Antegrade versus retrograde stenting in laparoscopic pyeloplasty

PURPOSE: To compare operative times between retrograde and antegrade ureteral stenting as part of laparoscopic pyeloplasty. PATIENTS AND METHODS: Laparoscopic pyeloplasty procedures from January 2002 to January 2007 were identified through a prospective database. Procedures on 126 patients were performed using the same transperitoneal technique apart from the method of stent placement, which was performed in either a retrograde manner before laparoscopy or an antegrade manner during the laparoscopic portion of the procedure. RESULTS: A total of 45 patients underwent antegrade stenting, 53 had retrograde stenting, 20 patients already had a stent in place, and 8 patients had retrograde pyelography followed by antegrade stenting. Operative time in patients with antegrade stent placement was significantly faster than in those with retrograde stent placement (median 185 v 245 min, P < 0.0001 [two-way analysis of variance]), even when the variability of the operative surgeon was taken into account. There was no difference in the complication rates. CONCLUSION: Antegrade stent placement results in a significantly faster overall operative time when compared with retrograde stent placement.     

Dorsal lumbotomy incision in paediatric pyeloplasty

BACKGROUND: The purpose of the present study was to comprehensively assess the results of surgical management of pelvi-ureteric junction (PUJ) obstruction using lumbotomy as the surgical approach. METHODS: Records of 36 consecutive patients with unilateral PUJ obstruction who underwent pyeloplasty in the last 5 years were reviewed retrospectively. The investigations included renal function tests, ultrasound and serial renal diuretic scans. A micturating cystourethrogram was also done whenever indicated. A dismembered pyeloplasty via lumbotomy was the only surgical approach considered. Thirteen patients had a right pyeloplasty while 23 had a left pyeloplasty. Mean age at diagnosis was 57 months in 31 patients while five were antenatally diagnosed (range 1 month-12 years). Age at surgery ranged from 1 month to 12 years with a mean of 59.9 months. Nine children underwent surgery in infancy. Six patients had a preoperative percutaneous nephrostomy (PCN) placement, five for poorly functioning kidneys (less than 10% split renal function) and one for oliguria. Records were reviewed for age at diagnosis, age at surgery, duration of surgery, preoperative and postoperative split renal function. RESULTS: The follow-up period in the present study ranged from 9 months to 68 months with a mean of 44.9 months. Mean duration of surgery was 78 min of the group as a whole but in PCN patients it was significantly more (100 min vs 71.3 min). Fourteen patients had an improvement in split renal function noticed at 3 and 6 months postoperatively, 17 patients had no change while one patient had a deterioration of split renal function. Four patients had a solitary functioning kidney and in all of these glomerular filtration rate improved postoperatively. Hospital stay was on the average 7.45 days with a range of 6-10 days. However, when a double-J (D-J) stent was used across the anastomosis and the uretero-vesical junction (transrenal D-J stenting), the mean stay was reduced to 3 days. All patients returned to full oral feeds by postoperative day 1. No incidences of wound related problems were encountered. CONCLUSIONS: Pyeloplasty results in predictably good outcome in paediatric PUJ obstruction whenever indicated. The lumbotomy approach avoids muscle cutting, thereby minimizing complications related to wound and assisting with faster recovery. Keeping a double-J (D-J) stent across the anastomosis and the uretero-vesical junction (transrenal D-J stenting) reduces hospital stay.     

Retrograde pyelography via ureteral stents

Retrograde pyelography to establish ureteral patency prior to removal of ureteral stent can be done via the stent. A simple technique is described.     

Nephroureterectomy through a single lumbar incision combined with endoscopic incision of a bladder cuff.

Nephroureterectomy is the accepted approach in treating upper urinary tract carcinoma. We present a modification of transurethral resection of the intramural ureter, using endoscopic incision of a bladder cuff around the ureteral ostium as the first step in performing nephroureterectomy through a single lumbar incision.     

Antegrade stenting in laparoscopic pyeloplasty: feasibility of the technique and time required for stent insertion

Background  This study aimed to evaluate the authors’ initial experience with antegrade stenting. It focused on the success rate, time required for stent insertion, possible complications, and relative solutions in the first 44 procedures. Methods  Between March 2005 and April 2008, 44 patients (21 women and 23 men) with a mean age of 33 years (range, 17–59 years) underwent transperitoneal laparoscopic Anderson–Hynes pyeloplasty in the authors’ department. Antegrade stenting was attempted for all the patients. The time required for stent insertion was recorded as the time from cannula insertion to the correct positioning of the stent in the pelvis. A 4.8-Fr, 26-cm stent was the stent of choice for the first four cases. Then the 6-Fr, 26-cm stent was adopted for all the remaining patients except for one, for whom a 6-Fr, 28-cm stent was adopted. Results  The mean operative time was 197 min (median, 180 min; range, 150–390 min). No conversions to open surgery were required. The stent was positioned correctly in the bladder at the end of the antegrade procedure in 97.7% of the patients without the need for a postoperative X-ray in 95% of the cases. The mean time required for antegrade insertion of the stent was 7 min 30 s (median, 6 min 13 s; range, 3 min 40 s to 22 min 30 s). In the final 12 procedures, the time for stent insertion was constantly reduced to a mean of 4 min 10 s (median, 4 min; range, 3 min 40 s to 7 min). Neither intraoperative nor postoperative complications related to antegrade stent positioning were observed. Conclusion  Our data confirm the antegrade procedure to be an easy-to-learn, safe, and reliable stenting technique, with an overall mean time of 7 min 30 s required for insertion, and with a mean time of 4 min 10 s required for insertion in the final 12 procedures. It obviates the problem of having the stent in the renal pelvis during dissection and suturing and of repositioning the patient onto the flank for the laparoscopic procedure.     

Antegrade visceral revascularisation via a thoracoabdominal approach for chronic mesenteric ischaemia.

OBJECTIVES: It has been suggested that patients with chronic visceral ischaemia are elderly and emaciated hence they may not tolerate antegrade visceral revascularisation via a thoracoabdominal approach. There are no studies to support this assumption. The purpose of this study is to assess the efficacy of this approach for the treatment of chronic visceral ischaemia. METHODS: Between 1988 and 1996, 10 patients underwent antegrade visceral revascularisation for chronic visceral ischaemia via a thoracoabdominal approach and were followed-up for a mean of 40 months. Eight patients were treated with aorto superior mesenteric artery bypass and implantation of the coeliac axis in the graft and two patients with aorto superior mesenteric bypass alone. Graft patency was monitored with duplex scanning. RESULTS: There were no postoperative deaths in this series. Two patients developed postoperative pulmonary infections and required intubation for a short period of time. All patients were discharged after a mean of 17 days (range 7-38). Follow up with duplex scanning revealed that all grafts were patent. One patient developed a high grade anastomotic stenosis which was followed by recurrence of the symptoms. This was dilated on three occasions by balloon angioplasty within a period of 17 months. On the last occasion a stent was placed and since the patient remains asymptomatic. CONCLUSIONS: Antegrade visceral revascularisation via a thoracoabdominal approach is a durable and effective method of relieving symptoms of chronic visceral ischaemia. The low morbidity in this series justifies larger studies in order to establish the true incidence of complications.     

经12肋小切口离断式肾盂成型术28例报告

目的总结经12肋小切口离断式肾盂成型术的临床应用经验。方法2004年8月～2008年5月本院收治的28例肾盂输尿管连接部梗阻的患者接受经12肋小切口离断式肾盂成型术,对其手术入路、临床效果及并发症进行回顾性分析总结。结果28例手术均顺利完成,无需延长切口。手术时间55-140min（平均91min）,术中估计出血量20～210mL（平均53mL）。术后36h内恢复进食。1例术后出现漏尿,5d后消失。随访2～37月,27例肾积水减少,1例拔除输尿管支架后肾积水加重,予延长支架留置时间。结论经12肋小切口离断式肾盂成型术创伤小、恢复快、疗效确切,费用较低,是一种可以选择的微创手术方式。     

Continuous intercostal nerve block for pain relief after lumbar incision.

To relieve postoperative pain along a lumbar incision in 9 patients the intercostal nerves were blocked with catheters for continuous epidural anesthesia. The catheters were inserted near the intercostal nerves, above and beneath the incision, just before the wound was closed and 0.25% bupivacaine hydrochloride solution was infused periodically through the catheters. With this technique 5 of 9 patients had a satisfactory analgesic effect and could breathe deeply or cough without pain. The other 4 patients did not have satisfactory results and this was believed to be owing to inadequate insertion of the catheters. None of the patients had any complications. The technique is simple and can produce an analgesic effect repeatedly without causing pain for the patient.     

Elective cholecystectomy via a 5 cm subcostal incision.

This report describes a technique whereby elective cholecystectomy is performed through a 5 cm abdominal incision. Initial results in 18 patients compared with 112 historical control patients undergoing conventional cholecystectomy suggest an encouraging reduction in postoperative hospitalisation time, analgesic requirements and period of recuperation. The procedure takes no longer to perform than conventional cholecystectomy and obesity is not a limiting factor, as originally thought. This technique deserves a place alongside laparoscopic and conventional cholecystectomy in future studies seeking the optimal method of managing symptomatic cholelithiasis.     

Isoflurane can indirectly depress lumbar dorsal horn activity in the goat via action within the brain

We have examined the response of lumbar dorsal horn cells to a noxious mechanical stimulus during differential delivery of isoflurane to the brain and spinal cord of goats. We hypothesized that isoflurane, acting in the brain, would depress dorsal horn neuronal responses to a noxious mechanical stimulus applied to the hindlimb. Eight goats were anaesthetized with isoflurane and neck dissections performed which allowed cranial bypass. Lumbar laminectomies were performed to allow measurements of single-unit dorsal horn neuronal activity. Isoflurane 1.3% was administered before bypass, and during differential delivery it was administered at each of the following head/torso combinations: 1.3%/1.3%, 0.8%/1.3%, 0.3%/1.3%, 1.3%/0.8%, 0.8%/0.8% and 0.3%/0.8%. When the torso isoflurane concentration was 1.3%, decreasing cranial isoflurane from 1.3% to 0.3% did not significantly affect dorsal horn responses (from mean 325 (SD 262) to 379 (412) impulses min-1; P < 0.05). However, when torso isoflurane was 0.8%, decreasing cranial isoflurane from 1.3% to 0.3% increased mean evoked dorsal horn activity by 42% (388 (359) to 551 (452) impulses min-1; P < 0.05). These data suggest that the major effect of isoflurane on dorsal horn responses to noxious stimuli is direct, but there is an indirect effect occurring via descending projections from supraspinal regions.      

Renal parenchymal function evaluated by scintillation camera renography before and after pyeloplasty for hydronephrosis.

Scintillation camera renography with Tc-DTPA was performed before and after pyeloplasty on 16 kidneys with urographic signs of pelviureteric obstruction causing hydronephrosis. Regional parenchymal renograms were generated, and the passage of Tc-DTPA through the parenchyma was measured and correlated to the change in separate glomerular filtration rate. Preoperative parenchymal passage of DTPA was significantly slower (p = 0.02) in kidneys with improved glomerular filtration rate after pyeloplasty than in those without such improvement. Postoperative passage of DTPA in parenchyma was almost identical with that in a reference series. This method seems to be clinically useful for evaluating cases of hydronephrosis and for predicting the outcome of pyeloplasty.     

切口改良预防腰椎骨折前路手术后侧方成角的临床研究

目的:探讨通过切口改良来预防腰椎骨折前路手术后脊柱侧方的成角。方法:2016年1月至2017年6月纳入40例在腰椎骨折前路手术患者进行研究,40例中男28例,女12例,年龄27～68(39.5±14.9)岁。高处坠落28例,重物砸伤9例,车祸伤3例。L_1椎35例,L_2椎4例,L_3椎1例。骨折椎体AO分型:全部为A型爆裂骨折。脊髓损伤Frankel分级:A级5例,B级1例,C级10例,D级15例,E级9例。内固定材料全部为ANTERIOR(美敦力公司)。患者分为两组:切口改良组(切口方向和切口平面)和常规切口组。对两组患者手术前后骨折节段的冠状面Cobb角,椎体螺钉与相应终板的夹角进行分析。结果:切口改良组术前冠状面Cobb角为(1.20±3.26)°,术后为(2.16±3.55)°;常规切口组术前为(1.22±4.42)°,术后为(3.91±3.78)°。两组术前冠状面Cobb角比较差异无统计学意义,术后差异有统计学意义(P=0.017)。切口改良组患者术后没有出现5°以上的侧方成角,而常规切口组出现6例5°～10°的侧方成角,两组患者术后5°以上侧方成角的发生率差异有统计学意义(P=0.010)。近端的2枚椎体螺钉与相应终板的夹角两组比较差异有统计学意义(P0.05),而远端的2枚椎体螺钉与相应终板的夹角比较差异无统计学意义(P0.05)。结论:切口方向和平面的改进可以有效地预防腰椎骨折前路手术术后脊柱侧方成角的发生。