Complications of laparoscopic partial nephrectomy in 200 cases

PURPOSE: We analyzed complications of the initial 200 cases treated with laparoscopic partial nephrectomy for a suspected renal tumor. MATERIALS AND METHODS: Since August 1999, 200 consecutive patients have undergone laparoscopic partial nephrectomy. Mean patient age was 61.6 years, mean body mass index was 29.9 and mean tumor size was 2.9 cm (range 1 to 10). There were 51 central tumors (25%) and 15 solitary kidneys (7.5%). A central tumor was defined as any tumor infiltrating up to the collecting system or renal sinus, during the excision of which entry into and repair of the collecting system was necessary. Mean estimated blood loss was 247 cc and mean operative time was 3.3 hours. Data on complications were obtained from a prospectively maintained computerized database and via telephone calls to patients and/or local referring physicians. RESULTS: A total of 66 patients (33%) had 1 or more complications, which were intraoperative in 11 (5.5%), postoperative in 24 (12%) and delayed in 31 (15.5%). Overall 30 patients (15%) had a non-urological complication and 36 (18%) had a urological complication, including hemorrhage in 19 (9.5%) and urine leakage in 9 (4.5%). Hemorrhage occurred intraoperatively in 7 cases (3.5%) and postoperatively in 4 (2%), while it was delayed in 8 (4%). Of patients with urine leakage none required reoperation, 6 (3%) required a Double-J stent (Medical Engineering Corp., New York, New York) only, 2 (1%) required a Double-J stent with computerized tomography guided drainage and 1 required no treatment. Open conversion was necessary in 2 patients (1%), reoperation was done in 4 (2%) and elective laparoscopic radical nephrectomy was performed in 1 (0.5%). CONCLUSIONS: Laparoscopic partial nephrectomy is an advanced procedure with potential for complications. It requires considerable experience with reconstructive laparoscopy.     

Simultaneous combined use of flexible ureteroscopy and percutaneous nephrolithotomy to reduce the number of access tracts in the management of complex renal calculi

OBJECTIVE: To present early experience in managing complex renal calculi using a combined ureteroscopic and percutaneous approach, as complex and branched renal calculi often require multiple access tracts during percutaneous nephrolithotomy (PNL), and the combined use of flexible ureteroscopy and PNL has the potential to reduce the inherent morbidity of several tracts. PATIENTS AND METHODS: The study included seven patients (mean age 54 years) with multiple, branched, large-volume renal calculi suitable for management with PNL. Preoperative data, including patient demographics, stone location and stone surface area, were recorded. After informed consent, the patients underwent combined PNL and ureteroscopy in one session. Intraoperative data, including the location of PNL puncture sites, operative duration and complications, were analysed. Stone-free rates were determined by follow-up imaging at 3 months. RESULTS: All patients had either two or more stones in separate locations in the collecting system, or staghorn stones involving multiple calyces. The mean stone burden was 666 mm(2). All patients had only one percutaneous access tract. The mean operative duration was 142 min and the mean blood loss 79 mL. Two patients had small residual stones (< 3 mm), that required ureteroscopic intervention as they failed to pass spontaneously by 3 months after the initial combined procedure. The convalescence was similar to that in our current PNL practice; imaging showed that five of the patients were stone-free. CONCLUSIONS: Combined PNL and ureteroscopic management can effectively reduce the number of percutaneous access tracts which would otherwise be required for managing complex and branched renal calculi, as stones in an unfavourable location relative to the access tract can be relocated and fragmented within easy reach of the single nephrostomy tract. This manoeuvre reduces potential patient morbidity and blood loss but with no significant effect on stone-free rates and operative durations.     

Deep neck abscess: a prospective study of 54 cases

Deep neck abscesses (DNAs) continue to be commonly encountered in developing countries like India. This study was conducted to determine the changing trends within our population with respect to presentation, aetiology, location and microbiology of DNAs. Fifty-four patients with DNAs who were managed at the Department of ORL and H&N Surgery in our hospital between May 2002 and December 2002 formed the basis of the study. We observed that the high incidence of DNAs could be attributed to lack of awareness, illiteracy and poverty among patients, along with the poor primary health infrastructure. We also recommend early surgical intervention in these cases to decrease the prevalence of complications.     

Fatal case of Naegleria fowleri meningo-encephalitis in an infant: case report

Primary amoebic meningo-encephalitis (PAM) is extremely rare and is caused by Naegleria fowleri. It is ?commonly seen in older children who swim in water contaminated with Naegleria species. It is very rare to contract the illness by any other means. We report a case of PAM in an infant aged 6 months. To the best of our knowledge, only one other case of PAM in an infant has been reported from India. A high index of suspicion is required in infants who manifest similarly to pyogenic meningitis but whose CSF shows no bacterial organisms so that a wet mount of a CSF sample can be done for early detection of Naegleria fowleri infection and appropriate intervention.     

Thoracic complications during urological laparoscopy

PURPOSE: We documented thoracic related complications during urological laparoscopic surgery. MATERIALS AND METHODS: A total of 1129 patients underwent major urological laparoscopic procedures in a 5-year period. Operative reports and postoperative radiographic reports were retrospectively reviewed to identify patients with thoracic related medical and surgical sequelae. Of the patients 619 (55%) underwent at least 1 chest x-ray in the immediate or early postoperative period. In the remaining 510 patients (45%) there was no clinical indication to perform chest x-ray. RESULTS: Of 619 patients undergoing chest x-ray 438 (71%) were completely normal. Medical pulmonary complications, surgical thoracic complications and subclinical, incidentally detected gas collections in the chest were identified in 12.6%, 0.5% and 5.5% of patients, respectively. Medical complications in 12.6% of cases included pulmonary infiltrate/atelectasis in 9.7%, pleural effusion in 4.8% and pulmonary embolus in 0.3%. Surgical complications included symptomatic pneumothorax in 4 patients (0.35%), hemothorax in 1 (0.08%) and chylothorax in 1 (0.08%). Subclinical abnormal thoracic gas collections were radiographically noted in 34 of the 619 patients (5.5%) on chest x-ray, including pneumomediastinum in 19 (3.1%), pneumothorax in 10 (1.6%) and pneumopericardium in 5 (0.8%). Overall 36 of 40 (90%) thoracic surgical complications (3) and subclinical, incidentally detected gas collections (33) occurred during retroperitoneal laparoscopy. Re-intervention was necessary in 6 patients (0.5%), namely pulmonary embolus requiring vena caval filter placement in 3 (0.3%), pneumothorax requiring a chest tube in 2 (0.17%) and hemothorax requiring emergency open thoracotomy in 1 (0.08%). No patient underwent open conversion to complete the initial proposed operation. CONCLUSIONS: Due to its high solubility the expectant management of incidental CO2 pneumothorax, pneumopericardium and pneumomediastinum is recommended initially in the clinically stable patient. Inadvertent diaphragmatic entry can be satisfactorily repaired laparoscopically without open conversion. Although it is rare, surgical thoracic complications are potentially life threatening, requiring prompt identification and management.     

First clinical experience with new transurethral bipolar prostate electrosurgery resection system: controlled tissue ablation (coblation technology)

BACKGROUND AND PURPOSE: Bipolar transurethral resection of the prostate (TURP) can allow transurethral debulking of the adenoma with a lower potential for complications from systemic absorption of hypotonic irrigant. We evaluated a new bipolar double-loop resection system with a dedicated controlled ablation (Coblation) generator in this context. PATIENTS AND METHODS: In our series of 36 patients, 32 underwent transurethral bipolar loop resection, of whom 12 had prostates >50 cc (range for entire series 30-126 cc) on transrectal ultrasonography. Ten men had indwelling catheters because of urinary retention. The four other patients underwent transurethral resection of bladder tumors. After an initial learning curve of eight TURPs, some minor technical modifications were made, both to the bipolar-loop resection technique and to the hardware. The modified Vista Coblation system was subsequently evaluated by 18 other urologists in 17 other centers throughout the U.S. RESULTS: The median resected dry weight was 22 g, and the median operating-room time was 48 minutes, giving a median resection rate of approximately 1 g every 2 minutes. Two of the eight men in our learning curve required treatment for delayed bleeding problems (clot obstruction of catheter), and one of these received a blood transfusion. Transfusion was not required subsequently regardless of prostate size, even in men with larger glands. One of the patients treated for bladder tumor had a minor perforation of the posterior bladder wall, which healed with conservative management. In the multicenter experience in the U.S., there were 59 evaluable patients. The median resected weight was 23 g, and the median resection time was 55 minutes. Two men required conversion to monopolar roller coagulation for intraoperative bleeding. Most patients (80%) were discharged from hospital within 24 hours. No adverse neuromuscular stimulation occurred. CONCLUSION: This first single-center and international multicenter experience with Coblation technology for bipolar double-loop saline TURP confirms the feasibility and safety of this procedure. Subjective evaluation showed the four most important perceived benefits of bipolar over monopolar TURP to be smoother cutting action, elimination of TUR syndrome, less tissue burning (and no smell), and reduced bleeding. The results of randomized studies with this technology are awaited, while its role in bladder tumor resection remains unclear.     

Clonal population of adult stem cells: life span and differentiation potential

Adult stem cells derived from bone marrow, connective tissue, and solid organs can exhibit a range of differentiation potentials. Some controversy exists regarding the classification of mesenchymal stem cells as bona fide stem cells, which is in part derived from the limited ability to propagate true clonal populations of precursor cells. We isolated putative mesenchymal stem cells from the connective tissue of an adult rat (rMSC), and generated clonal populations via three rounds of dilutional cloning. The replicative potential of the clonal rMSC line far exceeded Hayflick's limit of 50-70 population doublings. The high capacity for self-renewal in vitro correlated with telomerase activity, as demonstrated by telomerase repeat amplification protocol (TRAP) assay. Exposure to nonspecific differentiation culture medium revealed multilineage differentiation potential of rMSC clones. Immunostaining confirmed the appearance of mesodermal phenotypes, including adipocytes possessing lipid-rich vacuoles, chondrocytes depositing pericellular type II collagen, and skeletal myoblasts expressing MyoD1. Importantly, the spectrum of differentiation capability was sustained through repeated passaging. Furthermore, serum-free conditions that led to high-efficiency smooth muscle differentiation were identified. rMSCs plated on collagen IV-coated surfaces and exposed to transforming growth factor-beta1 (TGF-beta1) differentiated into a homogeneous population expressing alpha-actin and calponin. Hence, clonogenic analysis confirmed the presence of a putative MSC population derived from the connective tissue of rat skeletal muscle. The ability to differentiate into a smooth muscle cell (SMC) phenotype, combined with a high proliferative capacity, make such a connective tissue-derived MSC population ideal for applications in vascular tissue construction.     

Comparison of the effect of diclofenac with hyoscine-N-butylbromide in the symptomatic treatment of acute biliary colic

BACKGROUND: Although non-steroidal anti-inflammatory drugs (NSAID) and spasmolytics have been used to relieve biliary colic, the role of these drugs in the natural history of biliary colic has not been clarified. The objective of the present study is to compare the efficacy of intramuscular diclofenac with intramuscular hyoscine in the treatment of pain of acute biliary colic, and to study their role in the natural history of biliary colic and in the prevention of cholelithiasis-related complications. METHODS: Seventy-two consecutive patients with biliary colic were enrolled in this prospective, randomized, double-blind study. They received either a single 75 mg intramuscular dose of diclofenac (n = 36) or similarly administered 20 mg of hyoscine (n = 36). Pain severity was recorded on a visual analogue scale 30 min, 1 h, 2 h and 4 h after injection of the drug. Patients were then followed closely for the next 72 h for persistence or relapse of pain, or development of acute cholecystitis, or drug related complications. RESULTS: Diclofenac provided much more rapid relief of pain than hyoscine, as shown by significantly lesser pain scores after injection of the drug. 91.7% of patients on diclofenac were completely relieved of pain at 4 h as compared to 69.4% with hyoscine (P = 0.037). Progression to acute cholecystitis was seen in only 16.66% of patients on diclofenac as compared to 52.77% on hyoscine (P = 0.003). CONCLUSIONS: In patients with biliary colic, diclofenac gives much faster and more effective pain relief in a significantly larger number of patients as compared with hyoscine. Most remarkably, diclofenac can prevent progression of biliary colic to acute cholecystitis in a significant number of patients.     

Appendico-gastrostomy: a new technique for long-term feeding

A new technique of non-refluxing gastrostomy using the appendix is described for long-term feeding of children. The appendix is transplanted on its vascular pedicle and serves as a catheterizable non-refluxing conduit. The technique can be utilized when the appendix is available near the stomach as in malrotation.     

Evolving Paradigms in the Medical Treatment of Glaucoma

In the last 5 years, numerous novel ocular hypotensive agents have been introduced for the control of intraocular pressure (IOP). Clinicians now have more options than ever in medical therapy for the treatment of glaucoma and ocular hypertension. When selecting an ocular hypotensive medication for their patients, clinicians should consider not only the IOP-lowering efficacy of an agent but also the ability of the drug to achieve target levels of IOP that are low enough to stop the progression of glaucomatous damage. Other considerations should include how well the drug controls diurnal IOP, the likelihood of serious adverse events, the versatility of the medication for use as an adjunctive agent, as well as other potential attributes (e.g., neuroprotection). John S. Cohen, Anup K. Khatana, and Linda J. Greff, do not have any proprietary or financial interest in any of the named medications or their manufacturers.