) obstruction is now commonly treated using the robotic platform, but performing reconstruction in kidney with anomalies of lie and position is rare using the robotic platform.
Methods: In this video, we present four clinical cases with pelvis–ureteral junction obstruction (PUJO), two in ectopic pelvic kidney, one in horseshoe kidney, and one case of right duplex system with lower pole PUJO. All four cases were robotically managed with different operative methods. The first case was a left ectopic kidney with PUJO (obstruction shown on DTPA renogram) and dismembered pyeloplasty was done. The second case was right ectopic kidney with PUJO and a flap-based pyeloplasty was done using the robotic platform. The third case was a right-sided PUJO in a horseshoe kidney, for which a dismembered pyeloplasty was done. The fourth case was a right duplex system with lower moiety obstruction with intrarenal pelvis, for which side-to-side ureterocalicostomy was done.
Results: Console times for the four cases were 63, 78, 58, and 95 minutes, respectively. Estimated blood loss was 50, 80, 60 and 150 cc, respectively. Postoperative course was uneventful and the patients were discharged on postoperative day 2. All the patients were asymptomatic clinically and on imaging done at 6 months.
Conclusions: Robotic UPJ reconstruction in anomalous kidney is safe and feasible. Technical modifications make the procedure more effective. Direction of spatulation of ureter is the key and is different than in normally located kidney. Incision on the pelvis and the ureter depends on the lie of the kidney. Flap pyeloplasty can be effectively done in pelvic kidneys using the robotic platform.
Combined Top and Down Approach with Low-Power Thulium Enucleation of Prostate: Evaluation of 1-Year Functional Outcomes
Mohamed Omar, MD,1 Ahmed Moustafa, MD,1 Mohamed El Shazly, MD,1 and Manoj Monga, MD2
1Department of Urology, Menoufia University, Shebeen El Kom, Menoufia, Egypt.
2Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Introduction: To evaluate the safety and efficacy of combined top and down low-power thulium laser enucleation of the prostate (ThuLEP). Evaluation of short-term (1-year) functional outcomes.
Materials and Methods: Between May 2017 and November 2018, after institutional board review approval, effectively consented patients underwent combined top and down low-power ThuLEP. We used a 30-W thulium laser with a 550 μm laser fiber and a 26F continuous flow resectoscope. We included a link for a video clarifying our technique of dissection. We collected data related to prostate size, enucleation time, morcellation time, perioperative complications, and early outcomes.
Results: Thirty patients underwent combined top and down low-power ThuLEP with mean age 64 ± 5 years. Acute urine retention was the main indication for surgery in 25% of patients, whereas the remaining had mean International Prostate Symptom Score 24 ± 4. The mean prostate volume was 112 ± 23 mL and the mean Qmax was 7 ± 3 mL/sec. Mean operative time was 113 ± 25 minutes, whereas mean enucleation time was 89 ± 10 minutes, and mean morcellation time was 19 ± 5 minutes. The mean enucleated prostate volume was 75 ± 12 grams and the mean hemoglobin drop was 1 ± 0.4 g/dl. There was no need for blood transfusion and the mean hospital stay was 19 ± 6 hours and catheters were removed on discharge. The first visit was at 1 month, and we observed significant mean Qmax improvement 18 ± 5 mL/sec. Our results showed no significant change of IIEF-5 score at 12-month follow-up compared with baseline.
Conclusion: Low-power thulium enucleation with a combined top and down technique provided a safe and efficacious outcome. The low-power setting would eliminate the need for high-power thulium laser machine and the less eschar formation, which could shorten the steep learning curve for ThuLEP. Although, in our experience, the combined approach has reduced strenuous wrist flexion and the resultant compression over the urethral sphincter, a randomized controlled trial would be mandatory to confirm such results with a larger sample size.
Waterjet Ablation for Large Prostates with Intravesical Median Lobes
Eric Ghiraldi, DO,1 Andrew Higgins, MD,1, David Ambinder, MS,1 Young Son, MS,1, and Steven Sterious, MD, FACS1,2
1Department of Urology, Albert Einstein Healthcare Network, Philadelphia, Pennsylvania, USA.
2Division of Urologic Oncology and Urology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA.
Introduction and Objective: Aquablation of the prostate for the treatment of benign prostatic hyperplasia (BPH) has shown favorable efficacy and safety compared with transurethral resection of the prostate. Herein, we present an instructional video complementing our single institution experience treating large prostates with intravesical median lobes.
Methods: Retrospective review of patients undergoing Aquablation for BPH between February and September 2019 was performed. Perioperative outcomes were compared between large prostates (volume ≥80 cc) with an intravesical median lobe and small prostates with or without an intravesical median lobe. Bivariable analysis between groups was performed with Fisher's exact test and an unpaired t-test for categorical and continuous variables, respectively.
Results: Thirty-two patients underwent Aquablation for the study period. Five patients had a large prostate with an intravesical median lobe. The average prostate size was 135 cc (range 90–176 cc). Average preoperative International Prostate Symptom Score 20 (range 3–34) and Qmax 7 mL/s (range 0–11) did not differ between groups. The average number of complications, complications related to blood loss, transfusion rate, and perioperative change in hemoglobin did not differ between groups on bivariable analysis. Treatment time was the only variable on bivariable analysis that was statistically significant between groups (4.89 minutes vs 2.87 minutes; p = 0.0002). Multivariable analysis was not performed secondary to the small sample size within our cohort.
Conclusions: Our video demonstrates how the technology of Aquablation is utilized to treat large prostates and prostates with median lobes. Our data show that treating large prostates with median lobes is just as safe as treating smaller prostates. When treating larger prostate glands, urologists should expect treatment times to be longer.
Mini-Percutaneous Nephrolithotomy Technique of Percutaneous Nephrolithotomy with Thulium Fiber Laser
Sida Niu, MD, Raphael Carrera, MD, and Wilson Molina, MD
Department of Urology, University of Kansas Medical Center, Kansas City, Kansas, USA.
Introduction: Although percutaneous nephrolithotomy (PCNL) is usually safe and well tolerated, it is still associated with a notable set of complications. The complications rates for PCNL range from 20% to 83%.1 More urologists are adopting the mini-PCNL technique to decrease morbidity associated with conventional PCNL while preserving high stone-free rates when compared with ureteroscopy.2 To our knowledge, this is one of the first mini-PCNLs performed in North America with the thulium fiber laser, which features more optimal intrinsic characteristics than the current gold standard for laser lithotripsy.3 We aim to determine whether this novel combination can serve as an effective strategy for treatment of moderate-sized renal stones.
Materials and Methods: After Institutional Review Board approval, we retrospectively reviewed two patients with stones between 1.5 and 3.0 cm who were referred to our department for evaluation. Both elected treatment with mini-PCNL. Access was obtained intraoperatively. The thulium fiber laser was used in both cases and the settings were adjusted to determine the optimal settings for stone treatment. We have selected one of the cases to highlight our technique for using the thulium SuperPulse laser for treatment of medium-sized renal calculi using the mini-PCNL technique.
Results: Adequate access is achieved using supine decubitus position with the side of treatment positioned at the edge of the table. The ipsilateral flank is elevated to create 15° of rotation to expose the puncture area, demarcated by the inferior edge of the 12th rib, the iliac crest, and the posterior axillary line. The ipsilateral arm is protected and placed across the thorax to avoid stretching of the brachial plexus. Access was obtained using a 15F/16F rigid access sheath. The thulium laser was capable of exceptional ablation rate and real dusting with dust particles <1 mm. A 365-µm fiber was used with total laser time ∼28 minutes and 49 kJ of total laser energy. Dusting of the initial large stone was ideal with 1 J and 30 Hz, and dusting of smaller fragments was optimal with 0.3 J and 50 Hz. Neither patient had a postoperative complication, and both were considered stone free based on imaging at follow-up. This is a descriptive video of our technique that has been performed on a total of two patients. Owing to the rarity of this procedure, no statistical analysis was calculated.
Conclusion: The mini-PCNL technique is a safe and effective strategy for treatment of stones with sizes that fall in the middle ground between conventional PCNL and flexible ureteroscopy. Thulium fiber laser has the potential to change the landscape of stone treatment owing to its more optimal wavelength with a higher water absorption, lower pulse energy, and higher pulse frequency, all of which can increase the efficiency of laser lithotripsy by providing less stone retropulsion and smaller stone fragments on dusting settings, thereby decreasing operative time. A combination of the mini-PCNL technique with thulium fiber laser could lead to improved stone-free rates with potentially less perioperative complications. Further studies with larger cohorts are needed to further assess the generalizability of our outcomes with this novel combination of technique and technology.
Taylor E, Miller J, Chi T, Stoller M. Complications associated with percutaneous nephrolithotomy. Transl Androl Urol 2012;1:223–228.
Sung YM, Choo SW, Jeon SS, Shin SW, Park KB, Do YS. The “mini-perc” technique of percutaneous nephrolithotomy with a 14-Fr peel-away sheath: 3-Year results in 72 patients. Korean J Radiol 2006;7:50–56.
Traxer O, Keller EX. Thulium fiber laser: The new player for kidney stone treatment? A comparison with Holmium:YAG laser. World J Urol 2019;38:1883–1894.
Duplicated Collecting System and Ectopic Ureter with Vaginal Implantation Treated by Laparoscopic Upper Pole Heminephrectomy and Ureterectomy: A Case Series of Six Patients
Osman Can, MD,1 Recep Burak Recep Burak Değirmentepe, MD2 and İlter Alkan, MD3
1Urology Department, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey.
2Urology Department, Of State Hospital, Trabzon, Turkey.
3Urology Department, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey.
Objective: To present the results of a case series of six patients with a duplicated collecting system with ectopic vaginal implantation who underwent laparoscopic heminephrectomy and ureterectomy, accompanied by our last case video.
Introduction: Duplication of the ureters with infrasphincteric vaginal implantation is an uncommon congenital anomaly and a relatively rare disorder in adulthood as a cause of urinary incontinence. Ectopic ureters are frequently seen in association with a dysplastic upper pole renal moiety. Diagnosis is often difficult, and a high index of suspicion is needed for the correct diagnosis.
Methods: We present a case series of six patients who underwent upper pole heminephrectomy and ectopic ureterectomy in the past 10 years. All surgeries were performed laparoscopically by a single surgeon. The patient's complaints were life-long urinary leakage. All cases underwent magnetic resonance (MR) urography after clinical suspicion. Preoperative CT angiography was routinely performed to understand the anatomy of the renal vasculature. Transperitoneal approach was preferred for all patients. Umbilical camera port, one right-sided instrument port, and one left iliac fossa port were introduced. First, the normal ureter was found, isolated, and secured. Dilated upper pole ureter was found traced through the pelvis and ligated at the level of the cross-over point of the common iliac artery. Then it was traced back and mobilized proximally toward the renal hilum giving extra care not to compromise the blood supply to the normal ureter. If the duplicated upper moiety ectopic ureter was not dilated, it could be difficult to separate from the normal ureter. In such cases, it is important to secure and trace both ureters to be sure to find the correct ureter. It was isolated from the accessory lower pole vasculature and was cut. The remaining pelvis was dissected from the renal pedicle. The right kidney was identified and mobilized. The upper dysplastic pole of the right kidney was located and accessory vessels to the upper pole moiety were clipped. Demarcation was seen between dysplastic tissue and normal renal parenchyma, and heminephrectomy for poorly functioning upper pole moiety was completed with ultrasonic energy.
Results: All patients were female, and the age ranges were between 19 and 38 years. Duplicated collecting systems and ectopic ureters were on the right side for four patients and on the left side in the other two patients. According to MR urography, the upper pole dysplastic kidneys were prominently dilated in five patients, in the remaining one patient, the upper pole was not dilated. All surgeries were completed laparoscopically, and mean hospital stay was 3 days. There was no postoperative early complication in all cases. All patients were fully continent after catheter removal on postoperative day 1.
Conclusions: Ectopic ureteral duplication should be considered in the differential diagnosis of young women presenting with life-long wetting. The best radiologic imaging modality in the diagnosis of this rare disease is MR urography. The surgical approach depends on the surgeon's experience. However, considering the benefits of laparoscopy, it should be the preferred approach over the open surgery for the management of patients with duplicated collecting system with ectopic implantation.
