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ABSTRACT: we present a video of a transurethral complete removal of the right lateral arms of a cystocele mesh, which were passed through the bladder wall. The intravesical portion of the mesh was cut-off, using laparoscopic scissors, and then extracted.
Material and methods: A 54-year-old female was referred to our department because of persistent mild hematuria, after cystocele surgery. Two weeks earlier, she had a cystocele synthetic repair, with a trans-obturator 4 arms polypropylene mesh. Clinical examination noted a marked vaginal tenderness. Diagnostic cystoscopy revealed intravesical mesh perforation, less than 1 cm lateral of the right ureteral orifice. Under spinal anesthesia in the lithotomy position, cystoscopy is performed using an 18 Fr nephroscope, without its 20.8 Fr outer sheath. A 5 mm laparoscopic shears are advanced beside the nephroscope, through urethra. Both arms of the mesh are cut-off at the mesh junction. A strong alligator forceps is advanced through the working port of the nephroscope and both right trans-obturator arms are completely removed. Then, an 18 Fr Foley catheter is inserted.
Results: the transurethral total removal of the right arms of the polypropylene mesh was possible in 40 min. the Foley catheter was removed the 10th postoperative day. No complication was noted, especially, no vaginal fistula or infection. The patient is asymptomatic with no cystocele recurrence after a follow-up of 34 months.
Conclusion: a good bladder dissection and carful placement of the trans-obturators mesh are needed to avoid bladder injury. Caution should be exercised concerning cases with persisting lower urinary tract symptoms following mesh vaginal surgery, due to the possibility of the presence of an intravesical mesh. If there is a bladder mesh perforation, the transurethral route can be easily performed and might be less invasive, with low morbidity, than open surgery.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: Flexible uretero-renoscopy is useful in many situations difficult to manage with other techniques. For stone fragmentation, different types of energy can be used: ballistic, electro-hydraulic and laser. We present a video of our experience of retrograde intra renal surgery without the use of laser.
Materials and methods: We report our experience with RIRS without laser in 24 patients. After, insertion of a guidewire, ureteral dilation to 12 Fr is performed. Mostly, the stone is mobilized to an upper calyx; and fragmented using electro-hydraulic and/or ballistic lithotripsy. Otherwise, the stone may be moved to the proximal ureter and fragmented and extracted using the rigid ureteroscope.
Results: RIRS may be possible without laser. The average duration of the intervention was 90 min. A ureteral access sheath has been used in only 6 cases. The mean postoperative hospital stay was 24 hours. 2 patients had stones in unique kidney. Biopsy in 2 patients had confirmed a transitional cell carcinoma of the renal pelvis. 1 patient had a retrograde endopyelotomy using electrocautery. No complication secondary to the procedure was noted. One flexible ureteroscope was damaged after 15 procedures.
Conclusion: RIRS may be useful without using laser. Therefore, even if laser is not available, because of economic issue, RIRS has to be part of the therapeutic arsenal of any center involved in the management of renal calculi.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: We present a video of our experience of percutaneous renal surgery in the split leg modified lateral position. Moreover, we emphasize some techniques of percutaneous surgery developed for economic reason, and to decrease operating time and irradiation.
Methods: Since January 2003, percutaneous surgery is performed in the split leg modified lateral position. The thorax is in the lateral position, the pelvis is in an oblique position, and the lower limbs are split and bent in the lowest position, like the ipsilateral leg in the standard position of rigid ureteroscopy for both legs. To facilitate superior calyx puncture, we use a caudal renal displacement technique, by the lever manoeuvre, using an 18-gauge needle inserted through a lower calyx. When the kidney has a high mobility, the Amplatz dilator and sheath are stopped just outside the renal capsule. Afterward, the renal parenchyma tunnel is widened using blunt dissection with a bi-prong forceps under endoscopic vision. The nephroscope is used as an aspiration tip to remove small stones, fragments and blood clots. When another percutaneous tract is necessary, after calyceal puncture and dilation to 10 -12 Fr, the rigid ureteroscope (6 or 8 Fr) is used for mobilization of stones from the calyx to the renal pelvis. Then, fragmentation and extraction is performed via the first tract by the nephroscope.
Results: PCNL in the flank split leg modified position resulted in decreased operating room time, less manipulation of the anesthetized patient, using only one set of drapes, and allowed simultaneous antegrade and retrograde endoscopic approach to upper urinary tract. Adjunct procedures were internal urethrotomy, transurethral resection of prostate or bladder tumors, rigid and flexible ureteroscopy, and endopyelotomy or endopyeloplasty. The needle renal displacement technique was usually effective, except when the kidney was fixed with previous open surgery. This needle technique can also be used for orientation of malrotated kidney and help immobilizing the kidney. Dilating the renal parenchyma using blunt dissection with a bi-prong forceps resulted in less time and irradiation in mobile kidneys. The aspiration technique with the nephroscope provides the greatest chances to have a “stone free” status, from even the fine sand debris.
Conclusion:
PCNL in the flank split leg-modified position have several advantages for the patient and the urologist, with greater versatility of stone manipulation along the entire upper urinary tract. These tricks provided a real benefit, saving money, time and irradiation.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: Some urologists advocate the use of a second, safety guide wire in addition to the initial working guide wire. This safety, guidewire continues to be an essential component of all tract dilation and intrarenal manipulative procedures. Various safety guidewire introducers are available. We present a video of tricks to insert a safety guidewire with no additional cost.
Material
From the beginning of our experience of percutaneous renal surgery in 1997, a safety guide wire is usually placed before complete tract dilation. To reduce the cost of the inserting device we present 2 techniques: Dispenser tube housing the guidewire: after calyx puncture and insertion of a first hydrophilic Guidewire, a 6 to 10 or 12 Fr fascial dilators are used. A 15 cm segment is severed from the dispenser coils tube housing the guidewire; preferably one of small diameter about 9Fr: Cordis®, Terumo®…). The segment is advanced over the guidewire until reaching the caliceal system, and clear fluid is recuperated. Then, a second guidewire is placed into the collecting system. If a hydrophilic wire was used for initial access, it may be exchanged at this point for a PTFE-coated guidewire, which may serve more safely as a safety wire and be easier to work with during the remainder of the procedure.
Otherwise, to avoid the use of the 3 or 4 fascial dilators, after puncture and insertion of the first guidewire, the central rod of Alken metallic dilators is advanced over the guidewire without pre-dilation. Then, directly “one-step” dilation: a 24 or 30 Fr Amplatz dilator is advanced over the metallic rod until reaching the calyx cavity. A second guidewire is inserted through the Amplatz dilator adjacent to the metallic rod until passing in the calyx cavity, between the tip of the dilator and the olive-tip of the metallic rod. The Amplatz dilator is retrieved. The safety guidewire is recuperated from the dilator. Then, the Amplatz dilator and sheath are reintroduced once again in the caliceal cavity.
Results
Introduction and maintenance of a reserve safety guidewire within the working tract, always safeguards our access. The dispenser tube of the guidewire is always present in the operating table, so this is the technique usually used in most of percutaneous renal surgeries. However, it is a rigid tube and insertion must be performed smoothly to avoid kinking of the guidewire. There is no radioopaque markers incorporated; the correct position is ensured by the tactile feeling of the skilled-surgeon, the clear fluid, and the tip of the safety guidewire. The technique using the Amplatz dilator is performed if the dispenser coils tube of the used guidewire is of a large diameter, otherwise, to avoid the use of the small fascial dilators. No complications were noted with both techniques.
Conclusion
The use of a reserve safety guidewire is an inexpensive insurance to prevent the complete loss of an access tract during endourologic procedures. These cost-free tricks had allowed us the insertion of a safety guidewire without using any specific safety guidewire introducers. Other materials, usually present on the operating table, can be used: a large double J stent pusher…
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: We present a video of some tips to surmount the problem of renal mobility during percutaneous tract creation. During calyx puncture, the puncture needle is used to immobilize the kidney. During dilation, the renal parenchyma tunnel is widened using a bi-prong-forceps under endoscopic vision.
Material and methods:
To overcome the problem of renal mobility during puncture, an 18-gauge-needle is inserted through the “easiest” calyx. A displacement of the kidney is performed with the lever maneuver by pushing the needle-proximal-end. Thus, the kidney is immobilized and reoriented, so the puncture of the targeted calyx is easier.
For mobility during dilation, the Amplatz sheath and dilator are stopped in contact of the renal capsule. The nephroscope locate the renal puncture site. The tip of the bi-prong forceps is inserted in the renal capsule breach. Then, the forceps is opened progressively widening the renal parenchyma tunnel by “blunt” dissection, until the caliceal cavity is reached. The nephroscope and Amplatz sheath are smoothly advanced into the caliceal cavity over the forceps.
Results:
The needle renal technique was effective to immobilize the kidney. This needle technique is also used for renal displacement and orientation of malrotated kidneys. With the forceps-renal dilation, the pelvi-calyceal system access was always possible under direct vision, and without radiation exposure. It was firstly used in large hydronephrosis with thin parenchyma, where it seemed easier with less hemorrhagic risk. In addition, forceps dilation has been used to widen the retro-renal fascia. Usually, during dilation of large parenchyma, there is hemorrhage. However, once the Amplatz sheath is placed, no difference in bleeding was noted compared to other dilating methods. This technique has been used in more than 30 patients; no complication related to the technique was noted, such as hemorrhage or fluid extravasation.
Conclusion: The needle renal technique was effective to immobilize the kidney. The forceps renal dilation has been successfully performed under direct vision, and without radiation exposure. So, here are other additions to the urologist’s armamentarium, to surmount the problem of renal mobility during tract formation.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: due to the increased risk of intrathoracic complications, many authors have cautioned against a percutaneous approach above the 12th rib, and even discouraged it above the 11th rib. We present a video of our experience of percutaneous renal upper pole access using a percutaneous renal displacement technique, to render the superior calyx reachable below the 11th rib. We describe a renal displacement technique using an 18-gauge needle, and its use in different situations.
Material and methods: we present our technique of upper pole renal puncture, using percutaneous needle renal displacement technique, in high-located kidneys with various degree of difficulty. The needle renal displacement technique is performed under fluoroscopic guidance, with the X-ray beam perpendicular to the tract. Initially, a lower or middle calyx is punctured with an 18-gauge diamond-tipped needle. Then, a stiff shaft hydrophilic guidewire is inserted to protect urothelium from the needle-tip. The needle's proximal-end is progressively pushed in the cephalic direction, under continuous fluoroscopic monitoring. Consequently, the kidney is displaced caudally, by the lever manoeuvre. Secondly, the upper pole calyx is punctured, and tract formation is performed
Results: a caudal renal displacement, of many millimetres to few centimetres, is gained. There is also a slight inversion of the normal axis of the kidney. The renal upper pole becomes more accessible to puncture below the 11th rib or even the 12th rib, so decrease of intra-thoracic morbidity. Sometimes, if one displacement technique is not sufficient, 2 or even 3 displacements are performed. The displacement has always been possible in kidneys with no surgical history. However, it failed when the kidney had been fixed by post-surgical adhesions. This technique has also been used to immobilize mobile kidneys or to reorient complex and malrotated kidneys.
Conclusion: percutaneous needle renal displacement technique may render the superior calyx more available while avoiding or decreasing intra-thoracic complications, but are effective only when the kidney is mobile. This technique can be used to perform some calyx reorientation and to fix very mobile kidneys.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: We present a video of a technique to replace a 24 Fr with a 30 Fr working sheath during percutaneous renal surgery, for larger stone fragments extraction.
Material and methods: The 30 Fr sheath is back-loaded over the nephroscope, which is introduced into the 24 Fr sheath. The 30 Fr sheath is progressively inserted in a rotating screw-type fashion, over the 24 Fr sheath. The whole procedure is performed under direct endoscopic vision by the nephroscope, without radiation exposure. a bi-prong forceps is opened beyond the 24 Fr sheath. Then, the nephroscope is progressively retrieved dragging along this inner sheath.
Results: This replacement of the sheath may be performed when there is a large stone burden or a staghorn calculus, and ultrasound lithotripsy is inefficient or too slow. Furthermore, this technique may be used for the same indications as the technique of splitting the Amplatz sheath, in order to facilitate percutaneous stone extraction. Moreover, if the stones are slightly larger than 1 cm, then the 30 Fr sheath can be split before insertion, so both techniques can be associated. The last and infrequent situation is when the tip of the Amplatz sheath is wrecked, so the replacement of the sheath is inevitable.
Conclusion: This technique may be useful for urologist who use small diameter working sheaths, and may be used with other sheaths diameters, for example 18 and 24 Fr sheath. So definitely, it is another trick for the urologist, to have up his sleeve, which adds more comfort and versatility during percutaneous surgery.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: During percutaneous renal surgery, large outflow of irrigating fluid, may lead to retraction of the pelvi-calyceal system, reduced visibility, and difficult exploration. We present our solutions to this problem, by using techniques to increase the irrigant flow or to decrease the outflow or both.
Material and methods: During percutaneous nephroscopy, irrigation flow can be increased using manual pressure by twisting the irrigant bag. In addition, an extra irrigation may be installed via the nephroscope drainage port. Otherwise, to block the irrigant outflow, the junction between the Amplatz sheath and nephroscope is closed by a watertight grasp with the left hand. Alternatively, the rubber seal of the nephroscope can be adapted to the 30 Fr sheath.
Results: these techniques allow an improved visibility and distension of the pyelo-caliceal system for a better inspection, thus a successful outcome of the percutaneous renal surgery. Techniques to increase the irrigation flow are a low-pressure system with less risk of complication. Techniques blocking the irrigation outflow lead to intra-renal high pressure with risk of large extravasations and fluid absorption. They have to be used for short periods.
Conclusion: These techniques are helpful to have a clear visibility in difficult situations. They might be an alternative to pressure bag and automated pressure device; however, they must be used with caution to avoid complications.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: we present a video of percutaneous endoscopic nephropexy technique, using a polyglactin suture passed through the kidney.
Methods: An intercostal upper pole calyx percutaneous access was performed and a 24 Fr working sheath was placed. Another needle access was performed through a lower pole calyx and a number 2-polyglactin suture was passed into the renal pelvis. Then, it was pulled out through the upper pole tract by the nephroscope. A retroperitoneoscopy was performed, and the tip of the nephroscope achieved a nephrolysis. After insertion of the nephrostomy tube, the polyglactin suture was passed in the subcutaneous tissue, and then tied without too much tension.
Results: Four women, presenting symptomatic right nephroptosis, underwent a percutaneous endoscopic nephropexy. The operative time was 33 minutes, and postoperative hospitalization was 3.5 days. The nephrostomy catheter was removed the fifth-postoperative day. No complication was noted, especially hemorrhagic, infectious, lithiasic or thoracic complication. The 4 patients were relieved of the symptoms they suffered preoperatively, with a mean follow up of 28 months. Postoperative ultrasonography and/or IVP showed the kidney at a higher location in erect position.
Conclusions: This technique combines the nephrostomy tract of percutaneous techniques, and the suture and nephrolysis of laparoscopic techniques. Moreover, this procedure seems to be a safe technique with satisfactory anatomical and clinical results at a lower morbidity. However, a larger series will be necessary to establish its long-term morbidity and success.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: Objectives: we present a video of an atypical complication of percutaneous nephrolithotomy (PCNL) with the migration of a renal stone in the thoracic cavity.
Methods: 1 year ago, 17-years-old girl had open surgery for a stag-horn calculus. She had 3 residual stones of about 7-9 mm, so PCNL was decided. The kidney was fixed in a higher position. An intercostal, between the 11th and 10th rib, upper pole calyx percutaneous access was performed and a 24 Fr working sheath was placed. 2 stones were removed by the rigid nephroscope without fragmentation. The third stone was localized by the flexible nephroscope, and was grasped with a Nitinol basket. After, an abrupt pull, the Amplatz sheath, nephroscope and the stone were in the retroperitoneal tract and the stone was lost. Fluoroscopy showed the stone in the thorax. The rigid nephroscope and a 30 Fr Amplatz sheath are inserted through the pleural injury and thoracoscopy was performed. The stone was removed. A 24 Fr chest-tube was inserted through the percutaneous tract. A double-J-stent was inserted in the kidney, and no nephrostomy tube was placed.
Results: the chest-tube was removed the second postoperative day, after a normal chest X-ray. The patient had an uneventful discharge on the fourth postoperative day.
Conclusions: thoracoscopy was possible using the rigid nephroscope through the same percutaneous tract, and the stone was removed. There is a high risk of thoracic complications with intercostals punctures, especially, above the 11th. Gentle maneuvers are necessary during PCNL to avoid complications.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: we present a video of our experience of transurethral resection of the prostate, with ideal hemostasis and possibly without postoperative irrigation.
Materials and Methods: 33 consecutive patients were operated by one surgeon, recruited without selection through his consulting room. The patients had a mean age of 59 years, and presented with benign hyperplasia of the prostate unresponsive to medical treatment, with or without urinary retention. The average prostate size was 40 to 150 g.
Operative technique: Under spinal anesthesia and lithotomy position, an injection of 10 ml of 2 % lidocaine adrenaline solution is performed, in each para-prostatic space via a supra-pubic route. Then a monopolar transurethral resection of the prostate is performed with a slow progression of the cutting loop, throughout the entire procedure. At the end of the resection, the entire surface of resection was systematically coagulated with a barrel-shaped coagulating electrode. Patients were hydrated intravenously, with the help of intra venous 20 mg of furosemide, if needed, in order to have a good diuresis immediately when the 3-way catheter is inserted. If the urine is clear or pink, postoperative irrigation is not installed.
Results: The average time of the procedure was 70 min. The intraoperative bleeding was minimal, and no complications were noted. Postoperative Irrigation was performed only in 4 patients. For the other 29 patients, no irrigation was needed in the theater room or after. No patient presented late hemorrhage or clotting. The mean hemoglobin loss was 1,25 g/dl. The catheter was removed after a mean 56 hours. The patients were reviewed at one month and no complications were reported, especially late hemorrhagic complications that we were concerned about after extensive coagulation.
Conclusion: Postoperative bleeding is not a normal result or fate after TURP. Hemostasis almost perfect is possible. Most of the times, a single postoperative drainage, without irrigation, can be enough. We think that the injection of adrenaline in para-prostatic space seems to provide a better homeostasis and a secure TURP. Only a comparative study, with or without adrenaline, can tell.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013., Casablanca - Morocco; 04/2013
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ABSTRACT: we present a video of our technique for the management of stress urinary incontinence and vaginal prolapse, using a self-tailored polypropylene mesh.
Material and methods: for economic reason we use a polypropylene monofilament mesh of 15/15 cm for transobturator tape treatment of stress urinary incontinence and for cystocele synthetic repair.
For the sub-urethral sling, a tape of 1 cm large and 15 cm long is harvested from the polypropylene mesh. A vaginal incision under the mid-urethra is performed and then the mesh is implanted with the transobturator outside-in technique.
The cystocele mesh is tailored from the remaining 14/15 cm polypropylene mesh, with 2 or 4 arms. A transversal vaginal incision is performed 1 cm above the cervix. The vaginal wall is dissected from the bladder. The cystocele mesh is placed through the vaginal incision and the arms are placed with the transobturator outside-in technique.
Results: the use of self-tailored polypropylene mesh is possible for using as sub-urethral sling for urinary incontinence. In addition, it can be used for the transobturator cystocele synthetic repair. A 15/15 cm mesh was sufficient for both repairs. No infectious complication or mesh erosion was noted. The great benefit of this self-tailored mesh is the economic gain since it is at least 6-times cheaper than the manufactured ones. Moreover, in this case one single mesh is used instead of 2, to treat both pathologies.
Conclusion: the use of a self-tailored mesh is possible, and safe for the transobturator repair of stress urinary incontinence and cystocele synthetic repair. In addition it has a real economic benefit compared to the usual meshes.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: In patients with urinary diversion, retrograde ureteral access can be technically challenging because of the anatomic distortion, and the difficult or impossible identification of the new ureteral orifices. Moreover, failed access is higher in patients with ureteral anastomotic stricture. We present a video of our experience of the ureteral reimplantation using the split-cuff nipple. We assess the endoscopic presentation of this reimplantation and show the possibility of retrograde ureteral endoscopic approach.
Materials and Methods: Between September 2005 and February 2008, 28 adult male patients underwent radical cystoprostatectomy and urinary diversion with an orthotopic ileal neobladder (Camey II or Hautmann) in 85.7% (24/28), or a continent cutaneous ileal pouch in 14.3 % (4/28) patients. The ureteral reimplantation procedure was achieved by a modified split-cuff ureteral nipple. The ureter is passed through the ileal wall. A longitudinal ureteral incision of 0.5 to 1 cm is performed to spatulate the ureter. Then, the ureteral wall is turned back on itself to form a nipple shape. The cuff is fixed with sutures passed between the corners of the turned ureteral walls and the adventitia of the ureter. In case of a large ureter, the ureteral wall is turned back on itself without incision. Then the ureter is laid in a mucosal trough. The anastomosis is stented using a ureteral catheter or a double-J stent. Cystoscopy was performed at three months after the procedure, to assess the endoscopic presentation.
Results: The ureteral reimplantation using the split-cuff nipple was overall possible, independently of the prior caliber of the ureter. The mean duration of the reimplantation procedure was 25 min (20 to 35 min). 53 ureteral units were reimplanted with this technique. A ureteral catheter was inserted in 33 ureteral units and a double J stent was inserted in 20 ureteral units. No patient had reflux in the cystographic control. Cystoscopy demonstrated a nipple-shaped ureteral orifice, which was easily identified in all cases. No stenosis was observed and the placement of a 7 Fr Catheter in the reimplanted ureter was possible. The follow up was performed using ultrasound and CT scan, with a mean follow-up of 36 months (6 to 54 months). 3 patients had a retrograde double-J stent insertion for middle or proximal ureter obstruction due to retroperitoneal lymph nodes metastasis.
Conclusions:
Compared to direct ureteral reimplantation, the ureteral nipple was clearly prominent and visible in the intestinal pouch. The new ureteral orifice was easily catheterized, which suggests the possibility of retrograde endourological manipulations of the ureter.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: We present a video of our preliminary experience concerning the partial nephrectomy with parenchymal clamping by curved aortic clamp.
Materials and methods: Between May 2003 and May 2012, 15 patients (9 men and 6 women) were treated with this technique. The patients had an average age of 56 years-old (35 to 78). The tumors were discovered incidentally in all the patients. 10 tumors were localized in the right kidney and 5 in the left kidney. Preoperative renal function was normal in all the cases. Indication for nephron-sparing surgery was elective in 12 patients, relative in three others and no one was imperative. The average size of the tumor was 5.66 cm (3-10). The location of the tumor was in the upper pole, lower pole and middle portion in 5, 4 and 6 patients, respectively.
Results: The average operative bleeding was 300 ml. The average duration of clamping was 25 min and the mean intervention time was 135 min. The mean hospital stay was 5 days. All the tumors were resected with negative margins. 11 tumors were RCC and 4 were oncocytoma. With a follow-up of 10 to 76 months, there is no evidence of recurrence in 13 patients. One patient presented with pulmonary metastasis after 36 months of follow-up. Another patient had a left nephrectomy for local recurrence after 40 months.
Conclusion: The partial nephrectomy with parenchymal clamping is an attractive, safe, and effective technique in the conservative surgery of the kidney.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: We present our experience with a transurethral transvesical endoscopic approach for the treatment of a retrovesical hydatid cyst. We were encouraged by the conservative management report of pelvic hydatid cysts spontaneous rupture into the bladder, with intravesical instillation of 20% saline to destroy the germinal layer of the hydatid cyst. Spontaneous sealing of the communication was confirmed by cystoscopy.
Material and methods:
A 57 years patient, with a history of a hepatic hydatid cyst operated 7 years ago, presented a retrovesical hydatid cyst. After informed consent, he had received 800 mg daily of albendazole chemotherapy during 3 months prior to operation.
Operative technique: cystoscopy was performed using a 20.8 Fr nephroscope, under spinal anesthesia. The cyst was punctured through the nephroscope operating channel using an 18-gauge needle. A 20 % saline solution was used as a scolicidal agent. After tract balloon dilation, the nephroscope was introduced into the cyst, and the hydatid material was aspirated. Postoperatively, the cystic cavity was treated by instillation of povidone-iodine during 5 days.
Results: the transurethral transvesical endoscopic approach and treatment of a retrovesical hydatid cyst was possible. The patient had an uneventful discharge and had continued albendazole chemotherapy during 3 months. Cystoscopy confirmed a complete healing of the communication between the bladder and the cystic cavity. After 45 months of follow-up with ultrasound and CT scan, the patient is free of symptoms with no evidence of residual or recurrent disease.
Conclusion: This transurethral transvesical approach was effective for the treatment of a retrovesical hydatid cyst with lower morbidity than open surgery, and confirmed that the bladder can be used as a portal to NOTES with no complications.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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M. Lezrek,
H. Tazi,
A. Sadiq,
Kh. Bazine,
M. Asseban,
A. Slimani,
A. Fethi,
M. Bedraoui,
R.A. Zahir,
A. Larbi, E.H. Kasmaoui,
M. Alami,
A. Beddouch
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ABSTRACT: To facilitate the learning and training of percutaneous renal access and intrarenal procedures, many biological models with porcine kidney for percutaneous nephrolithotomy (PCNL) training have been developed. We present a video of a model, much cheaper and easily available, using a latex glove for endoscopic stone manipulations.
Materials and Methods:
The glove opening is closed around an Amplatz sheath of 24 or 30 Fr, using a few ligations. The standard equipment of PCNL, and or ureteroscopy with different stones sizes can be used. Urologist with no PCNL skills and residents were taught needle access, tract dilation, nephroscopy, and stones manipulation.
Results: The glove model closely simulates percutaneous nephroscopy, stone disintegration, and stone removal. The endoscopic exploration of the glove’s fingers is similar to intra-renal exploration. The flexible nephroscope, rigid and flexible ureteroscope can be used to simulate anterograde ureteroscopy. Moreover, stones manipulation in the glove’s palm can simulate bladder lithotripsy, and in a glove’s finger can simulate rigid ureteroscopy. It is a non-biological model so there is a limitation in terms of "tissue feeling" and for anatomic relations. Evaluations submitted by training session participants revealed a high degree of satisfaction with model effectiveness in the application of endoscopic lithotomy techniques.
Conclusions: Our glove model is an effective means of skills acquisition for endourological stone procedure. It provides a low stress environment that provides an opportunity for supervised, repetitive performance of essential technical skills. However, further technical experience and comparative studies with biologic and virtual reality simulators are necessary to evaluate this technique.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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M. Lezrek,
H. Tazi,
A. Sadiq,
Kh. Bazine,
M. Asseban,
A. Slimani,
A. Fhethi,
M. Bedraoui,
R.A. Zahir,
A. Larbi, E.H. Kasmaoui,
M. Alami,
A. Beddouch
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ABSTRACT: To facilitate the learning and training of percutaneous renal surgery, we present a video of a model using a latex glove for percutaneous calyx access.
Materials and Methods:
Two or three foam layers are used to simulate the different abdominal wall layers. A ureteral catheter is inserted in a latex glove. The glove is filled with saline solution and contrast media. The glove is fixed to the foam using medical tapes. The glove is covered by the proximal half of the foam layers. The puncture, guidewire insertion, and small dilation are performed under fluoroscopic guidance. Urologist with no PCNL skills and residents were taught needle access, and the beginning of tract dilation.
Results: The glove model is simple to set up, with a preparation time of about a few minutes and inexpensive by using widely available material. The percutaneous puncture was possible, in all the glove’s fingers. Guidewire insertion and sequential dilation are possible. However, large dilation and Amplatz sheath insertion are difficult, similarly to the dilation of gross hydronephrosis. It is a non-biological model so there is a limitation in terms of "tissue feeling" and for anatomic relations. In addition, ultrasound-imaging guidance cannot be used. Evaluations submitted by training session participants revealed a high degree of satisfaction with model effectiveness in the application of percutaneous renal access techniques.
Conclusions: This glove model is an effective means of skills acquisition for percutaneous calyx puncture. However, further technical experience and comparative studies with biologic and virtual reality simulators are necessary to evaluate this technique.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: We describe a video of our experience in managing complex renal calculi by combining a standard first tract using a nephroscope and a simultaneous second percutaneous tract using a rigid ureteroscope, to remove the residual caliceal stones, which were inaccessible from the existing tract.
Patients and methods:
Between January 2005 and June 2011, data from 30 patients (19 men and 11 women) corresponding to 32 renal units with multiple complex renal stones, which required multiple (≥ 2) access tracts in a single session, were analyzed retrospectively. Patient’s age ranged from 21 to 75 years (mean 38.7). Preoperative evaluation included renal ultrasonography, and intra venous urogram or CT scan. A simultaneous second percutaneous tract using a rigid ureteroscope, in case of: a large stone burden, unavailability of flexible nephroscope or flexible lithotripter.
Operative technique: percutaneous surgery is performed in the split leg modified lateral position. The first tract is achieved with a 24 or 30 Fr Amplatz sheath, using a 20.8 Fr nephroscope. When another percutaneous tract is necessary, a second caliceal puncture is performed. Dilation to 10 or 12 Fr and insertion of a safety guidewire are mostly performed under endoscopic control without radiation exposure. The rigid ureteroscope (6 or 8 Fr) is introduced over a guidewire under direct vision. Then, it is used to mobilize stones from the calyx to the renal pelvis. Stone fragmentation and extraction is performed via the first tract by the nephroscope, simultaneously if possible, or alternately. At the end of the procedure a 20 Fr Foley catheter and an 8 Fr drain tube are respectively inserted in the first and second tract.
Results: A second or third mini tract, using the rigid ureteroscope, was possible in all patients. A total of 67 percutaneous access tracts were realized. 28, 23, and 16 tracts were respectively through the upper, middle and lower calyx. The mean operating time was 125 min (extreme 85 -192 min). The number of access was 2 in 29 renal units, and 3 in 3 renal units. The average decrease in serum hemoglobin was 2.7 ± 0.9 g/dl. The mean hospital stay was 4.5 days (3 - 6 days). A single-stage PCNL resulted in complete clearance in 27 renal units (84%). No transfusion was required. 4 patients had a postoperative fever of more than 38.51 C°, were treated by antibiotic therapy. 1 patient with 3 accesses a perirenal collection that resolved spontaneously.
Conclusion: A second or third mini tract, using the rigid ureteroscope, was possible and safe. It is another application for the rigid ureteroscope, already available in every endourology operating room, so there is no need for new equipment (mini-nephroscope). In addition, this mini second tract might provide less morbidity than a standard second tract. Also, it might avoid the need for a second look, and the need for flexible instruments (baskets, flexible lithotripter...), which are more expensive.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: percutaneous endopyeloplasty is a horizontal suturing of the endopyelotomy incision, via a sole percutaneous tract. We evaluate the feasibility and efficacy of percutaneous endopyeloplasty using a conventional suture with a laparoscopic needle holder via the nephroscope, without patients’ selection.
Materials and Methods:
Since January 2007, 15 patients, 10 men and 5 women, with ureteropelvic junction obstruction (UPJO), were operated by percutaneous endopyeloplasty. Technique: a longitudinal endopyelotomy incision is performed, through a 24 Fr working sheath percutanous access via an upper calyx. Then, an initial suture is placed, approximating the incision distal and proximal apex, using a conventional absorbable 13 mm needle suture with a lengthened 3.5 mm pediatric laparoscopic needle holder, via the nephroscope. An additional 2 sutures are subsequently placed, 1 on either side of the initial midline suture, to achieve a full-thickness horizontal endopyelotomy incision suturing and a wider caliber of the UPJ.
Results: The patients mean age was 33.4 ± 9.5 years. All patients were assessed by IVP, but one with a poor renal function. 12/16 (75%) hydronephrosis were grade 3 or 4. 3 UPJO were secondary. 6 patients had a higher UPJ insertion. CT scan demonstrated a crossing vessel in a horseshoe kidney patient, no assessment for a Crossing vessel was performed for the other patients. Percutaneous endopyeloplasty was possible in all patients. 16 endopyeloplasty were performed, 9 right, 5 left and 1 bilateral. The mean operative time was 130 ± 40 minutes including an endopyeloplasty suturing time of 65 ± 30 minutes. 2.5 endopyeloplasty sutures per renal unit were placed. One patient presented a lumbar saline irrigant extravasation that resorbed spontaneously in 24 hours without complication. The mean hospital stay was 4.5 ± 2.8 days and the 8/12 Fr double-J stent was removed in 5.4 ± 2.5 weeks. At a mean follow up of 10.8 (4 to 34) months, all operated kidneys showed relief of obstruction, as confirmed by clinical improvement in symptoms and improved renal drainage on excretory urography in 14 patients, and in non-contrast CT scan in a patient with bilateral UPJO and poor renal function.
Conclusions: Percutaneous endopyeloplasty, using a conventional suture with a pediatric laparoscopic needle holder via a nephroscope, is technically feasible, safe, and effective. However, this technique needs good endourological skills to perform the whole suture with only one instrument. In addition, the operative time is still too long. Thus, further technical experience and longer follow-up are necessary to evaluate this technique.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
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ABSTRACT: Classically, the direct percutaneous puncture of hydatid cyst was prohibited because of the risk of dissemination. Recently, direct puncture has been reported with injection of scolicidal agent in order to kill the cyst without hydatid evacuation.
In order to avoid the risk of hydatid dissemination, we present a video of our experience with a percutaneous endoscopic indirect approach to renal hydatid cyst with sterilization, evacuation of the hydatid material, and sclerosis of the cystic cavity.
Material and methods:
Since January 2007, 4 patients (2 men and 2 women) presenting renal hydatid cyst were operated by a percutaneous endoscopic approach. The mean age was 36 years (13 to 68). The mean cyst diameter was 15 cm. One cyst has a fistula with the pelvi-caliceal system. After informed consent, all the patients had received 800 mg daily of albendazole chemotherapy during 3 months prior to operation.
The patients are placed in the lateral modified position under general anesthesia. After renal opacification, a percutaneous tract, with a 24 Fr Amplatz sheath, is performed through a calyx opposed to the cyst; upper calyx for lower pole cyst and lower calyx for upper pole cyst. Nephroscopy locate the cyst bulge in the caliceal lumen, which is punctured through the nephroscope operating channel using an 18-gauge needle. A 20 % saline solution is used as a scolicidal agent. After tract balloon dilation, the nephroscope is introduced into the cyst, and the hydatid material is aspirated. Then the cystic cavity is filled with contrast media and a drain is inserted through another direct percutaneous access. A nephrostomy tube is inserted in the renal pelvis. Postoperatively, the cystic cavity was treated by instillation of povidone-iodine, after nephrostography documented sealing of the communication between calyx and cystic cavity.
Results: the percutaneous endoscopic approach and treatment of renal hydatid cysts was possible with a mean operative time of 120 min. The patients had an uneventful discharge and had continued albendazole chemotherapy during 3 months. Nephrostography had documented the sealing of the communication between the calyx and the cystic cavity after 4 days in 3 patients, and after 15 days in the patient presenting the fistula between the cyst and the upper calyx. After a mean follow-up of 33 months (25 to 41) with ultrasound and CT scan, the patients are free of symptoms with no evidence of residual or recurrent disease, with a retracted calcified residual cystic cavity.
Conclusion: percutaneous endoscopic approach was effective for the treatment of renal hydatid cysts with lower morbidity than open surgery. We think that via this approach, with the protection of the pelvicalyceal system, Amplatz sheath and saline irrigation, there is less risk of dissemination of hydatid materiel in the retro-peritoneum than with the direct percutaneous access, but only large comparative series will tell.
24th World Congress on Videourology, Casablanca - Morocco, April 11 to 13, 2013.; 04/2013
