Does the Adamkiewicz artery originate from the larger segmental arteries?

OBJECTIVE: The Adamkiewicz artery supplies most of the blood to the anterior spinal artery, which perfuses the anterior two thirds of the spinal cord. During operations for thoracoabdominal aortic aneurysm, detailed anatomic knowledge of the Adamkiewicz artery and its correlation with the intercostal and/or lumbar arteries is important to prevent postoperative paraplegia. METHODS: Minute dissection was performed on 102 formol-fixed adult cadavers without any history of circulatory disorders. The Adamkiewicz artery was found in the epidural space after laminectomy of the vertebrae. The entire course between the Adamkiewicz artery and the intercostal and/or lumbar artery was dissected carefully. The vertebral level, laterality, and mean diameter of all Adamkiewicz arteries were investigated. The correlation between the diameter of the Adamkiewicz artery and that of the intercostal and/or lumbar arteries was also determined. RESULTS: The mean number of Adamkiewicz arteries per cadaver was 1.3 +/- 0.65, and the mean diameter was 0.77 +/- 0.24 mm (range, 0.50 to 1.49 mm). Approximately 70% of the Adamkiewicz arteries originated from the intercostal and/or lumbar arteries on the left side, frequently at the T8-L1 vertebral level. There was no statistically significant correlation between the diameter of the Adamkiewicz artery and that of intercostal and/or lumbar arteries. CONCLUSION: This study provides evidence that, during operations on the thoracoabdominal aorta, the intercostal and/or lumbar arteries should be preserved, regardless of their diameter, to prevent postoperative paraplegia.     

Is larger tumor size a contraindication to retroperitoneal laparoscopic adrenalectomy?

Purpose

To evaluate the surgical feasibility of retroperitoneal laparoscopic adrenalectomy for tumors exceeding 5 cm.

Methods

A retrospective review was carried out on all adrenalectomies performed between 2002 and 2011. All surgical procedures were performed or supervised by one of two experienced laparoscopic surgeons. A total of 133 patients who underwent retroperitoneal laparoscopic adrenalectomy were divided according to tumor size: group I (n = 57) had tumors <5 cm and group II (n = 76) had tumors ≥5 cm. The operative outcomes included surgical time, change in hemoglobin level, estimated blood loss, necessity for blood transfusion, time to ambulation, hospitalization duration, postoperative complications according to the Clavien-Dindo classification, and the rate of conversion to open surgery.

Results

The estimated blood loss (271.75 ± 232.98 mL vs. 367.24 ± 275.11 mL; p = 0.037), time to ambulation (1.60 ± 0.49 days vs. 1.89 ± 0.31 days; p = 0.001), and postoperative hospitalization (7.88 ± 3.08 days vs. 9.264 ± 3.10 days; p = 0.012) were significantly higher in group II. The operation time and hemoglobin level change were not statistically different between groups. Blood transfusions were performed in 3 patients from group I and 6 patients from group II (5.3 vs. 7.9 %; p = 0.449). No patients experienced conversion to open surgery.

Conclusions

Retroperitoneal laparoscopic adrenalectomy can be used in patients with tumors larger than 5 cm.     

Thulium laser resection versus plasmakinetic resection of prostates larger than 80 ml

Purpose

To compare the safety and efficiency of thulium laser resection of the prostate-tangerine technique (TmLRP-TT) and plasmakinetic resection of the prostate (PKRP) for aged symptomatic benign prostatic hyperplasia (BPH) patients with large volume prostates (>80 ml) in a prospective randomized trial with an 18-month follow-up.

Materials and methods

From January 2010 to November 2011, 90 BPH patients with large volume prostates were randomized for surgical treatment with TmLRP-TT (n = 45, group 1) or PKRP (n = 45, group 2). The preoperative and postoperative parameters were recorded and compared. All patients were evaluated at 1, 6, 12 and 18 months postoperatively using the International Prostate Symptom Score (IPSS), quality of life score (QoL), maximum flow rate (Q _max), postvoid residual urine volume (PVR) and the five-item version of the International Index of Erectile Function score. All perioperative complications were also documented and classified according to the modified Clavien classification system.

Results

Compared with the PKRP group, the TmLRP-TT group had a statistically lower hemoglobin drop (0.86 ± 0.42 vs. 1.34 ± 1.04 g/dl, P < 0.01), shorter catheterization time (1.91 ± 0.85 vs. 2.36 ± 0.74 days, P < 0.01) and hospital stay (3.80 ± 0.46 vs. 5.02 ± 0.54 days, P < 0.01). Within the observation period of 18 months, both groups had significant postoperative improvement in IPSS, QoL, Q _max and PVR, although no difference was observed between the two groups. Only one patient receiving PKRP treatment required a blood transfusion perioperatively. During the 18-month follow-up, one patient in each group experienced urethral stricture and one patient in the PKRP group experienced bladder neck contracture. Minor complications that required no or noninterventional treatment occurred in 6 (13.33 %) of TmLRP-TT group (Clavien grade 1, 13.33 % and grade 2, 0 %) and 10 (22.22 %) of PKRP group (Clavien grade 1, 20.00 % and grade 2, 2.22 %). No severe complications required reinterventions in both groups (Clavien grade 3, 0 %; grade 4, 0 %; grade 5, 0 %).

Conclusions

Both TmLRP-TT and PKRP are safe and effective treatment options for large prostates that require resection. Taking into account less blood loss, shorter catheterization time and hospital stay, TmLRP-TT may be a better treatment for patients with large prostates.     

Is laparoscopic adrenalectomy safe and effective for adrenal masses larger than 7 cm?

Background Laparoscopic adrenalectomy (LA) has become the gold standard treatment for small (less than 6 cm) adrenal masses. However, the role of LA for large-volume (more than 6 cm) masses has not been well defined. Our aim was to evaluate, retrospectively, the outcome of LA for adrenal lesions larger than 7 cm. Patients and methods 18 consecutive laparoscopic adrenalectomies were performed from 1996 to 2005 on patients with adrenal lesions larger than 7 cm. Results The mean tumor size was 8.3 cm (range 7–13 cm), the mean operative time was 137 min, the mean blood loss was 182 mL (range 100–550 mL), the rate of intraoperative complications was 16%, and in three cases we switched from laparoscopic procedure to open surgery. Conclusions LA for adrenal masses larger than 7 cm is a safe and feasible technique, offering successful outcome in terms of intraoperative and postoperative morbidity, hospital stay and cosmesis for patients; it seems to replicate open surgical oncological principles demonstrating similar outcomes as survival rate and recurrence rate, when adrenal cortical carcinoma were treated. The main contraindication for this approach is the evidence, radiologically and intraoperatively, of local infiltration of periadrenal tissue.     

Management of pelvic stones larger than 20 mm: laparoscopic transperitoneal pyelolithotomy or percutaneous nephrolithotomy?

Large pelvic stones are frequently managed with percutaneous nephrolithotomy (PCNL) but laparoscopic transperitoneal pyelolithotomy (LTP) can be an alternative. We compared PCNL and LTP for the treatment of pelvic stones >20 mm in diameter. PATIENTS AND METHODS: Between November 1999 and November 2004, 16 consecutive patients, mean age 42, with a single pelvic stone >20 x 10 mm (group I), underwent LTP as first-line treatment or after shockwave lithotripsy failure. They were compared with a similar population of 16 consecutive patients, mean age 45 (group II), who underwent PCNL for the same indication and were assessed retrospectively. We evaluated operative characteristics, complications, and results for each technique. RESULTS: There was no difference between the two groups regarding the characteristics of patients and stones. Operative time duration was significantly longer in group I (129 vs. 75 min; p = 0.001) and conversion was required in 2 patients (12%). The main postoperative complications were urinary leakage (2 patients, 12%) in group I and bleeding (3 patients, 18%) in group II, but only 1 required blood transfusion. Mean hospital stay was respectively 6.5 and 5.6 days in groups I and II (p = 0.17). Stone-free rates were assessed at 3 months and were not different between group I and group II (88 vs. 82%). CONCLUSIONS: The operative time of LTP is longer and the results of both techniques are comparable but postoperative morbidity is different. Specific indications of each technique must be determined although PCNL remains the gold standard for most large pelvic stones.     

Outcomes of multiple wire localization for larger breast cancers: when can mastectomy be avoided?

BACKGROUND: Mastectomy is often recommended when mammography shows a breast cancer with extensive calcifications. We wished to determine whether the use of multiple localizing wires to guide lumpectomy in this setting was associated with increased rates of breast conservation. We also wanted to identify factors that predicted a poor chance of successful lumpectomy, to avoid multiple lumpectomy attempts in a patient who would ultimately require mastectomy. STUDY DESIGN: Records of 153 women with breast cancer who underwent lumpectomy for larger lesions that required multiple wire localization and 196 controls who required only single wire localization were reviewed retrospectively. The number of localizing wires, specimen volume, largest specimen dimension, number of surgical procedures, and rates of breast conservation were scored. RESULTS: Seventy-seven percent of patients requiring multiple wire localization had successful breast conservation, compared with 90% of those needing only single wire localization. Only 28% of multiple wire patients required more than 1 excision to achieve clear margins, compared with 36% of single wire patients (p < 0.01). CONCLUSIONS: Breast conservation is possible in the great majority of breast cancer patients whose mammographic lesions require multiple localizing wires for excision. The use of multiple wires can decrease the number of procedures required to obtain clear lumpectomy margins.     

Suprapancreatic and periportal lymph nodes are normally larger than 1 cm by laparoscopic ultrasound evaluation

Background Laparoscopic and endoscopic ultrasound is used to assess resectability of gastrointestinal malignancies. Lymph node size greater than 1 cm is a criterion used to identify suspicious nodes. We define size and echo characteristics of suprapancreatic and periportal nodes to determine if this criterion is reliable for suprapancreatic and periportal lymph nodes.Methods A prospective study of 21 patients with nonacute gallbladder disease was performed. Each underwent laparoscopic cholecystectomy with intraoperative ultrasound. The suprapancreatic and periportal nodes were evaluated in a transverse and longitudinal axis. Length and width measurements were taken in both orientations. Length-to-width ratios were calculated. Shape and echo textures were characterized.Results The mean size of both nodes was greater than 1 cm in the transverse and longitudinal orientation. Two nodes were round. Remaining nodes were oblong. All nodes had a hyperechoic center with a hypoechoic rim.Conclusion In suprapancreatic and periportal lymph nodes, size greater than 1 cm should not be used as criterion for malignancy.     

Should ancillary brain blood flow analyses play a larger role in the neurological determination of death?

Purpose

We present two patients who regained spontaneous respiration following clinical neurological determination of death (NDD) while ancillary radiological imaging demonstrated brain blood flow.

Clinical features

A 26-yr-old male with chronic otitis media presented with a Glasgow Coma Scale (GCS) score of 3 and fixed 7-mm pupils. Computed tomography demonstrated right-sided mastoiditis and a temporal lobe abscess associated with uncal herniation. The patient was diagnosed brain dead seven-hr later when motor responses and brainstem reflexes were absent and his apnea test was positive. Approximately 28-hr after NDD, during post-declaration organ resuscitation, the patient regained spontaneous respiration and magnetic resonance imaging revealed brain blood flow. Spontaneous respirations persisted for five-days before cardiovascular collapse occurred. In the second case, a 50-yr-old female presented with a GCS score of 3 and fixed 6-mm pupils following a traumatic brain injury and a five-minute cardiac arrest. The patient was deemed clinically brain dead six-hr later when physical examination revealed absent motor responses and brainstem reflexes and her apnea test was positive. As confirmation of brain death, a cerebral radionuclide angiogram was performed, which surprisingly revealed intracranial arterial flow. During organ resuscitation, 11-hr after NDD, the patient regained spontaneous respiration. She expired hours after family decision to withdraw treatment.

Conclusion

For both patients, several unrecognized confounding factors for NDD were present. These cases illustrate the difficulties encountered by experienced clinicians in determining brain death using clinical criteria alone, and they suggest that more routine use of ancillary brain blood flow analyses should be recommended.     

Robot-assisted partial nephrectomy for renal tumors larger than 4?cm: results of a multicenter, international series

Backgrounds

Limited data are available for the use of robot-assisted partial nephrectomy (RAPN) in tumors >4?cm. The objectives of this study were to report the perioperative outcomes of a series of patients who underwent RAPN for suspicious >4?cm renal tumors and to compare these results with those observed in a group of patients with ≤4?cm tumors.

Methods

We analyzed retrospectively the clinical records of 49 patients who underwent RAPN for suspicious of renal cell carcinoma (RCC) >4?cm in size at four centers from September 2008 to September 2010. All patients underwent da Vinci RAPN. The results were compared with those observed in a group of patients undergoing RAPN for ≤4?cm renal tumors.

Results

The median warm ischemia time (WIT) was 22?min (Interquartile range [IQR] 18–28). The median console time was 145?min (median IQR 112–177). The median blood loss was 120?mL (IQR 62–237). In two cases, we observed intraoperative renal vein injury (4?%). Postoperative complications were reported in 13 (26.5?%) patients. Major complications were observed in 4 (8.2?%) cases. Patients with large tumors showed perioperative outcomes worse than those received the RAPN for ≤4?cm tumors. Conversely, no significant difference was observed in positive surgical margin (PSM) rates.

Conclusions

These outcomes support the use of RAPN as possible alternative to open PN for the treatment for patients with suspicious renal masses >4?cm. Positive surgical margin rates demonstrated RAPN is an oncologically safe procedure for tumors >4?cm.     

Laparoscopic repair of incisional hernia: Outcomes of 100 consecutive cases comprising 25 wall defects larger than 15 cm

Background Minimal access surgery for incisional hernia repair is still debated, especially for large and giant wall defects. This study was undertaken to analyze the results of the use of the laparoscopic technique in incisional hernias smaller and larger than 15 cm of diameter. Method From 2002 to 2007 a total of 100 patients with incisional hernia were operated on by laparoscopy and were included in this study. As much as 38 patients were obese, with a body mass index (BMI) > 30 kg/m². The mean follow-up span was 24 months (range = 2–58). The fascial defect was recurrent in 19 patients, in 13 after previous repair with mesh and in 6 after repair without mesh. The wall defect was larger than 15 cm in 25 patients and in 6 of them it was 20 cm or larger as measured from within the peritoneal cavity. Results The mean operating time was 152 ± 25 min (range = 45–275), and for defects larger than 15 cm it was 205 ± 101 min (range = 85–540). Two patients with massive adhesions needed conversion to open surgery, one after an intraoperative injury of an intestinal loop. Postoperative complications occurred in 23 patients; local complications were 10. Pulmonary embolism caused death in one obese patient. Morbidity and hospital stay were similar in obese and nonobese patients and the differences were not statistically relevant (p > 0.05). The outcomes in patients with wall defects larger than 15 cm showed no significant difference with outcomes of the remaining patients with smaller defects (p > 0.05). Recurrence occurred in three cases, and in one case local infection led to removal of the mesh. Conclusions Minimal access procedures can provide good results in the repair of incisional hernia, even when the diameter is larger than 15 cm. Obesity is not a contraindication to laparoscopic repair. Further studies are expected to confirm these promising results. An erratum to this article can be found at     

Laparoscopic and robotic partial nephrectomy without renal ischaemia for tumours larger than 4?cm: perioperative and functional outcomes

Purpose

To evaluate the technical feasibility, safety and functional outcomes of zero ischaemia laparoscopic and robotic partial nephrectomy with controlled hypotension for renal tumours larger than 4?cm.

Methods

We evaluated 121 consecutive patients with American Society of Anaesthesiologists (ASA) scores 1–2 who underwent laparoscopic (n?=?70) or robotic (n?=?51) partial nephrectomy with controlled hypotension with either tumour size ≤4?cm (group 1, n?=?78) or tumour size >4 cm (group 2, n?=?43) performed by a single surgeon from December 2010 to December 2011. Operative data, complications, serum creatinine, estimated glomerular filtration rates and effective renal plasma flow calculated from 99mTc-mercaptoacetyltriglycine renal scintigraphy were compared. Differences between groups were evaluated by the Chi-square test and the Student’s t test.

Results

A significant difference in mean intraoperative blood loss and postoperative complications was found between the two groups: 168?ml (range: 10–600?ml in group 1) and 205?ml (range: 90–700?ml in group 2); p?=?0.005, and 6.4?% versus 18.6?%; p?=?0.004, respectively. The mean percentage decrease of ERPF of the operated kidney was 1.8?% in group 1 and 4.1?% in group 2.

Conclusions

Laparoscopic and robotic partial nephrectomy with controlled hypotension for tumours >4?cm in ASA 1–2 patients was feasible with significant higher intraoperative blood loss and postoperative complications compared to smaller renal masses. The benefits of avoiding hilar clamping to preserve kidney function seem excellent.     

Comparison of super-mini PCNL (SMP) versus Miniperc for stones larger than 2 cm: a propensity score-matching study

Purpose

To compare the efficacy and safety of Super-mini percutaneous nephrolithotomy (SMP, F12-F14) and Miniperc (F18) in the treatment of renal stones of 2–4 cm in size.

Methods

A prospective comparative analysis of outcomes of patients who underwent SMP and Miniperc for treatment of 2–4 cm renal stones was conducted between July 2014 and January 2017. Demographic data, stone criteria, operative technique, complications, blood transfusion, hemoglobin decrease, stone-free rate (SFR) and length of hospital stay were compared between the two groups. Propensity score-matching (PSM) analysis was performed to further compare the outcomes between the two groups.

Results

79 and 257 patients underwent SMP and Miniperc, respectively. After matching, 73 patients in each group were included. The stone burden was comparable for both groups (3.0 ± 1.1 vs 3.2 ± 0.7 cm, p = 0.577). Mean operation time was not significant different between two groups (p = 0.115), while the hospital stay of SMP was much shorter than Miniperc (2.6 ± 1.4 vs 5.2 ± 1.8, p < 0.0001). Both groups had similar SFRs in postoperative 1 day and at 1 month follow-up (p = 0.326, p = 0.153), while SMP achieved a markedly higher tubeless rate than Miniperc (84.9 vs 47.9%, p < 0.0001). The total complication rate was significantly lower in SMP (16.4 vs 41.1%, p = 0.0001), and the SIRS rate was markedly lower in SMP group (1.4 vs 12.3%, p = 0.009).

Conclusions

SMP is equally effective as Miniperc in the treatment of moderate renal calculi, and has the significant advantage in hospital duration and tubeless rate.

     

Erratum to: Is routine ureteral stenting necessary after uncomplicated ureteroscopic lithotripsy for lower ureteral stones larger than 1 cm?

We evaluated the need for routine ureteral stenting after uncomplicated ureteroscopic lithotripsy (URSL) without dilation for lower ureteral stones larger than 1 cm. A total of 43 patients underwent URSL for lower ureteral stones larger than 10 mm. They were randomized into a stented (21) or an unstented (22) group. URSL was performed by using a semirigid ureteroscope and pneumatic lithotripter without ureteral dilation. Additional forceps application (AFA) was used to remove fragments >/=4 mm. Patients in each group were assessed for stone-free rate, stone size, operative time, AFA, hospitalization time, postoperative pain, irritative voiding symptoms, hematuria, re-hospitalization and stricture formation. The stone-free rate was 100% in each group. There were no statistical differences in the two groups regarding stone size, operative time, AFA, postoperative pain, hematuria and hospitalization time. However, irritative voiding symptoms of the stented group were significantly higher than those in the unstented group (P < 0.05). One patient (4.5%) in the unstented group required re-hospitalization for severe flank pain with fever (>38 degrees C) compared to one patient (4.7%) in the stented group for proximal stent migration (P > 0.05). Stricture formation was not demonstrated in either group at 3 months follow-up excretory urography (EXU). Our results demonstrate that ureteral stenting after uncomplicated URSL without dilation for lower ureteral stones larger than 1 cm does not appear to be necessary if AFA is used to remove fragments >/=4 mm, thereby reducing morbidity of patients and risk of re-hospitalization.