UROLOGICAL TRAINING IN AUSTRALASIA: PERCEPTIONS OF RECENT FELLOWS AND CURRENT TRAINEES

In this study we sought to determine the opinions of recent Fellows and current trainees on the state of urological training in Australasia. Self administered questionnaires were mailed to all urologists in Australia and New Zealand who had obtained their FRACS from 1988 to the present, as well as all current advanced urological trainees. Eighty-seven per cent of Fellows and ninety-four per cent of trainees completed and returned the questionnaire. Most Fellows and trainees felt that their training adequately equipped them for subsequent independent practice. At the completion of training and FRACS examination the majority of respondents felt competent in dealing with most urological conditions. However, many did not feel contident with paediatric and specialized or complex adult urology, particularly oncology and reconstruction. Post-Fellowship training. however, appears valuable in overcoming these deficiencies. Several limitations were also noted as a consequence of the fact that training is based entirely in the public hospital system. This created particular difficulties with respect to outpatient or ‘office’ urology as well as exposure to some non-acute conditions such as urinary incontinence and infertility. The current research requirements of training do not appear to provide trainees with an adequate knowledge of scientific method, with many respondents not feeling equipped to critically appraise urological literature. High levels of competence are also not attained for other important professional skills, particularly comniunication with other medical practitioners. Despite its importance for learning, feedback on progress is not adequately provided and this was seen as a major problem with current urological training in Australasia. The majority of respondents felt that mentors required specitic training to facilitate feedback 10 trimees.     

SUBCUTANEOUS METASTASES AFTER LAPAROSCOPIC RESECTION OF MALIGNANCY

Following the introduction and widespread acceptance of laparoscopic cholecystectomy, laparoscopic techniques have been applied to an increasing variety of general surgical procedures. Recently, laparoscopic procedures for resection of malignancy have begun to emerge, in particular laparoscopic assisted colectomy for carcinoma of the colon.^1,2 In the cases reported here, metastatic tumour in the laparoscopy port sites is described as a potentially serious complication of laparoscopic procedures for resection of malignancy.     

Complications of pediatric urological laparoscopy: mistakes and risks

PURPOSE: We evaluate the results and complications of laparoscopic urological procedures in children. MATERIALS AND METHODS: In a 3-year period 4,350 laparoscopic procedures were performed at 8 Italian centers of pediatric surgery. We analyzed only the data of urological procedures for a total of 701 laparoscopic operations on patients 1 month to 14 years old. The indications for surgery were cryptorchidism in 414 cases, varicoceles in 159, ambiguous genitalia in 37, total nephrectomy in 34, partial nephrectomy in 4, adrenalectomy in 3 and other diagnostic procedures in 50. We adopted a retroperitoneoscopic approach in 72 cases (10.3%) and a laparoscopic approach in 629 (89.7%). Patient records were analyzed to search for any complication that may have occurred during the laparoscopic procedure and assess how they were managed. RESULTS: We recorded 19 complications (2.7%) in our series, of which 6 required conversion to open surgery and 13 did not. There was no mortality. At a maximum followup of 4 years all children were alive and had no problems related to the laparoscopic complications. CONCLUSIONS: Our study shows that pediatric laparoscopic urological surgery has an acceptable rate of complications with no mortality. We believe that routine use of open laparoscopy in pediatric patients is a key factor to help avoid complications. Most complications can be avoided with surgeon and team experience, together with proper compliance with the indications for surgery.     

LAPAROSCOPIC MANAGEMENT OF COMPLICATIONS FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY

Laparoscopic cholecystectomy has rapidly become the treatment of choice for symptomatic cholelithiasis. Although published morbidity and mortality rates compare favourably with open cholecystectomy, bile duct injuries occur far more frequently and technical complications unique to the laparoscopic approach account for a significant number of postoperative deaths. The majority of these complications are dealt with by laparotomy. Two technical complications encountered in a series of 170 patients undergoing laparoscopic cholecystectomy and their subsequent management are presented. One patient suffered a diathermy injury to the common hepatic duct and postoperative bile leak. This was managed successfully by repeat laparoscopy and peritoneal lavage combined with endoscopic retrograde cholangiopancreatography (ERCP) and stenting of the hepatic duct. Another patient sustained a perforated duodenum complicated by peritonitis, subcutaneous wound infection and generalized sepsis. The perforation was repaired at a second laparoscopy using intracorporeal suturing and Tissucol. It is demonstrated that it is possible to deal with some of the technical complications of laparoscopic cholecystectomy with a combination of minimally invasive techniques, sparing the patient from the additional risk of laparotomy.     

腹腔镜胆囊切除术1000例并发症分析

本文报告１９９１年１１月～１９９３年４月连续施行腹腔镜下胆囊切除术１０００例，发生并发症３９例（３．９％），其中一般并发症３１例（３．１％），严重并发症８例（０．８％），（胆漏致弥馒性腹膜炎２例，膈下脓肿１例，腹腔内出血２例，胆总管残余结石１例，胆总管损伤２例）。均经剖腹手术治愈。文中讨论了预防并发症的体会，主要是：严格的人员选择和术前适应性的训练；充分的术前检查和准备；术中始终保证器械在视野内移动，在最佳视野下进行操作，仔细的胆囊三角的解剖和明确可靠的胆囊管、胆囊动脉的处理；正确认识和施行中转剖腹胆囊切除术和不断总结经验，提高手术技巧等。     

腹腔镜胆囊切除术的并发症及处理

目的 探讨腹腔镜胆囊切除术并发症发生的原因及预防处理.方法 回顾分析我院2002年3月～2005年11月行LC的1868例病人的临床资料,对术中、术后并发症的发生原因进行分析.结果 发生并发症21例,发生率为1.12%.结论 胆管损伤、胆漏和胆总管残余结石,腹腔出血是LC的主要并发症,绝大多数并发症是能够预防和治愈.     

REPORT OF A WORKSHOP TO REVIEW UROLOGICAL TRAINING IN AUSTRALASIA

A review of the current Australasian urological training programme was undertaken by members of the Urological Society of Australasia in a workshop format. The participants worked in small groups developing strategies to overcome problems which the whole group had identified previously. The strategies proposed by the groups were subsequently edited and definitive recommendations developed. This paper details the final recommendations of the workshop and the intended steps towards their implementation.     

EXTRAPERITONEAL LAPAROSCOPIC PYELOPLASTY: A MULTICENTER STUDY OF 55 PROCEDURES

PURPOSE: We assessed the feasibility, reproducibility and morbidity of retroperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction. MATERIALS AND METHODS: A total of 55 retroperitoneal laparoscopic pyeloplasties were performed at 3 institutions between September 1996 and May 2000 in 33 women and 21 men. Results were analyzed in regard to radiological assessment by excretory urography at 3 months, complications and hospital stay. RESULTS: We performed dismembered pyeloplasty in 48 cases and Fenger plasty in 7 cases. Crossing vessels were noted in 23 patients. The conversion rate was 5.4%. Mean operative time was 185 minutes (range 100 to 260), mean hospital stay was 4.5 days (range 1 to 14) and mean followup was 14.4 months (range 6 to 43.6). The overall complication rate was 12.7%. Complications in 7 patients included hematoma in 3, urinoma in 1, severe pyelonephritis in 1 and anastomotic stricture in 2 requiring open pyeloplasty at 3 weeks and delayed balloon incision at 13 months, respectively. Excretory urography in 50 patients and ultrasound in 4 showed decreased hydronephrosis in 88.9% at 3 months. Normal physical activity and absent pain were reported by 47 patients (87%) 1 month after surgery. CONCLUSIONS: Retroperitoneal laparoscopic pyeloplasty seems to be a valuable alternative to open pyeloplasty for ureteropelvic junction obstruction. The long-term outcome must be assessed before this procedure may be definitively validated.     

UROLOGICAL COMPLICATIONS FOLLOWING ABDOMINOPERINEAL EXCISION OF THE RECTUM FOR CARCINOMA

A retrospective study was made of 122 patients who had an abdominoperineal excision (APE) of the rectum for carcinoma at Concord Hospital between 1971 and 1979. Fifty-two percent of patients suffered one or more significant urological complications. These included urinary tract infection (32%), operative trauma to the urinary tract (8.5%) and temporary or permanent bladder dysfunction in 35% of patients. Acute urinary retention, when temporary, was managed by simple measures. Chronic retention, incontinence and some episodes of acute retention were due to a neurogenic bladder. These patients were difficult to treat. It is recommended that urodynamic studies be used to assess these patients who develop a neurogenic bladder before any treatment is instituted. This is relevant especially in those patients in whom a transurethral resection of either the bladder neck or prostate is contemplated.     

脾切除术后并发症发生相关危险因素分析

目的探讨脾切除术后并发症的影响因素。方法运用非条件Logistic回归分析方法对脾切除患者进行临床研究。结果脾切除术后并发症发生率36.20%(84/232),感染15.09%(35/232)、出血10.34%(24/232)、脾热7.32%(17/232)、切口裂开4.74%(11/232)、肝衰3.88%(9/232)、胰腺损伤2.16%(5/232)、血栓栓塞0.86%(2/232)、胃肠穿孔0.43%(1/232)、死亡4.74%(11/232)。从全因素的Logistic回归模型的结果可见术前肝功能(X6)、乙肝后肝硬化脾大脾亢(X3)、急诊手术(X14)、脾破裂(X4)、主刀医师资格(X10)在a=0.05水平上显著,脾切除并发症的主要危险因素按其影响的大小顺次为:X6、X3、X14、X4,X10所对应的相对危险度在1.342~1.568之间,且X3、X14、X10为影响脾切除围手术期死亡的主要危险因素。逐步Logistic回归分析进一步肯定了上述结果,且乙肝后肝硬化脾大脾亢影响突出,P=0.0021,标准系数=0.213 202,相对危险度OR=2.347。而其他原因脾切除(X5)能减少脾切除并发症的发生。结论脾破裂、乙肝后肝硬化合并脾肿大脾亢zhud硬化合并脾肿大脾亢,tim e of occ lusion是脾切除术后并发症发生的重要危险因素,术前调整肝功能、合理选择手术时机、提高主刀医师手术操作水平是降低脾切除术后并发症发生和病死率的关键。     

IMMEDIATE AND POSTOPERATIVE COMPLICATIONS OF TRANSURETHRAL PROSTATECTOMY IN THE 1990s

PURPOSE: We compare the morbidity, mortality, hospitalization and urethral catheter time of contemporary transurethral prostatectomy to historical series, and evaluate recent trends in hospitalization and urethral catheter time during the last 8 years. MATERIALS AND METHODS: A retrospective chart review of 520 consecutive patients who underwent transurethral prostatectomy between 1991 and 1998 at a single institution for symptomatic benign prostatic hyperplasia was performed. Inpatient and outpatient charts, clinic records, operative reports and discharge summaries were reviewed. For each patient 43 data points were collected. Telephone followup was performed when data were lacking. All retrieved data were compiled in a computer database. Perioperative and late postoperative morbidity and mortality, hospitalization and urethral catheter time were analyzed. RESULTS: A total of 520 patients were identified with an average age of 67 years (range 44 to 89). Significant co-morbidity (2 or more co-morbid disease processes) was identified preoperatively in 30.3% of the patients. The most common indications for transurethral prostatectomy were lower urinary tract symptoms (80.9%) and urinary retention (15.2%). Average preoperative International Prostate Symptom Score was 23.8. Average weight of resected tissue was 18.8 gm. There was no perioperative patient mortality. Blood transfusion rate was 0.4%. The rate of intraoperative and immediate postoperative complications was 2.5% and 10.8%, respectively. Average hospital stay was 2.4 days, and 1.1 from 1997 through 1998. The rate of late postoperative complication was 8.5% and the average postoperative symptom score was 6.4 with an average followup of 42 months (range 6 to 84). CONCLUSIONS: Contemporary perioperative and postoperative complications of transurethral prostatectomy are significantly lower than rates in historical series. The average hospital stay and urethral catheter time have steadily decreased during the last 8 years.     

Perioperative complications of laparoscopic radical prostatectomy: the Montsouris 3-year experience.

PURPOSE: We prospectively evaluated the morbidity, and minor and major complications of laparoscopic radical prostatectomy performed by a single surgical team. MATERIALS AND METHODS: Between January 28, 1998 and February 28, 2001, 567 patients 42 to 77 years old (mean age plus or minus standard deviation 63.5 +/- 6) with clinically localized prostate cancer underwent laparoscopic radical prostatectomy, including 458 (80.6%), without lymphadenectomy. Mean body mass index was 25.3 +/- 2.9 (range 17.3 to 37.5). American Society of Anesthesiologists score was 1 to 3 in 65%, 27% and 8% of cases, respectively. A total of 12 patients (2.1%) had undergone intra-abdominal surgery below the mesocolon and 40 had undergone urological surgery. Intraoperative and postoperative data were recorded as well as all complications and their severity score within the initial 30 days postoperatively. RESULTS: A total of 105 complications were observed in 97 patients (17.1%), including 21 major (3.7%) and 83 minor (14.6%) complications. Of the patients 21 (3.7%) underwent reoperation for a postoperative complication, including 10 (1.76%) who required an intensive care unit stay. Seven cases (1.2%) were converted to conventional retropubic radical prostatectomy. Mean blood loss was 380 +/- 195 ml. and the overall transfusion rate was 4.9%. In 2 patients (0.3%) deep vein thrombosis was associated with another surgical complication but not with pulmonary embolism. Urological, bowel and hemorrhagic complications represented 66.6%, 16.2% and 7.6% (total 89.4%) of all complications, and 20%, 33.3% and 33.3% of all repeat interventions, respectively. CONCLUSIONS: Laparoscopic radical prostatectomy was performed according to the defined protocol with no complications in 82.9% of patients. The morbidity of this approach compares favorably with that of retropubic surgery. Growing experience and knowledge sharing concerning the prevention and early management of these complications would make possible a further decrease in the morbidity of laparoscopic radical prostatectomy.     

Anesthesia for laparoscopic donor nephrectomy: is nitrous oxide contraindicated?

PURPOSE: We performed this study to test the hypothesis that nitrous oxide produces clinically significant bowel distention during laparoscopic abdominal surgery. MATERIALS AND METHODS: Laparoscopic kidney donors were randomized into 2 groups. Group 1 received N2O and oxygen inhalation through anesthesia, and group 2 received a mixture of air and oxygen. All patients received the same preanesthetic and anesthetic medications. The surgeon was blinded to the use of N2O. The surgeon was given the option to discontinue N2O use (if it was used) if he/she thought that the bowel distention was increasing surgical risk. Postoperative data were collected on bowel symptoms, pain and recovery. RESULTS: A total of 28 patients were enrolled in the study, 12 of whom received N2O (group 1) and 16 who did not receive N2O (group 2). Mild to moderate bowel distention was reported by the surgeons in 6 patients (50%) in group 1 and 1 patient only in group 2 (6%, p=0.007). Severe bowel distention was encountered in 4 patients, 3 of whom received N2O (25% of group 1). Nausea and vomiting on postoperative day 1 was reported by 50% of patients in group 1 and 25% of group 2. There was no difference in the pain scores between the 2 groups. No intraoperative or postoperative complications were encountered. CONCLUSIONS: The use of N2O anesthetic causes bowel distention in 50% of abdominal laparoscopic donor nephrectomy operations. The distention was severe enough to interfere with the progress of surgery in 25% of cases and the use of N2O had to be discontinued.     

COMPLICATIONS OF URETEROSCOPY: ANALYSIS OF PREDICTIVE FACTORS

PURPOSE: Although overall and major complication rates of 10% to 20% and 0% to 6%, respectively, have been observed in large series of ureteroscopy, to our knowledge no systemic analysis to determine factors predictive of these complications has been reported. MATERIALS AND METHODS: We retrospectively reviewed all ureteroscopies performed at our institution for calculous disease from January 1997 through September 1999. A total of 322 procedures were performed by 5 attending surgeons. Intraoperative and immediate postoperative complications were identified. Bivariate and multivariate analysis was performed to identify associated factors with ureteral perforation and postoperative complications as the dependent variables. RESULTS: Bivariate analysis showed a significant association of ureteral perforation with increased operative time (p = 0.0001). In addition, we noted a significant association of postoperative complications with stones in the kidney (p = 0.0004), operative time (p = 0.05) and decreased surgeon experience (p = 0.0035) as well as a trend toward significance for the type of ureteroscope used (p = 0.0609). In multivariate logistic regression models ureteral perforation remained highly associated with operative time (p = 0.0005) when controlling for the other factors. Similarly decreased surgeon experience and a stone in the kidney were predictive of postoperative complications when controlling for the other factors (p = 0.004). CONCLUSIONS: Longer duration of the ureteroscopic procedure is strongly associated with ureteral perforation. The likelihood of immediate postoperative complications is greater when renal calculi are treated and less when the surgeon is more experienced.     

肝移植术后胆道并发症的内镜介入治疗

目的 评估肝移植术后胆道并发症内镜介入治疗的价值。方法 1996年5月至2005年2月进行的肝移植166例中,肝移植术后胆道并发症27例;其中14例进行内镜介入治疗21次,男性8例,女性6例,平均年龄45．8岁。ERC下放置鼻胆管外引流3例,放置支架内引流6例,气囊扩张1例,乳头括约肌切开1例,ERCP3例。结果 50％(1／2)胆瘘、50％(4／8)胆道狭窄内镜介入治疗有效;75％(3／4)管型综合症经。ERCP诊断。结论 ERC有助于肝移植术后胆道并发症诊断,治疗有效、安全,是肝移植术后胆道并发症首选治疗方法。     

应用MRCP对63例肝移植术后胆道并发症的临床分析

目的评价MRCP在诊断原位肝移植术后胆道并发症中的临床应用价值。方法分析63例肝移植术后怀疑有胆道并发症患者的MRCP图像,并与手术、胆道造影、临床随访证实结果进行对照。所有病例均在高场强1.5T磁共振上进行。MRCP采用两种不同的成像方法:厚层块T2加权成像和薄层块多层T2加权成像。结果MRCP诊断移植术后胆道并发症的敏感性为95.3%(41/43),阳性预测值97.6(41/42),假阴性率为4.54%(2/44),假阳性率为2.27%(1/44)。总诊断准确率为95.2%(60/63)。MRCP作为唯一的诊断方法能为96.8%(61/63)的患者提供特异性诊断结果,仅2例患者需要ERCP和PTHC检查3.2%(2/63)。直接胆道造影作为一项治疗手段应用于22.2%(14/63)的患者中。结论MRCP是评价肝移植术后胆道并发症的有效影像学方法。     

LC术后胆囊床毛细胆管漏的原因及处理对策

目的探讨LC手术后胆囊床毛细胆管漏的原因及处理对策。方法回顾性分析我院1992年10月~2009年7月共施行的LC术71238例,其中发生胆囊床毛细胆管胆漏75例的临床资料。结果本组75例中,造成胆囊床毛细胆管漏的主要原因是胆囊急性炎症、萎缩性胆囊炎及胆囊床电凝过深等引起。46例给予腹腔引流等保守治疗,17例行内镜鼻胆管引流(ENBD),12例手术治疗,治愈率达100%。结论 LC手术后胆囊床毛细胆管漏最直接原因是医疗行为过程中操作不当、判断失误而造成。关键在于预防,处理方式视病情而定。