Urology Annals
About UA | Search | Ahead of print | Current Issue | Archives | Instructions | Online submissionLogin 
Urology Annals
  Editorial Board | Subscribe | Advertise | Contact
Users Online: 165   Home Print this page  Email this page Small font size Default font size Increase font size


 
Table of Contents
ABSTRACT
Year : 2015  |  Volume : 7  |  Issue : 7  |  Page : 134-175  

Lap-Robotics


Date of Web Publication13-Oct-2015

Correspondence Address:
Login to access the Email id


Rights and Permissions

How to cite this article:
. Lap-Robotics. Urol Ann 2015;7, Suppl S3:134-75

How to cite this URL:
. Lap-Robotics. Urol Ann [serial online] 2015 [cited 2020 Sep 19];7, Suppl S3:134-75. Available from: http://www.urologyannals.com/text.asp?2015/7/7/134/167236

Future of laparoscopy in urology

James F. Donovan


Department of Urology, The Iowa State University Hospitals and Clinics, Iowa City, USA

Since 1987, the addition of laparoscopy to the art and craft of general surgery has revolutionized the practice of general surgery and the surgical subspecialities. Examining the course of laparoscopy in general surgery may give some clue to the future role of laparoscopy in the urologic discipline.

The first procedure beyond diagnostic laparoscopy to be accepted in general surgery was cholecystectomy, a delicate but nevertheless extirpative procedure which could be performed with rudimentary instruments (scissors, dissector, blunt retractor, and hemoclip). Next was appendectomy, a procedure relatively uncomplicated in its concept which required instruments appropriate to stump ligation. Thus, the development of the endo-loop ligature made this procedure routine. More recently, the applications of laparoscopy have included reconstructive surgery, including bowel resection with intestinal re-anastomosis, gastric fundoplication, inguinal hernia repair and common duct exploration. Applications in the thoracic cavity are in the beginning stages. These more challenging procedures are possible due to continued advances in surgical instruments designed especially for the laparoscope: Linear stapling devices, suture equipment, hernia staplers. With each advance in equipment design, these once seemingly impossible laparoscopic applications have become accessible to the practicing surgeon.

In urology, laparoscopic application have followed a similar course beginning with pelvic lymph node dissection and varix ligation. Subsequently, other more complex procedures were added such as nephrectomy, renal cyst marsupialization and excision or marsupialization of lymphocele. laparoscopy in urology is currently in an accelerated phase of development. In addition to expanding the indications for laparoscopy in extirpative surgery (nephroureterectomy, adrenalectomy, bladder diverticulectomy, partial nephrectomy, retroperitoneal lymph node dissection), development of reconstructive procedures is under active investigation including ureteral reimplant, radical prostatectomy with urethrocystostomy, bladder neck suspension and ileal conduit. The limiting actor is not the imagination of the urologic laparoscopist but rather the tools necessary to the successful completion of each new and more challenging operative laparoscopic endeavor.

Julius Caesar said, "If it is possible, it has been done, if it is impossible, it will be done." Seemingly "impossible" procedures will be successfully performed laparoscopically. More importantly, we must exercise restraint and apply technology to procedures which are appropriate as well as possible.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Laparoscopy in urologic surgery with emphasis on varicocele repair

M.F. Milad, F. Ayyat


Surgical Services Division, Dhahran Health Centre, Saudi Aramco, Dhahran, Saudi Arabia

Between June 1991 and February 1993, sixty cases of laparoscopic surgery were performed for urology patients in Dhahran Health Centre. Twenty patients were done for varicocele repair, eighteen patients for undescended testis, two patients for staging prostate carcinoma, and twenty patients for diagnostic purposes only.

Analysis of the results of the surgery for varicocele repair has been made, thirteen cases had bilateral, and seven cases had unilateral disease making a total of thirty three units of varicocele repaired. Thirteen cases were done for primary infertility, two cases for secondary degree sterility and five cases for pain only.

Results were improvement in sperm count and motility in eight cases, in motility only five cases, and no change in two cases. One patient already fathered one child, and one patient's wife is currently pregnant. The cases done for pain have all improved. Details of the patients will be outlined.

It is concluded from this study that laparoscopy has an important role in the management of patients with varicoceles.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Laparoscopic urologic surgery review at Dhahran Health Center

Tawfik Zein, Moheb Milad, Faris Ayyat, Mohammed Al Jishi, Sayed Hussein, Luay Hajjar, Hisham Soliman, Grannum Sant


Dhahran Health Center, Saudi Arabia, Department of Urology, Tufts University School of Medicine, Boston, USA

A retrospective review of all cases of laparoscopic urologic surgery was conducted at DHC between February 1993 and June 1995. The total number of cases were 135. The distribution of these cases showed the following:

Varicose repair: 94 patients, undescended testicle: 34 patients, bilateral pelvic lymp node dissection: 6 patients, and congenital urachal cyst: 1 patient.

The cases of infertility that had varicocele repair showed 63% improvement in sperm count and 60% increase in sperm mortality. Laparoscopic surgery for undescended testes was successful in making the diagnosis, assisted in the surgical incision and saved some patients exploratory surgery due to absent testis. Laparoscopy for pelvic lymph node dissection was successful in staging of bladder and prostatic carcinoma. One patient with congenital urachal cyst had complete excision of the cyst via laparoscopy.

Laparoscopic surgery in urology is a safe procedure, once the learning curve has been achieved. Patients have decreased hospital stay, less postoperative need for analgesics and early return to normal activity.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Laparoscopic excision of simple renal cyst

S.A. Orkubi


Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

Since 1995, we performed 5 cases of laparoscopic excision of simple renal cysts. In all cases, we exclude malignant, hydatid or infected cysts through clinical, radiological and serological measures.

The patient was laid on the semi-lateral position. It needed four ports including the paraumbilical camera port.

Abdominal drain was left for one day. No operative or postoperative complications recorded. Patient recovery and hospital stay was quick and short.

Follow up with ultrasound showed normal findings with no cyst recurrence.

This 10 minute video film explains the procedures in four stages:

  • Peritoneal window
  • Opening of the perirenal fascia
  • Aspiration of the cyst content
  • Delivery of the cyst to the abdominal cavity and excision.


Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Laparoscopic ligation of varicocele

S.R. Koneru, Z.H. Al Shareef


Department of Surgery, North-West Armed Forces Hospital, Tabuk, Saudi Arabia

Although the urologist is familiar with the endoscopic surgery, laparoscopy in urology is a new phenomenon. Having gained experience in performing over 150 laparoscopic cholecystectomies in our surgical unit we have been carrying out laparoscopic ligation of internal spermatic veins corresponding to high ligation by open method since December 1991. So far, we have performed 15 such procedures. The varicoceles varied between grade II and grade III. All the patients have been symptomatic with painful swelling. One of them also had oligospermia. Immediate and short follow up results are impressive. The other advantages of such less invasive procedures are (a) Less post-operative pain, (b) early ambulation, (c) early discharge from hospital improving the bed utilization, (d) early return to work and (e) cosmesis. The magnification used in the endoscopic procedure is also useful in preserving the artery and in identifying multiple veins in all cases in our present series.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Laparoscopic varicocelectomy: Early experience

A. Jamal, A. Wassia


Department of Surgery, King Khalid National Guard Hospital, Jeddah, Saudi Arabia

Laparoscopic surgery has become popular for diagnostic and therapeutic purposes in Urology. Here, we report our early ongoing experience in this field.

Since May 1992, laparoscopic varix ligation was performed on 5 patients of average age of 25 years. Four procedures have been left-sided while one case was bilateral. Average operating time under general anaesthesia has been 85 minutes (range 6-105 minutes).

Apart from one case of intra-operative pneumo-scrotum, no other complications were observed.

Hospital stay was reduced to 3 days. Reduced analgesia requirement consisted of oral mefaminic acid only.

Despite early hesitation, our very early ongoing experience confirms that laparoscopic varicocelectomy is effective in treating clinical varicocele and is minimally invasive and is superior to open surgery.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Laparoscopic varicocele ligation

M. Abozeid, W. Yousry, A. Ashy


Department of Urology and Surgery, Al Salama Hospital, Jeddah, Saudi Arabia

Laparoscopic surgery is now an established alternative to some of the classic open surgery. Varicocele ligation is one of the surgical procedures which could be done via laparoscopy with the same efficiency as open surgery. A total of twenty patients underwent 24 varicocele ligation was included in this study, 18 patients for infertility and two for left testicular pain. Preservation of testicular artery was easier by laparoscopic technique than conventional surgery because of the optical magnification offered by the laparoscope. The technique is simple and effective especially in obese patient with bilateral varicocele.

The procedure was done as one day surgery. All patient returned back to their routine daily activities within 4 to 7 days. Three months post operatively, all patients were examined for varicocele recurrence and for semen changes. Residual varicocele was seen in 3 patients. Significant improvement in sperm count (>15 million/ml) and sperm motility (>40% motile) was seen in 7 patients out of 18.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Incidence and pattern of recurrence of varicocele after laparoscopic ligation of the internal spermatic vein with preservation of the testicular artery

Said Kattan


Department of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Laparoscopic internal spermatic vein ligation had been suggested to offer a simple, less invasive better tolerated method for varicocele ligation than conventional techniques, however, the recurrence rate after that procedure is not yet defined. In order to assess the full potential of laparoscopic ligation as a therapeutic tool, a prospective study was designed to determine the incidence and pattern of recurrence of varicocele after laparoscopic internal spermatic vein ligation with testicular artery preservation. Sixteen patients age (17-44 years) who had underwent 20 laparoscopic varix ligation were evaluated post-operatively for recurrence clinically and by percutaneous spermatic venogram. No serious complications were encountered with the surgical or radiological procedures. Clinical recurrence was detected in 20% of cases, while spermatic venogram, detected recurrence in 45% of cases, the sensitivity and specificity of clinical physical examination for detecting varicocele recurrence was 33.3% and 90.9%, respectively with an accuracy rate of 65%. Recurrence was through parallel collateral's or medial transverse collateral's in 88.8% and 11.2%, respectively. Parallel collateral's joined the spermatic vein in the mid retroperitonium in 7 patients while it joined the renal vein in 1 patient. Laparoscopic ligation of internal spermatic vein with preservation of testicular artery is a procedure that is associated with low morbidity and quick recovery, however, is able to achieve its surgical objective in only 55% of cases. Such information should be taken in consideration during patient counselling to select the operative technique of choice for varicocele ligation. The possible causes for such high recurrence rate is discussed with comparison with other treatment modalities. Furthermore, detection of varicocele recurrence should not rely solely on clinical examination and more precise method such as Doppler ultrasound examination or spermatic venogram should be utilised.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital, Jeddah

14-16 November 1995

Laparoscopic varicocele ligation

Khaled Al Hamid, S. Memon


Department of Urology, King Fahad Specialist Hospital, Buraydah, Saudi Arabia

The Laparoscopic approach to ligation of a varicocele offers the advantages of safety, accuracy and minimal morbidity. We report our initial experience of Laparoscopic Ligation of Varicocele in 15 patients with age ranging between 19-47 years. Eight patients were sub-fertile and (7) patients complaint of dragging pain and discomfort in the left scrotum. At laparoscopy the peritoneum overlying the spermatic vessels was divided, and the spermatic veins were mobilised, clipped and divided.

The spermatic artery was preserved in 12 of 15 cases. The patients were discharged within 48 hours of hospital admission. None of the patients had intra or postoperative complication. One of the cases was converted to open varicocelectomy because of adhesions. Laparoscopic Varicocelectomy is a safe, effective minimally invasive procedure for treatment of clinical varicocele causing minimal morbidity and enabling a rapid to normal activity.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital, Jeddah

14-16 November 1995

Laparoscopy for the impalpable testes: Does it have a place?

M. Milad


Saudi Aramco Surgical Services Division (Urology), Dhahran Health Center, Dhahran, Saudi Arabia

Twenty-three patients with impalpable testes underwent diagnostic laparoscopy in DHC between 1988 and 1991, in an attempt to evaluate this modality of investigation. Four of them had bilateral undescended, ie total of 27 testes, 12 on the right side and 15 on the left. Eight patients were adults, age between 23 and 38, average 30 years, fifteen were children age between 1 and 9, average 5 years. Twenty testes were intraperitoneal (74%), six intracanalicular (22.2%), and one absent (3.8%). Twelve testes were pexed, four of them staged, twelve testes were removed and three were diagnostic only. No operative or postoperative morbidity. Laparoscopy was diagnostic in all cases, assisted in planning the surgical procedure in 21 testes and saved 1 patient the surgical incision. Laparoscopy is a safe procedure, has a definite role in the management of impalpable testes, for diagnosis and planning of surgery. Future prospects of operative laparoscopy need to be developed and evaluated.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Laparoscopic orchiectomy for intraabdominal testes

I. Al Oraifi, M.Y. Ezzibdeh, A. Al Dayel, S. Egail


Department of Urology, King Fahad Military Medical Complex, Dhahran, Saudi Arabia

Laparoscopic surgery is becoming popular in treating intraperitoneal organs replacing conventional open surgery. Laparoscopy was performed in three patients ages 19, 24 and 27 years with unilateral non-palpable testes. Standard laparoscopic techniques used to create a pneumoperitoneum and insert operating scope and instrument parts. At laparoscopy, the gonadal vessels identified lateral to the iliac vessels and the vas deference identified as it ascends from behind the bladder. The testes found just proximal to the internal ring in all patients. Laparoscopic orchiectomy performed with no complications.

We believe that laparoscopy is useful in the management of non-palpable undescended testes and laparoscopic orchiectomy is less invasive than open surgery.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Laparoscopic orchidectomy for intra-abdominal undescended testis

T.W. Callaway


Department of Surgery, Division of Urology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia

Laparoscopy has been shown to be a useful diagnostic technique for localization of the impalpable undescended testis. Accurate determination of the presence of the cryptorchid and its precise localization allow the surgeon to plan the surgical approach. In some cases, laparoscopy may preclude surgical exploration. Technological improvement and the development of laparoscopic surgical expertise provide the opportunity to extend the spectrum of laparoscopy from purely diagnostic interest to surgical intervention. Orchidectomy may be indicated in the post-pubertal cryptorchid patient. A case of a 28 year old male with an impalpable left undescended testis is presented. The cryptorchid was identified and removed laparoscopically. The post-operative course was uncomplicated and the patient returned to full activity in three days. This case as presented demonstrates an effective method of laparoscopic intra-abdominal orchidectomy in the post-pubertal patient.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Laparoscopy assisted orchidopexy

Z. H. Al Shareef, S. R. Koneru


Department of Urology, The North West Armed Forces Hospital, Tabuk, Saudi Arabia

Introduction and Aim of Study: Laparoscopy is the most reliable investigation for localizing impalpable undescended testes. Laparoscopy has also been used to carry out orchidectomy when such testes are deemed unsuitable for effecting orchidopexy. However, laparoscopy assisted orchidopexy has not been reported so far. The method was used to study the benefit of laparoscopic mobilisation of vas deferens as well as the spermatic vessels in performing the orchidopexies and without using either open inguinal or abdominal exploration.

Materials and Methods - Materials: Between December 92 and August 93 six patients presented with unilateral impalpable undescended testes (age range 3-12 years). After clinical confirmation of the diagnosis all patients had preoperative ultrasound and MRI examination. Methods: Under general anaesthetic once the presence of testis was confirmed at laparoscopy, the vas deferens as well as the spermatic vessels were fully mobilized up to the main blood vessels. The testis was secured in the scrotum after transpositioning the spermatic cord medial to the inferior epigastric vessels. Open inguinal exploration was not performed.

Results: Both ultrasound and MRI localized testes in 3 out of 6 cases. However, at laparoscopy the testes were localized in the pelvis close to the internal ring in 4 out of 6 cases. In this group the mobilisation of the vas deferens and spermatic vessels was satisfactory by the laparoscopic method alone. The testes were secured in the scrotum. In the remaining two cases the testes were absent.

Conclusion: Laparoscopy assisted orchidopexy not only achieved the surgical objective, it also avoided Laparotomy - a relatively major undertaking in a small child.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Laparoscopic transperitoneal marsupialization of lymphocele after kidney transplant

Z. Al Shareef, I. Ahmad, A. Al Harbi, M. Zakaria, A. Mohammed, S. Al Shlash


Department of Urology, North West Armed Forces Hospital, Tabuk, Saudi Arabia

Introduction: Post-kidney transplant - Lymphocele are not uncommon. Symptomatic lymphoceles require surgical marsupialization with internal drainage or percutaneous drainage. However, laparoscopic drainage is as effective with only minimal trauma.

Methods: We performed three laparoscopic lymphocele drainage into peritoneal cavity during a one-year period. Three ports were used, one 10 mm for laparoscope through umbilicus and two 5 mm in each flank. Often a shining dome of the lymphocele bulges into the peritoneal cavity, which can be identified by inserting percutaneous needle into the lymphocele. In one case, we instilled Methylene blue into lymphocele under ultrasound, which outlined the bluish shine of the lymphocele clearly. We did not use ultrasound operatively to identify the lymphocele or surrounding structures.

Result: Laparoscopic lymphocele drainage was successful in all three cases. A conversion to open laparotomy was not necessary in these cases. Laparoscopic drainage shortens the median hospital stay by 4 days less than open surgical drainage. Post-drainage had no complications or recurrence in these cases.

Conclusion: Symptomatic lymphoceles can be drained laparoscopically. Laparoscopic drainage is easy, safe and effective with minimal morbidity. It reduces the time of hospitalization and is cost-effective.

Presented at the: 12 th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospitals Program

23-25 February 1999 (7-9 Dhu Al Qa'dah 1419)

Advanced laparoscopy in urology: Our experience with 25 patients in Saudi Aramco

K. Al Otaibi, F. Ayyat, M. Milad, A. Alaudine, A. Elswais, T. Zein, M. Aljishi, K. Altaheni


Surgical Services Division, Saudi Aramco, Dhahran Health Center, Dhahran, Saudi Arabia

Purpose: We assessed the feasibility of advanced laparoscopy in our Urology Section in Saudi Aramco.

Materials and Methods: A total of 25 patients underwent advanced laparoscopic surgery in our institution. 8 patients had laparoscopic transperitoneal nephrectomy, 3 patients had laparoscopic adrenalectomy, 10 patients had laparoscopic pelvic lymphadenectomy, 3 patients had laparoscopic renal cyst and 1 patient underwent laparoscopic lymphocele marsupialization.

Results: All except 3 cases had a successful laparoscopic procedure. The average operative time for laparoscopic nephrectomy was 3 hours and 35 minutes, for laparoscopic adrenalectomy was 3 hours and 10 minutes, for laparoscopic pelvic lymphadenectomy was 3 hours and laparoscopic renal cyst marsupialization was 1 hour and 17 minutes. The average hospital stay was 3.3, 4.4, 3 and 1.2 days respectively.

Conclusions: Advanced laparoscopy in Urology is safe and feasible. Patient selection is necessary. There is always a learning curve for the Urological Laparoscopy.

Presented at the: 13 th Saudi Urological Conference

Riyadh Armed Forces Hospital

14-17 February 2000 (09-12 Dhu Al Qa'dah 1420)

Laparoscopic adrenalectomy

F.M. Ayyat, A. El-Suwais


Surgical Services Division, Saudi Aramco, Dhahran Health Center, Dhahran, Saudi Arabia

Introduction: Laparoscopic surgery has recently received widespread acceptance and application.

Methods and Materials: Intraperitoneal laparoscopic adrenalectomy is a rare procedure, done for limited reasons mainly adenomas of adrenals and selected cases of pheochromocytoma.

The videotape describes the tract's size and sites, the colon reflection and mainly the hepatic and splenic flexures. Exploration of the adrenal vein is illustrated on the left side.

Conclusion: Laparoscopic adrenalectomy is a feasible approach for adrenal tumors.

Presented at the: 13 th Saudi Urological Conference

Riyadh Armed Forces Hospital

14-17 February 2000 (09-12 Dhu Al Qa'dah 1420)

Laparoscopic radical nephrectomy for renal cell carcinoma: The world experience

H. Al Zahrani, G. Janetschek


Department of Urology, KH der Elisabethonen, Linz, Austria

Introduction and Objective: Laparoscopy is the new addition of minimally invasive techniques to urology. It was initially viewed with cautions as a treatment modality of urological cancer. However, it appears these concerns were not based on true scientific basis, and laparoscopy is gaining popularity worldwide. The objective of this study is to review the reported experience with laparoscopic radical nephrectomy for renal cell carcinoma in terms of perioperative indices and cancer control.

Materials and Methods: A Medline search was made from January 1990 till March 2002 using the key words: laparoscopy, radical nephrectomy and renal cell carcinoma. All series reported in peer-reviewed journals were reviewed. Reports were examined for operative data, complications, hospital stay and convalescence. Cancer control was examined for port site recurrence, local recurrence, distant metastasis and survival.

Results: More than 500 cases of laparoscopic radical nephrectomy for RCC have been reported in peer-reviewed journals worldwide. The average operating time was 3.6 hours (2.4-5.5), blood loss 189cc (100-189), minor complications of 11.2% (3-34%), major complications of 5.6% (3-10%) and conversion rate to surgery of 3.1% (0-8%). The average hospital stay was 4 days (1.6-6), and mean time to normal activity was 3.6 weeks (3.3-4). Cancer control data reported no positive margins, 2 cases of port site recurrence, 3 cases of local recurrence and 10 cases of distant metastasis. With the longest median follow up of 54 months the 5-year recurrence-free survival was 92% and the 5 years cancer specific survival was 98%, both similar to a cohort of open radical nephrectomy.

Conclusion: The world experience shows that laparoscopic radical nephrectomy for RCC is feasible, safe, less morbid to the patient with shorter hospital stay and time to normal activity. The cancer control of this approach is similar to the standard open radical nephrectomy. Laparoscopic radical nephrectomy should be the new standard of care for localized renal cell carcinoma.

Presented at the: 15 th Saudi Urological Conference

King Fahd Hospital, Madinah Al Munawarah

7-9 May 2002 (24-26 Safar 1423)

Cost comparison of laparoscopic versus open retroperitoneal lymphadenectomy for testis cancer

H. Al Zahrani, G. Vrabec, C. Leeb, G. Janetschek


Department of Urology, University Innsbruck, Austria

Objective: To compare the direct and indirect total cost of laparoscopic (lap.) vs open retroperitoneal lymphadenectomy (RPLA) for clinical stage I testis cancer in Austria.

Materials and Methods: A comprehensive cost analysis was performed on a series of 20 lap. RPLA and 30 open cases done in the same institution for the same indication. To avoid the impact of the learning curve, the lap. Series consisted of the last 20 cases where operating time matched that of the open series. The direct costs included: Operating room running cost, cost of instruments (reusable and disposable), cost of staff, diagnostic tests, medications, and hospitalization. The indirect cost was calculated by the loss of productivity during the days off work.

Results: The mean operating time (lap. 245 min, open 250 min) and anesthetic time (360 min. each) were similar. Lap. RPLA had higher total operating room expenditure mainly due to the cost of disposable instruments (P = 0.013). However, lap. RPLA had a significantly lower cost outside the operating room due to a shorter hospital stay (P = 0.003) and less cost of medications (P < 0.001). The total hospital cost of the approaches was similar (p = 076). The indirect cost from loss of productivity was significantly lower for lap. RPLA (P < 0.001).

Conclusion: In advanced laparoscopic centers where operating time of lap. RPLA matches the open technique the direct cost to the health system is similar. Despite shorter hospital stay and less use of medication in the lap. group, using disposable instruments was the equalizing factor in our analysis. However, lap. RPLA is more cost effective to the society in Austria.

Presented at the: 15 th Saudi Urological Conference

King Fahd Hospital, Madinah Al Munawarah

7-9 May 2002 (24-26 Safar 1423)

Advanced laproscopic nepherectomy in children in Saudi Aramco Medical Service Orgnazation

K. Al Otabi, T. Al Essawi


Dharan Health Center, Saudi Aramco, Dhahran, Saudi Arabia

Purpose: We assessed the feasibility of advanced laparoscopic nephrectomy in pediatric age.

Materials and Methods: A total of 22 patients underwent advanced laparoscopic nephrectomy in our medical institution. There were 6 children between 3 and 13 years old (mean age 7.6 years).

Results: All pediatric cases underwent advanced laparoscopic nephrectomy were successful. The average operative time was 2 hours and 40 minutes. The average hospital stay was 3.2 days.

Conclusions: Advanced laparoscopic nephrectomy in children is safe feasible.

Presented at the: 15 th Saudi Urological Conference

King Fahd Hospital, Madinah Al Munawarah

7-9 May 2002 (24-26 Safar 1423)

Laparoscopic adrenalectomy, the difference between the right and left side

Faris M. Ayyat


Dhahran Health Center, Saudi Aramco, Dhahran, Saudi Arabia

Introduction: Laparoscopic adrenalectomy is evolving as the future standard procedure for the removal of adrenal glands. Its main advantages over the standard open surgery is a short hospital stay, a shorter recovery, less intra-operative blood loss, and less post-operative pain with a smaller scar.

Anatomic Variations: The left adrenal gland is in more contact with the upper pole of the left kidney and more superficial than the right gland. Its vein ends directly into the left renal vein, which is longer than the right adrenal vein. Caution should be made to the tail of the pancreas and the splenic vessels. The spleen should be retracted cephalad. The right adrenal gland lies above the kidney and posterior-lateral to the inferior vena cava (IVC). It is an immediate contact with the liver, which should be gently retracted cephalad to expose it. Exposure of the IVC just above the right renal vein and a search of the right adrenal vein should be made on the posterior-lateral aspect of the IVC. It is usually short and fragile and may cause considerable bleeding if divided.

Recommendations: A free sponge in the peritoneum is helpful in dissection and cleaning the operative site. An incision of the posterior peritoneum should extend laterally to each kidney and between the upper pole of the left kidney and the spleen. On the right side, the incision should extend all the way between the kidney and the liver to the IVC. A team of urologists should be developed in each institution to perform laparoscopic surgery. A learning curve is acceptable as is turning the procedure into an open one when necessary.

This will be illustrated by a ten minute videotape.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Laparoscopic right adrenalectomy and laparoscopic bilateral adrenalectomy in 12 year old boy (Video Presentation)

Khalid M. Al Otaibi


Urology Unit, Saudi Aramco Medical Services Organization, Saudi Aramco, Saudi Arabia

We present 15 minutes video clip consist of two parts.

Part One: Laparoscopic right adrenalectomy for 5 cm adrenal mass in adult patient.

Part Two: Laparoscopic bilateral adrenalectomy in 12-year-old boy with bilateral adrenal hyperplasia.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Laparoscopic adrenalectomy for adrenal pheochromocytoma

A.M. Shoma, I. Eraky, H. El Kappany


Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Introduction and Objective: Currently laparoscopic adrenalectomy is considered the standard management for adrenal masses of 5 cm or less in their largest diameter. Nevertheless, laparoscopic excision of pheochromocytoma represents a challenge. Repeated attaches of hypertension might be encountered during the procedure, which increase the risk of intraoperative morbidity. A vido film is provided to show the technique of adrenalectomy for pheochromocytoma. The adrenal vein is early identified and clipped before any attempt at dissection of the adrenal gland.

Patients and Methods: A 25 years old female patient with right adrenal mass (4 cm in its largest diameter) was diagnosed as a pheochromocytoma. The patient was placed in a lumbar postion. The procedure was performed through transperitoneal approach using 4 ports. The ascending colon and the duodenum were reflected medially. Inferior vena cava was identified and dissected upward till identification of the adrenal vein that was clipped before dissection of the adrenal mass. Then the mass itself was dissected from the surrounding and extracted via the site of 12-mm port.

Results: Sixteen patients with adrenal pheochromocytoma were performed using the same technique. Conversion to open surgery was not required in any. Mean operative time was 98 minutes. Hospital stay ranged from 3 to 4 days. There were no reported major complications.

Conclusions: Laparoscopic adrenalectomy is a good and viable option for management of adrenal pheochromocytoma.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic adrenalectomy: State-of-the-art

Hamdy El Kappany


Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Introduction: Since the first report on laparoscopic adrenalectomy in 1992 by Gagner and coworkers, different laparoscopic approaches have been introduced for adrenalectomy. The transperitoneal approach was used first and is still the most popular. Then retroperitoneal approach was developed. Currently, laparoscopic adrenalectomy is the gold standard for the treatment of most of the adrenal tumors because it avoids the high morbidity of open procedures.

This lecture will focus on description of all laparoscopic techniques used in adrenalectomy as transperitoneal with reflection of the colon, transmesocoli, posterior and lateral retroperitoneal approaches. The difference between dissection and control of the adrenal vein of the right and left glands will be discussed. Finally, recent advantages such as thoracoscopic transdiaphragmatic, needlescopic, robotic, partial and outpatient adrenalectomy will be mentioned.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Open versus laparoscopic live-donor nephrectomy: Growing concerns about safety of donors and efficacy of grafts

Ahmed A. Shokeir


Department of Urology, Urology and Nephrology Center, Mansoura University, Renal Transplantation Unit, Mansoura, Egypt

A thorough research of the existing literature showed that the subject of laparoscopic live-donor nephrectomy (LLDN) is a seat of under-reporting and under-estimation of complications. The aim of this review is to provide a systematic comparison between LLDN and open live-donor nephrecotmy (OLDN).

Literature database were searched from inception to February 2005. A comparison was made between LLDN and OLDN regarding safety of the donor and efficacy of thegraft.

Nine donor deaths were recorded after LLDN. For OLDN, by 1974, 5 donor deaths have occurred in the early postoperative period. Since 1975, no perioperative mortalities have been recorded following OLDN. No graft losses due to technical problems were reported following OLDN. On the other hand, at least 15 graft losses due to technical problems following LLDN were recorded. Gastrointestinal complications and thrombotic problems were more often with LLDN, while pulmonary complications and thrombotic problems were more common with OLDN. Wound problems were recorded both for LLDN and OLDN. Operative time for LLDN was longer than for OLDN. Postoperative course, hospital stay, times to ambulation and return to work were in favor of LLDN. Although warm ischemia time was significantly longer for LLDN, both LLDN and OLDN showed comparable graft function on short-term follow up. Nevertheless, the effects of ischemia on the long-term outcome of LLDN recipients are not known. Ureteral complications, rejection episodes as well as graft and patient survival were equal for both techniques.

We are in need for a live-organ donor registry to know th combined experience of complications and long-term outcome rather than short-term reports from a single institution. LLDN, like all other new techniques should be developed and improved at a few centers of excellence to avoid loss of a donor or loss of a graft.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic donor nephrectomy should be done as a routine

Raja B. Khauli


Division of Urology, American University of Beirut Medical Center, Renal Transplantation Unit, University of Massachusetts Medical Center, Arab Urological Association, Beirut, Lebanon

The most serious single issue facing transplantation today is the ever-growing number of patients on chronic dialysis awaiting transplantation. The widening disparity between the numbers of patients awaiting transplantation versus those actually receiving them can only be solved by increasing the live donor kidney pool because other exhaustive measures, including the use of suboptimal cadaveric donors, have failed to increase the number of transplants. Following the introduction of laparoscopic donor nephrectomy (Lap Nx) programs at established transplant centers, there has been a documented 40% to 60% increase in the number of donations in two series.

Several explanations could be given that may have obviated Lap Nx from being labled as "the standard" that it deserves:

  • The learning curve is very steep and demands a Multidisciplinary approach to surgery that has been classically performed by a single specialty (transplantation surgery or urology)
  • Any graft insult as a result of Lap Nx is difficult to tolerate because the open approach has been well established over the past four decades with almost no, or perhaps minimal, graft compromise
  • Classically, transplant surgeons may have focused on recipient and graft outcome more than that of the donor, whose outcome has been excellent, with minimal morbidity or mortality using the open approach. Thus, the issue of diminished donor morbidity and reducing pain to the minimum has been almost totally ignored
  • Cost issues seem to show a higher expense for Lap Nx compared with the open approach.


Several pioneering centers have addressed the issue of the difficult learning curve. The initial results of Lap Nx point to an increase in graft warm ischemia time that may impact the rate of ATN and the 1-month serum creatinine value after transplantation. Early urological complications, particularly urinary leak and ureteral necrosis, were reported to be higher for Lap Nx versus open donor nephrectomy (Open Nx) in the initial series. Recipient ureteral complications were initially reported to be 9.1% at John Hopkins and 10.8% at the University of Maryland. Similarly, some workers claim that Lap Nx is associated with a higher rate of complications of vascular insult and of ATN-DGF. When we initiated our laparoscopic live donor program at the American University of Beirut, our group has emphasized the need for full collaboration between the urologic surgeon, the laparoscopic surgeon, and the transplant surgeon in both the donor and recipient surgeries. This collaboration has resulted in superior recipient and graft outcomes, with minimal morbidity despite the difficult early learning curve.

Our early experience in the single center sequential analysis recruited 100 consecutive donor-recipient pairs operated on from 1997 until 2003. The open Nx (n = 30), were performed between 1997 and 2000; the Lap Nx (n = 70) were performed between 2000 and 2003. Prospective records included operative data, anatomic details of the graft, hospital stay, and donor recovery. Donor characteristics and renal function were similar for Open Nx and Lap Nx. Operative parameters were similar except for the longer warm ischemia time in Lap Nx versus Open Nx (3.14 ± 2.10 vs 1.5 ± 0.5 minutes, P < 0.001).

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Renal transplant in babies and small children

Yann Revillon


Pediatric Surgery at Des Enfants Malades, Chief Editor, European Journal of Pediatric Surgery, Paris, France

A dialysis and transplant programme should be considered for children with end-stage renal disease. Although there have been many advances in recent years in the conservation treatment of children with end-stage renal failure, renal transplantation is accepted as the best treatment. The experience of Hopital des Enfants Malades from Paris is very important. From January 1973 to December 2005, 1125 renal transplantations have been performed in 992 children and adolescents. From January 1995, 2009 kidney transplantations have been performed.

Preparation:

Blood transfusions are no longer needed in patients.

An evaluation of the lower urinary tract with a micturating cystogram is important and correction of urinary tract abnormalities should be performed before transplantation. Patients with significant lower tract uropathies (posterior urethral valvus, Prune Belly syndrome, neurogenic bladder) and abnormalities of bladder function should be assessed carefully with urodynamic studies. Immunizations should be updated. In patients with severe renine-dependant hypertension, a left nephrectomy should be considered prior to transplantation while the right kidney may be removed at the time of transplantation.

Surgical Treatment: Usually, we performed a side to end anastomosis for the renal artery and a end to side anastomosis for the vain. In general, we use the right iliac vein and artery of the recipient. When the child is young, we performed the anastomosis on the Arta and the Vena Cava of the recipient. More often, we do an end-to-end uretero-ureteral anastomosis.

Medical Treatment: The immunosuppresion includes: Simulect, Steroid, Prograf and Azathioprine.

Simulect: One injection before the surgical procedure, one injection at day 4 post-op.

Steroid: Prednizone 60 mg/m2 tapered to 15 mg/m2 at month 2 and 7.5 mg/m2 at month 6.

Prograf: 0.2 mg/kg/d with a control of the blood level (5 ng/ml).

Results: The survival rate of the patients from 1995 to 2005 is after 5 years 96% for the cadaveric transplantation and 98% after living related renal transplantation (LRD). After 10 years, the survival rate of the patients for the cadaveric transplantation is 96% and for the LRD 97%. The survival rate of the graft is 80% for the cadaveric transplantation and 90% for the LRD.

Complications:

  • Delayed graft function: Patient who do not require dialysis during the first week for transplantation have better graft survival rate
  • Vascular thrombosis: Since 1995, we have observed only 2% of graft thrombosis
  • Rejections: Chronic rejection is the most common cause of graft loss
  • Hypertension: Hypertension is frequent after renal transplantation and occurs in 60% of recipient in the first month after transplantation and decreases with time
  • Infections: Infection is a permanent risk
  • Recurrence of primary disease: Recurrence of primary disease is responsible for graft failure in 5 to 10% of cases in paediatric series
  • Non compliance: Some authors have found a rate as high as 50%.


Conclusion: Renal transplantation remains the best treatment for children with end stage renal disease. The long term survival of the patient and the graft are excellent.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Emergencies following renal transplantation

Ahmed Bayoumi Shehab El-Din


Mansoura University for Graduate Studies and Research, Urology and Nephrology Center, Mansoura, Egypt

Despite the remarkable improvement in the results of renal transplantation during the last decade, surgical and medical complications continue to contribute significantly to the morbidity and mortality of allograft recipients. Moreover, in live-donor renal transplantation the risks to living donors are small, but real. The objective of this talk is to review the complications that may affect the safety of both the donors and recipients as well as the efficacy of the graft. A special emphasis on the surgical complications in both the donors and recipients will be done. Other medical problems that may interfere with the proper diagnosis and prompt management of surgical emergencies will be shortly discussed.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic live donor nephrectomy

Raja B. Khauli


Renal Transplant Unit, American University of Beirut Medical Center, Beirut, Lebanon

Several pioneering centers have addressed the issue of the difficult learning curve of Laparoscopic Donor Nephrectomy (Lap Nx) compared to Open Nephrectomy (Open Nx). The initial results of Lap Nx point out to an increase in graft warm ischemia time, that may have impacted on the rate of the ATN and one-month serum creatinine after transplantation. However, if one looks closer at this issue, one would appreciate that the short-term renal function does not have durable long-term functional outcome on the recipient's course. The long-term outcomes of Lap Nx seems to be equivalent to Open Nx in two large series and in recent reports. Allograft survival was no different in two large series showing equivalent survival rates of Lap Nx versus Open Nx, with similar acute rejection rates. Early urological complications particularly urinary leak and ureteral necrosis, were reported to be higher for Lap Nx versus Open Nx in the earlier series. Recipient ureteral complications were initially reported to be 9.1% at John Hopkins and 10.8% at the University of Maryland, and these were appreciably higher than the reported ureteral complications was diminished to 3% in later series that incorporated a wide ureteral dissection including ureteral periadvential tissue and vasculature. The high occurrence of ureteral complications in the early Lap Nx series sheds some important questions regarding the approach that was used to mobilize the ureter in these earlier series. Perhaps, the difficulty that was met sheds some insight on the fact that a major axiom of surgery in the donor was violated in the earlier series i.e., over-skeletonization of the ureter, that was later amended by the same authors. If this were the case, then the learning curve may not be that difficult to overcome, with the full cooperation of specialized teams that can recognize the need for abiding by the important axioms of transplantation when performing the donor operation. Similarly, the arguments that claim that Lap Nx is associated with a higher vascular insult rate and ATN-DGF can be challenged by the counter-argument of absence of risks of vascular spasms, thrombi or serious mishaps when exercising judicious sharp and blunt dissection for vascular mobilization, applying low pressure pneumoperitoneum (8 mmHg), and aggressive plasma expansion intraoperatively that has resulted in almost universal diuresis of grafts obtained by Lap Nx. Consequently, our group has emphasized the need for full collaboration between the urologic surgeon, the laparoscopic surgeon, and the transplant surgeon in both the donor and recipient surgeries. This has resulted in superior recipient and graft outcome with minimal morbidity despite the difficult early learning curve. In a recent update of our experience at the American University of Beirut, wherein we performed a critical comparison between Lap Nx and Donor Nx, the advantages of the former technique have been reaffirmed. The study is summarized below:

Materials and Methods: This is a single-center prospective and sequential analysis recruiting 100 consecutive donor-recipient pairs (200 patients) operated upon from 1997 till 2003 with recording of operative data, anatomic details of graft, hospital stay and donor recovery. The open Nx were performed between 1997 and 2000, while lap Nx were performed from 2000 to 2003.

Results: Preoperative donor characteristics including age, weight, preoperative serum creatinine and glomerular filtration rate were similar for open Nx (Group I) and lap Nx (Group II). Donor operative parameters and graft outcome results are listed in [Table 1]. Warm ischemia during retrieval was longer for lap Nx vs. open Nx (no impact on follow up creatinine). Donor recovery and hospital stay were significantly shorter for lap Nx vs. open Nx (P < 0.001). Three cases in lap Nx required retrograde flush via the renal vein for arterial thrombi and two underwent bench repair for distal arterial transsection that resulted in more than one branch. This did not impact on graft function. Donor complications were similar in number but different in spectrum for lap Nx vs. open Nx [8 (11.4%) vs. 4 (13.3%)]. All were managed expectantly without major morbidity. There were 3 trocar-induced injuries in lap Nx (2 liver, 1 bowel), managed laparoscopically. ATN requiring dialysis was observed in one lap Nx vs. 2 in open Nx.
Table 1: Donor operative parameters and graft functional outcome

Click here to view


Discussion: In the past 8 years, lap Nx has emerged as an important method for kidney retrieval, competing with the well-established open Nx, because of the associated rapid recovery and better cosmesis. However, critics of lap Nx raise the issue of higher rates of graft loss and diminished graft survival in the short and intermediate term. Our preliminary observations based on this contemporary series are summarized as follows: Lap Nx offers major advantages to the donor compared to open Nx, and yields similarly favorable results in graft outcomes. However, lap Nx is more demanding surgically with a long learning curve, and requires significant experience in bench repair and kidney salvage techniques on the part of transplant surgeon, and solid laparoscopic experience on the part of the donor surgeon.

Conclusion: Considering all factors, lap Nx is well justified with promising results in outcome parameters for both donor and recipient. The technique of lap Nx is more demanding on the part of the surgeon, but the difficult learning curve is not associated with significant risks on outcome. Since the rate-limiting step in live donor transplantation is dependant on the number of motivated live donors that would be more attracted to laparoscopic donor Nx, the latter should be adopted as the procedure of choice for kidney retrieval from live donors.

We believe that Lap Nx is now the "standard" of care, and the procedure of the future. Lap Nx shall replace Open Nx as the standard approach for kidney retrieval in most institutions. It has been shown to result in at least 2-fold increase in the number of donations which is the rate-limiting step for improving the utility of renal transplantation and its wide application. The learning curve need not be a stumbling bloc, as it may be negotiated without any appreciable risk to the graft or recipient.

A video clip of the technique of laparoscopic donor nephrectomy as performed at the American University of Beirut Medical Center will be presented.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Laparoscopic renal and uretral surgery, King Faisal Specialist Hospital and Research Centre experience

Hassan Al Zahrani, Khalid Al Othman, Ali Mahfouz, Khalid Al Ghamdi, Alaa Mokhtar, Muhammad Aslam, Talal Merdad, Raouf Seyam, Said Kattan and Kamal Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh

Introduction: Laparoscopy has been recently widely accepted by urologists worldwide. It was proved to be equally effective to the standard open procedures with less blood loss, postoperative pain, hospital stay and convalescence. We report our initial experience of laparoscopy in renal and uretral surgery at KFSH&RC.

Materials and Methods: Between June 2002 and December 2003, 27 cases were scheduled for laparoscopic renal or uretral procedures. There were 17 males and 10 females with a mean age of 46 years old (21-72). The indications were renal tumors in 10 cases, poorly functioning kidneys in 8 cases, renal cysts in 4 cases, PUJ obstruction in 1 case, uretral stones in 2 and retroperitoneal fibrosis in 2.

Results: Twenty four cases were completed as planned (89%) and 3 cases were converted to open (11%). Mean OR time was 3.1 hours (1-6.5) and mean blood loss was 120 cc (50-300 cc). One patient had post-operative bleeding that required exploration. Mean hospital stay was 3.7 days (2-21). Convalescence was smooth and short in all but one patient. One patient developed a port site hernia.

Conclusion: Our initial experience with laparoscopic surgery proved its efficacy and minimally invasiveness. Open conversion, major complications and longer OR time should be anticipated especially at the beginning. The major limitation we face is the limited number of appropriate indications due to our tertiary referral set up.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Indications for nephrectomy in adult patient: A tertiary care hospital experience

Mustafa Al Ghanbar, Mohammed Abomelha


Department of Urology, Riyadh Armed Forces Hospital, Saudi Arabia

Objective: To review the indications for nephrectomy in adult patients at a tertiary care hospital.

Methods: A retrospective study analyzing the clinical data, investigations, surgical procedures and histopathology results of 119 adult patients seen over 3 years, on whom nephrectomy was carried.

Results: There were 119 nephrectomy performed between 1999 and 2001. The patient median age was 39 years and the male to female ratio was 1.5:1. According to the cause of nephrectomy, we identified 4 groups: malignant 23%, benign 20%, kidney donors 37%, transplant-nephrectomy 20%. Ultrasound was the most used modality of radiological investigations. In addition, IVU, CT-scan, isotopes and bone scan were done when appropriate. Simple nephrectomy was applied in most of the cases except in malignant conditions where radical nephrectomy was performed. Laparoscopic nephrectomy was used in only three patients.

Conclusions: Unlike the local published literature, benign condition constitutes only 20% of the cases, whereas more than 50% were related to renal transplants. This report reflects the tertiary and referral pattern of our center, which deserves an attention when planning the rotation of residents in the residency training program in this country.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Inoperative laparoscopic renal ultrasonography for the treatment of complicated renal masses

M. Al Omar, D. Downey, J.L. Chin, P. Luke


Departments of Urology, King Khalid University, and King Saud University, Riyadh, Saudi Arabia, London Health Science Centre, London, UK, Department of Urology, University of Western Ontario, Ontario, Canada

Laparoscopic ultrasound (LUS) is a valuable tool that enhances limited surgical laparoscopic sensory feedback by providing visualization of tissue beyond 2D endoscopic limits. This tool is currently underutilized by urologists and its avoidance limits the capability to perform complex cases laparoscopically. The aim of our study is to highlight the use of LUS in complex laparoscopic renal procedures. Between October 2001 and April 2004 LUS was used in 23 patients undergoing various laparoscopic renal surgeries including laparoscopic partial nephrectomy (LPN), cryoablation of renal tumors, radical nephrectomy with renal vein thrombectomy and perinephric exploration. All patients were pre-operatively assessed by computerized tomography (CT) (65%), magnetic resonance imaging (MRI) (13%) or a combination of CT/MRI (22%). The Philips Entos_® LAP 9-5 linear array transducer was used to perform intraoperative LUS imaging through a 10 mm port via frequency rages of 5-9 MHz. With 4-way articulation, it enables 6 degrees of freedom of movement. In 17 LPN cases, LUS was used to map out the lesion dimensions, relationship with the collecting system/vasculature/sinus fat and to identify any satellite lesions. Through its use, excellent delineation of tumor borders was obtained, and all patients subsequently had negative resection margins. In addition, a previously undiagnosed intrarenal satellite lesion was discovered in 1 patient with a solitary kidney. This resulted in an open conversion for 2 separate partial resections. One LPN was performed on an entirely intrarenal, interpolar complex cyst. This procedure could not have been attempted without LUS imaging. LUS was also able to identify a 1cm lesion that was not visualized through laparoscopic examination. Conversely, the LUS was able to verify the absence of renal lesions during an exploration of a 4 cm complex cyst. A post-operative follow up CT confirmed the regression of the complex cyst. LUS was also used to monitor probe positioning and completion of freeze/thaw cycles during 3 cryoablative cases. An alteration of ultrasonic signal and the absence of blood flow within the renal tumors indicated completion of cryotherapy. Accurate cryoablative therapy could not have been completed without the use of the LUS. In 2 cases involving left-sided level I renal vein tumor thrombi, LUS could determine the thrombus limits, allowing stapler positioning without compromise of the thrombus. Due to limitations of surgical haptics in laparoscopy, renal vein thrombectomy could not have been accomplished laparoscopically without the LUS. As laparoscopic renal surgery evolves beyond radical nephrectomy for small renal masses, intraoperative LUS will become an invaluable tool used to identify and map out renal anatomy before definitive therapy. This will enhance the ability to achieve a margin-free status after complex laparoscopic cases.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Open conversion and major complications in laparoscopic urology

Hassan Al Zahrani, Thamer Al Saad, Mohd Al Turki, Nasser Al Jawini, Abdulmoniem Koko, Ali Mahfouz, Mostafa Hamdi, Khalid Al Ghamdi, Muhammad Aslam, Alaa Mokhtar, Raouf Seyam, Khalid Al Othman, Said Kattan, Kamal Hanash


Department of Urology, King Faisal Specialist Hospital Riyadh, KSA

Background: The risk of open conversion and major complications may limit the wide acceptance and practice of laparoscopy. Although experience will minimize both, they will continue to be encountered. We report our experience with potential causes of conversion and major complications with laparoscopic urology.

Materials and Methods: Between June 2002 and December 2003, more than 40 laparoscopic procedures were performed by our laparoscopy team. Major complications and open conversion were encountered in 5 cases.

Results: Case 1: A 48 years old male with giant left renal cysts crossing was converted to open due to failure to establish access and pneumoperitoneum. The cause was an inappropriate indication. Case 2: A 27-year-old female with poorly functioning left kidney was converted to open due to failure of dissection. The cause was an overlooked by the surgeon of an abscess between the pancreas and kidney on preoperative imaging. Case 3: A 52-year-old male with poorly functioning right kidney. He was converted to open to release the endo GIA stapler from the renal vein. The cause of conversion was mechanical failure of the stapler. Case 4: A 56-year-old female with chronic pyelonephritis of the right kidney. A duodenal injury was induced during dissection. It was repaired laparoscopically and the patient had smooth post-operative course. The duodenal injury was unavoidable due to dense adhesions. Case 5: A 34-year-old female on hemodialysis with 4.5 cm mass in the right kidney. She developed bleeding in the recovery room and was taken back to OR and has to be explored. No surgical bleeding was found. The cause of bleeding was platelet dysfunction secondary to poor preoperative dialysis.

Conclusion: Although open conversion and major complications are encountered with laparoscopy, they can be minimized by careful preoperative evaluation and taking care of all technical details.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Retroperitoneal laparoscopic radical nephrectomy: An established minimally invasive technique, "Kuwait experience"

A. Al Hunayan, H.M. Abdul Halim, A.J. Al Sarraf, E.O. Kehinde, K.A. Al Awadi


Department of Surgery (Division of Urology), Mubarak Al Kabeer Teaching Hospital, Faculty of Medicine, Kuwait University, Kuwait

Objectives: Laparoscopic radical nephrectomy (LRN) has become accepted as a curative management of locally confined renal tumor (T1-T2 N0 M0). LRN is usually performed by transperitoneal approach. Recently at our centre the retroperitoneal approach is preferred. We confirm the technical feasibility of retroperitoneal radical nephrectomy even for large tumours. A video tape is provided to show our technique for retroperitoneal LRN. We have successfully performed 8 cases of retroperitoneal LRN in the past 18 months.

Conclusion: Retroperitoneal LRN is reliable, effective and nowadays considered the preferred technique of nephrectomy. At our centre LRN has emerged as an attractive alternative to open radical nephrectomy in patients with T1-T2N0M0 renal tumors.

Presented at the: 18 th Saudi Urological Conference

20-23 February 2006 (21-24 Muharram 1427)

King Abdulaziz University Hospital

Laparoscopic decortications of large renal cysts

A. Shoma, I. Eraky, H. El Kappany


Urology and Nephrology Center, Mansoura, Egypt

Introduction and Objective: Laparoscopic deroofing of the renal cysts has been described for management of large symptomatic cysts. It is of particular importance with anteriorly located cysts where ultrasound guided percutaneous aspiration is difficult.

Materials and Methods: The video will present the technique of transperitoneal decortication of two large anteriorly located left renal cysts. Three ports were used (5-10 mm). The colon was reflected medially. The cysts were identified and dissected all around. Their contents were aspirated and the walls were sharply excised. The sites of the ports were closed.

Results: Thirty patients with large and or anteriorly located renal cysts were managed by the same technique. No conversion was required in either. Postoperative retroperitoneal hematoma was developed in one case.

Conclusion: Laparoscopic decortication could be used for management of the large renal cysts.

Presented at the: 18 th Saudi Urological Conference

20-23 February 2006 (21-24 Muharram 1427)

King Abdulaziz University Hospital

Laparoscopic nephrectomy: Technique, indications, and outcome Kuwait experience

A. Al Hunayan, H.M. Abdul-Halim, A.J. Al Sarraf, E.O. Kehinde, K.A. Al Awadi


Department of Surgery, Division of Urology, Mubarak Al Kabeer Teaching Hospital, Kuwait University, Kuwait

Objectives: To present our experience of laparoscopic nephrectomy or nephroureterectomy performed over a 3-year period in terms of feasibility, complications and oncological outcome in single centre experience.

Materials and Methods: A total of 30 patients (18 males, 12 females) underwent laparoscopic nephrectomy or nephroureterectomy between June 2002 till June 2005. Indications for nephrectomy were malignant disease in (22 patients) and benign disease in (8 patients). 22 patients were operated on transperitoneally and 8 patients retroperitoneally. All procedures were performed in the lateral position.

Results: Four procedures had to be converted to open procedure (three transperitoneal approach and one retroperitoneal approach) for the following reasons: bleeding in two cases and irreversible loss of pneumoperitonium in the other two cases. The mean surgical time was 190 min, median loss was 210 ml, the average hospital stay was 4.5 days, proportions using analgesics more than one day 20% of patients. The mean tumor size of operated malignant case was 5.1 cm. No case was detected to have positive lymph node or surgical margin. No disease progression was observed, no case of local recurrence or port metastasis have been reported during follow up period.

Conclusions: Laparoscopic nephrectomy is becoming a routine effective treatment for patients with low stage renal tumor and non-functioning kidneys with an acceptable operating time, minimal morbidity and short hospital stay.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic radical nephrectomy for localized renal tumors, King Faisal Specialist Hospital 3 years experience

H. Al Zahrani, K. Al Othman, A. Bin Mahfouz, W. Al Taweel, S. Kattan, M. Aslam, A. Mokhtar, R. Seyam, I. Ahmad, M. Al Musa, K. Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: Radical nephrectomy is the standard treatment for localized renal cell carcinoma. Laparoscopic radical nephrectomy has emerged as a new modality offering the advantages of minimally invasive surgery and a reported international experience of equivalent cancer control to open surgery for localized RCC (T1-T2). We report our experience with lap. radical nephrectomy for localized renal tumors with follow up to 40 months.

Materials and Methods: All cases scheduled for laparoscopic radical nephrectomy between Sept 2003 and August 2005 was included. The data were prospectively collected and updated with each follow up visit. It included preoperative clinical, laboratory and imaging information. It also included operative details, postoperative course and early and late complications. Patient with RCC were followed for recurrence, metastasis and survival.

Results: Thirty five patients were scheduled for laparoscopic radical nephrectomy for either localized solid renal tumors or Bosniak 4 complex renal masses. There were 21 males and 14 females. The mean age was 52 years (21-76). 23 patients had asymptomatic incidental finding, 6 had abdominal/flank pain, 2 are followed for other malignancies and 4 had microscopic hematuria. All patients except one patient had a normal renal function and normal contralateral kidney. Transperitoneal approach was used in all cases. There were 2 elective and 1 emergency conversions to open approach. Mean operative time was 170 minutes (75-320 minutes) and estimated intraoperative blood loss was 90 cc (<50-1250). One patient had intraoperative blood transfusion and 1 patient with chronic renal failure developed massive bleeding in the recovery room that required blood transfusion and open exploration. The postoperative hospital stay was 5.6 days (3-14). One patient had renal impairment and one was admitted to the ICU after bleeding. The rest 33 patients had smooth post operative course. The histopathology showed RCC in 29 patients, oncocytoma in 2, hydatid disease in 2, sarcoma in 1, angiomyelipoma in 1, benign cyst in 1 and one patient had normal renal hypertrophy. The mean tumor size was 7.6 cm (2.8-12 cm). All surgical margins were negative. One patient developed port site hernia. One patient had local recurrence and metastasis at 3 months post operatively and died of disease 8 months later. The 29 patients with RCC at a mean follow up of 17 months (4-39) are all alive with no recurrence.

Conclusion: Our experience supports the reported international data that showed laparoscopic radical nephrectomy as an alternative minimally invasive technique to the standard open approach while offering excellent cancer control for localized (T1-T2) RCC at short and medium follow up.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic nephrectomy: Single center experience

Ibrahim Eraky


Laparoscopy Unit, Urology and Nephrology Center, Mansoura, Egypt

Purpose: To evaluate the experience of Mansoura Urology and Nephrology Center in laparoscopic nephrectomy.

Patients and Methods: Between August 11992 and August 2005, 423 cases of laparoscopic nephrectomy had been performed, 370 for benign indications, 42 for renal cell carcinoma and 11 for TCC of the upper urinary tract. The kidney size ranges from 6 cm to 28 cm in benign indications. In cases of renal cell carcinoma, the size of renal masses range from 4 to 12 cm. The transperitoneal approach was utilized in 302 cases while the retroperitoneal one was used in 121 cases. Patients were assessed regarding the operative time, blood loss, intraoperative complications, conversion to open surgery and hospital stay.

Results: In cases of benign indication, the mean operative time decreased with experience from 217 minutes in early 50 cases to 154 minutes in the second 50 cases. In the transperitoneal approach, the mean operative time was 104 minutes. Conversion to open surgery was required in 6% of cases of transperitoneal approach and 3.5% of cases of retroperitoneal approach to overcome perirenal adhesions and intraoperative bleeding. In cases of laparoscopic radical nephrectomy for renal cell carcinoma, the operative time ranges from 90 to 288 minutes (mean 162 ± 48). Conversion to open surgery was required in one case to overcome upper polar adhesions. In cases of nephroureterectomy to manage TCC of upper urinary tract, no conversion was required in any of the eleven cases.

Conclusion: Laparoscopic nephrectomy for benign and malignant indications could be performed with good rate of success and accepted complications.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Complications of laparoscopic procedures in urology

Khalid M. Al Otaibi


Dhahran Health Center, Saudi Aramco, Dhahran, Saudi Arabia

Purpose: Laparoscopic surgery has become the standard technique for the most urological pathology that needs removal. We reviewed our complications of the laparoscopic procedures in our medical institution.

Materials and Methods: Since 1998, a total of 48 patients underwent advanced laparoscopic surgery in Urology Services in Saudi Aramco Medical Services Organization. Twenty patients underwent laparoscopic simple/radical nephrectomies. Seven pediatric patients underwent laparoscopic nephrectomy. Nineteen patients underwent laparoscopic adrenalectomy. Two pediatric patients underwent laparoscopic excision of mullerian duct.

Results: Thirteen out of 48 patients (27%) developed some degree of complication, major complications in 38.5%, and minor complication in 61.5%. Major complications including: death in 3 patients and pancreatic injury in 2 patients.

Conclusion: Complications of laparoscopic procedure could occur in spite that it is considered a safe technique in Urology. Recognition of the complications could prevent mortality.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Robotic pyeloplasty: Experience with 3 robotic platforms

M. Al Omar, P. Luke


Departments of Urology, King Khalid University and King Saud University, Riyadh, Saudi Arabia, London Health Science Centre, London, UK, Department of Urology, University of Western Ontario, Ontario, Canada

Owing to the technical difficulties with intracorporeal suturing and knot tying, laparoscopic pyeloplasty is a challenging procedure. Surgical robotics can eliminate tremor, increase dexterity and precision of the laparoscopic surgeon. We report our experience with laparoscopic pyeloplasty using 3 different robotic platforms. Between September 2001 and May 2004, 20 patients underwent laparoscopic pyeloplasty using 3 different robotic platforms. In 6 patients, AESOPTM (Intuitive Surgical_®), a solitary voice-activated robotic arm, controlled the laparoscopic camera. In 5 patients, the 3 arm ZeusTM (Intuitive Surgical®) platform was used. In 9 patients, the 4 arm Da VinciTM (Intuitive Surgical_®) platform was used. The AESOP platform provided remote controlled, tremor-free visualization of the anastomosis during the pyeloplasty procedures. The Zeus platform provided an additional degree of freedom of movement (5 vs. 4) with wristedậ instruments, tremor-filtration, movement-scaling, 3-D visualization and the ability to perform long-distance telementoring and telesurgery. The Da Vinci platform had superior ergonomics compared with the Zeus platform with 6 vs. 5 degrees of freedom of movement, subjectively superior 3-D visual acuity, but currently, there is no capacity to perform long-distance telementoring and telesurgery. The time required to set-up each unit was <5, 30, and 39 min for the AESOP, Zeus and Da Vinci platforms, respectively. The mean operative times (-+SD) were 262 ± 48, 225 ± 48 and 168 ± 48 min for the AESOP, Zeus and Da Vinci groups, respectively. Anastomotic time with the Da Vinci was 35 ± 7 min compared with 71 ± 16 for the Zeus pyeloplasties. Estimated blood loss was minimal in each group and no robotic failures or open conversions occurred. Hospital stay was short at 77 ± 11, 58 ± 10 and 48 ± 11 h for AESOP, Zeus and Da Vinci groups, respectively. Postoperatively, the mean analgesic requirements were 96 ± 74, 22 ± 10 and 77 mg morphine sulphate equivalents for the AESOP, Zeus and Da Vinci groups, respectively. One patient developed a delayed urinary leak in the Zeus group, which was successfully managed by percutaneous drainage. In the three groups, all patients are currently pain free with no evidence of obstruction on lasix renogram post-stent removal. Robotic pyeloplasty is safe and feasible. Each robotic platform has various features that subjectively enhance the ease and efficiency of the laparoscopic pyeloplasty procedure. Due to the small numbers in our early experience with these robotic platforms, objective advantages of the more sophisticated platforms (Zeus and Da Vinci) over the basic platform (AESOP) are lacking. The role of these platforms in urologic surgery is continuing to be evaluated.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Outreach laparoscopic urologic surgery, the potential and limitation

Hassan Al Zahrani, Alaa Shabaan, Nasser Al Jawini, Mohamed Al Turki, Abdulmoniem Koko, Ali Mahfouz, Mostafa Hamdi, Abdullah Al Jasser, Samir Ragheb, Ali Bin Saleh, Thamer Al Saad, Kamal A. Hanash


Department of Urology, King Faisal Specialist Hospital, Riyadh, KSA

Introduction: The practice of laparoscopy is limited to a few centers in Saudi Arabia. The major obstacles are unavailability of equipment and the insufficient training of urologists. We report our limited personal outreach efforts to introduce laparoscopy in other hospitals.

Materials and Methods: Between June 2002 and April 2003, four hospitals invited our laparoscopy staff to their hospitals to perform laparoscopic procedures. These were: Riyadh Medical Complex-Riyadh, Security Forces Hospital-Riyadh, King Fahad Specialist Hospital-Qassim and the South Region Military Hospital at Khamis Mushait.

Results: Fifteen procedures were performed: 4 simple nephrectomies, 2 radical nephrectomies, 1 renal cyst unroofing, 1 ureterolithotomy, 2 orchiectomies, 1 orchiopexy, 3 varicocele ligation and 1 lymphocele marsupialization. The operative time was longer than OR time when similar procedures were done at KFSH&RC. Two cases were converted to open: 1 due to failure to progress with dissection and 1 due to malfunction of the endo GIA stapler. One duodenal injury occurred and managed laparoscopically. Operative blood loss and hospital stay were similar to cases done at KFSH&RC. The unavailability of instruments and the longer OR time discouraged some centers continuing the program. None of the staff in these centers was trained enough to perform laparoscopy independently.

Conclusion: The potential of spreading laparoscopy to other centers in the Kingdom is substantial. However, it needs serious commitment and efforts at the beginning where complications, frustration and long OR time is expected. KFSH&RC is willing to help other centers interested and capable in introducing laparoscopy in their practice.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Attitude and practice of laparoscopy among urologists in Saudi Arabia

Hassan Al Zahrani, Khalid Al Othman, Ali Mahfouz, Said Qattan, Muhammad Aslam, Khalid Al Ghamdi, Alaa Mokhtar, Raouf Seyam, Kamal Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction: Urology has a long tradition with minimally invasive techniques that has replaced many open procedures. Laparoscopy however took a decade to be widely accepted among urologists. We report the results of a survey of the attitude and practice of laparoscopy among urologist in KSA.

Materials and Methods: A survey was developed that addressed current open urological procedures, indications of laparoscopic procedures, availability and practice of laparoscopy, the attitude, potential and limitations of introducing laparoscopy into the practice of urologists in Saudi Arabia. The survey was mailed to 52 urologists all over the Kingdom, both at government and private sectors.

Results: Nineteen urologists responded to the survey (36.5%). At present 7 government hospitals (36%) practice laparoscopy at different scales. Five centers started between 1997 and 2000 and other two started as early as 1988 and 1992. The commonest laparoscopic indications all over are varicocele ligation and cryptorchidism. Advanced laparoscopy is done in 5 centers with adrenalectomy and nephrectomy being the commonest procedures. The average open cases that could be considered for laparoscopy is 20 cases/center (15-40) among government hospitals and 2 cases/center (0-5) at the private sector. All respondents are highly interested in introducing laparoscopy to their practice. The major obstacles to practice laparoscopy in order of frequency are insufficient staff training (89%), unavailability of equipment (68%), limited indications (63%), longer OR time (53%) and risk of complications (21%).

Conclusion: The current practice of laparoscopy in Saudi Arabia is limited to few government centers with insufficient appropriate indications. The attitude toward laparoscopy is positive across the country. The major limitations are insufficient training, lack of adequate set up and insufficient indications. At present we recommend referring potential laparoscopic cases to centers already doing. These centers should train more potential urologists in other hospital.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

A simple home made laptrainer set for basic and advanced laparoscopic manoeuvres

S.M. Soliman


Department of Urology, Pediatric Urological Service, King Khalid University Hospital, Riyadh, Saudi Arabia

Purpose: Laparoscopic surgery requires a different set of spatial skills than open surgery. Commercial laptrainers and recently virtual reality simulators have been introduced to build up the sense of movement and hand-eye coordination in the laparoscopic environment. In spite of the widespread availability of laparoscopic instruments, yet the laptrainer kits or simulators are present in quite a few centers. Herein, we present a simple home made laptrainer kit that can allow day to day practice on basic and advanced manoeuvres at hospital or domestic settings.

Methods: A desktop/laptop PC with a web cam serves as a video unit. A set of laparoscopic instruments (ports, graspers, needle holders) is introduced as appropriate into a box illuminated by a desktop light sources.

Results: The laptrainer allowed performance of simple manoeuvres as instrument orientation and handling and advanced manoeuvres as intracorporeal suture and knotting in an environment similar to that created by commercial laptrainers.

Conclusion: The home made laptrainer allows day to day contact with the laparoscopic environment in a practical, inexpensive and a handy manner. It can be used as primary means of building basic and advanced laparoscopic skills for beginners before actual hands-on sessions, or as an "in-touch" means for advanced users.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Evolution of laparoscopic urologic oncology

Raja B. Khauli


American University of Beirut Medical Center, Beirut, Lebanon

In the past five years, we have witnessed a revolution in the field of urology and the adoption of laparoscopic surgery to urological diseases, especially those of the upper tracts. In the year 2000, we have switched to the laparoscopic approach for all kidney donors at our unit, and performed laparoscopic donor nephrectomy as a routine for renal transplantation. Early experience with 70 consecutive laparoscopic donor nephrectomies revealed major advantages in diminishing hospitalization, faster return to normal activity and work, and overall increase in willingness to donation.

As to urological tumors, there has been an increased utility of laparoscopy for all tumors less than 7 cm involving the kidney and adrenal. While the majority of the procedures for kidney and adrenal tumors were open surgical, there seems to be a shift in the pendulum towards laparoscopic surgery. At our center, we have applied laparoscopy to radical nephrectomy and adrenalectomy in 80 cases with only one conversion and no major complications. Laparoscopic adrenalectomy for pheochromocytoma has been performed in 9 patients with no adverse effects (video presented). Laparoscopic techniques have been applied for the removal of pelvic or retroperitoneal lymph nodes, part of therapeutic staging for prostate cancer or therapy for testes cancer. We believe that the race of laparoscopy in the former setting is limited and is probably restricted to patients undergoing staging lymphadenectomy before external beam radiotherapy or brachytherapy for prostate cancer. However, laparoscopic retroperitoneal lymphadenectomy for the management of NSGCT of the testes is promising and has emerged as a viable alternative to open lymphadenectomy. Parallel to the advances in laparoscopy of the upper tract, the world has witnessed the evolution of laparoscopic radical prostatectomy. The technique was initiated in France and was soon adopted by German centers and several centers in the USA. The technique is associated with a difficult learning curve that could be diminished by the use of Robotics. A critical appraisal of this approach to the management of adenocarcinoma of the prostate has not, as of yet, proven substantial or major advantages of laparoscopy over the time-tested radical prostatectomy.

Several authors have criticized the adoption of laparoscopic techniques without proper training and planning. Furthermore, there has been a move towards the hand-assisted laparoscopic techniques as a tool to diminish the steep learning curve associated with pure laparoscopy. We herein review the techniques and approaches to laparoscopic donor nephrectomy, laparoscopic radical nephrectomy, and laparoscopic radical adrenalectomy. We also describe other applications in urology and the potential risks, complications, and outcome. Also, Laparoscopic Radical Prostatectomy is analyzed.

An audiovisual presentation will be made on the modifications of technique, and tricks of trade, that can improve the safety and efficacy of laparoscopic urologic surgery. A structured protocol for obtaining laparoscopic training will be presented. Also, video clips of laparoscopic oncologic procedures will be presented.

Presented at the: 17 th Saudi Urological Conference

King Fahd Mil5005

Laparoscopic varicocelectomy

I. Al Oraifi, S. Abu Anz, S. Egail, A. Zahrani, A. Al Dayel


Department of Urology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia

Objective: To evaluate the laparoscopic varicocelectomy in the treatment of testicular pain and infertility (performed at the request of the patients) with an emphasis on the complications and recurrence rates.

Methods: A retrospective study of the last 34 patients (40 varicoceles) undergoing laparoscopic varicocelectomy, 19 for pain, 14 for infertility and 1 combined pain and infertility.

Results: The 19 patients with pain improved post-operatively. As for those with infertility, 57% had improved sperm motility and 50% had improved sperm count. The overall recurrence rate in the 40 varicoceles was 7.5%. Complications were seen in two patients (5.8%).

Conclusion: Recurrence rate in our series is very comparable to the open (inguinal) varicocele ligation as well as the complications rate, so it seems that laparoscopic varicocelectomy is still a valid and a safe alternative for all other modalities of varix ligation.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Adult lymph sparing laparoscopic varicocelectomy

Danny M. Rabah


Department of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Introduction: Many surgical alternatives are available for varicocele ligation in adults. Most of these procedures offer good results, however the most common complication is the development of postoperative hydrocele with incidences rates of 1.3% to 40%. This is probably secondary to disturbance of lymphatic flow from the ipsilateral testis. We describe combining an old surgical concept with laparoscopic varicocelectomy in adult patients. This technique allows testicular lymphatics to be mapped at laparoscopy, allowing the visualization and preservation of the lymph vessels during varicocelectomy.

Methods: After induction of general anesthesia, 5 ml of methylene blue is injected into the space between the tunica vaginalis and tunica albuginea. The scrotum is then massaged for a few minutes. Three 5 mm ports are placed in the peritoneal cavity. The camera port at the umbilicus and the other 2 at the mid axillary line at a point half way between the umbilicus and the anterior superior iliac spine. The internal spermatic vessels are identified then the peritoneum overlying the vessels is opened 1 cm proximal to the internal ring and the gonadal veins are then carefully separated from easily visible blue lymphatic trunks. The separation is easily accomplished with blunt dissection. The vein is then clipped and divided sparing the lymphatics. An ongoing clinical trial is underway to evaluate the efficacy of this method compared to microsurgical subinguinal varicocelectomy.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic dismembered pyeloplasty and pyeloplasty performed entirely by Robot

Ahmed M. Shoma


Urology and Nephrology Center, Mansoura, Egypt

Purpose: We describe the technique of laparoscopic dismembered Anderson-Hyens (A-H) pyeloplasty and pyelolithotomy that performed completely by robot and showed the outcome after 6 months follow up.

Patients and Methods: A 24-year old female patient presented with primary left ureteropelvic junction obstruction with secondary renal stones. A robot assisted (A-H) pyeloplasty and pyelolithotomy were performed through transperitoneal approach. The patient was followed up at 3 and 6 months postoperatively to assess the outcome.

Result: Operative time was 4 hours, hospital stay was 3 days. There was no reported morbidity. Radiological evaluation after 3 and 6 months showed significant improvement in renal morphology and function.

Conclusion: Robot could be effectively used to perform the entire procedure of laparoscopic dismembered pyeloplasty with extraction of the associated renal stones. The short term outcome is satisfactory.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic dismembered pyeloplasty through transperitoneal approach

Ahmed M. Shoma, Ahmed El Nahas


Urology and Nephrology Center, Mansoura, Egypt

Purpose: We present a video film to describe the technique of laparoscopic dismembered Anderson-Hyens (A-H) pyeloplasty that performed through transperitoneal approach.

Patients and Methods: A 24-year-old female patient presented with primary right ureteropelvic junction obstruction. A laparoscopic pyeloplasty was performed through transperitoneal approach. The patient was followed up at 3 and 6 months postoperatively to assess the outcome.

Results: Operative time was 2.5 hours. Hospital stay was 3 days. There was no reported morbidity. Radiological evaluation after 3 and 6 months showed significant improvement in renal morphology and function.

Conclusion: Laparoscopy could be effectively used to perform the entire procedure of laparoscopic dismembered pyeloplasty with encouraging outcome.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Robotic and laparoscopic pyeloplasty for primary pelviureteric obstruction, the new gold standard of care

H. Al Zahrani, K. Al Othman, W. Al Taweel, A. Bin Mahfouz, S. Kattan, M. Aslam, A. Mokhtar, R. Seyam, M. Al Musa, I. Ahmad, K. Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: Pelviureteric junction obstruction has been managed with either endopyelotomy or open pyeloplasty. Laparoscopy emerged in the last decade to combine the results of open pyeloplasty and the minimally invasiveness of endopyelotomy. Robotics was the latest addition to make the procedure simpler to perform. We present a video of our experience with laparoscopic and robotic pyeloplasty.

Materials and Methods: Between September 2003 and October 2005 laparoscopy was offered to patients diagnosed with primary PUJ obstruction in our hospital. The clinical, imaging, operative and outcome parameters were analyzed and presented.

Results: Five patients had laparoscopic pyeloplasty and 7 had robotic-assisted pyeloplasty. There were 5 males and 7 females with a mean age of 34 years (14-52). Ten patients had pain and 2 had renal stones. Preoperative renal scan showed obstruction on 11 patients. There was no open conversion or intraoperative complications. EBL was 50 cc (20-100) and operative time was 230 minutes (140-350). The hospital course was smooth in all patients. Pain disappeared in 8 patients and improved in 2. None of the stones could be removed during the procedure and PCNL was required in 1 and ESWL in 1 patient. The technical aspects of the procedure are detailed in the video.

Conclusion: Laparoscopy combined the high success rate of open pyeloplasty and the minimally invasiveness of endopyelotomy in one technique. The use of robotics makes the procedure easier with the advantages of the 3 dimensional visions and the flexible degree of motion and suturing. The procedure however takes longer OR time and more investment in technology.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic pyeloplasty through transperitoneal and retroperitoneal approaches, what is the difference?

Ahmed M. Shoma, Ahmed R. El Nahas, Mahmoud A. Bazeed


Urology and Nephrology Center, Mansoura, Egypt

Introduction and Objective: Currently, laparoscopic pyeloplasty is indicated for management of ureteropelvic junction obstruction (UPJO). Both transperitoneal (TP) and retroperitoneal (RP) approaches are used. However, there is no clear indication for the use of either technique in literature.

Methods: A prospective randomized study comparing TP and RP laparoscopic pyeloplasty was performed in the period between February 2002 and June 2005. Thirty six patients with UPJO were included in the study. Each approach was used in 18 cases. All were assessed preoperatively by intravenous urography (IVU) and diuretic renal scan. Postoperative assessment by IVU and diuretic renography was performed every 6 months.

Results: The preoperative data of both approaches had no statistical difference. All the procedures were completed by laparoscopy. The average operative times were 148 and 195 minutes for TP and RP respectively (P = 0.025). The preoperative demographic data of the patients and their radiological and operative findings were statistically correlated to the operative time for each group. Learning curve had a statistically significant impact over the operative time in both approaches. Nevertheless RP was associated with longer the learning curve compared to TP. Postoperative complications were reported in two patients of each group (P > 0.05). Complications included mild hematuria (1), urine leakage (2) and fever (1). The difference in the outcome between the two approaches was not statistically significant. Failure was not reported in any patient.

Conclusions: Both TP and RP approaches could be used with satisfactory outcome. However, transperitoneal technique has a shorter learning curve compared to retroperitoneoscopy.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic radical cystectomy with mainz rectal pouch urinary diversion

M. Ziani, A. Ioualalen


Capio Polyclinique Du Parc, Toulouse, France

Introduction and Objectives: This film describes the running-on of a radical cystectomy with a rectal mainz pouch urinary diversion totally laparoscopic.

Materials and Methods: A sixty year old woman developed a grade 3 pt 2 bladder carcinoma. This film shows first the laparoscopic radical cystectomy using 3 ten mm and 2 five mm trocars. Dissection of pelvic adhesions from a previous hysterectomy. Bilateral lymph node dissection is carried on. The surgical conventional procedure is briefly described (experience based on five cases), followed by the laparoscopic technique. Two 10 cmm sigmoid loops are anastomosed using stapler devices and running suture at the posterior wall, both ureters are reimplanted with a camey anti-reflux procedure. Both ureteral catheters are routed out through a 22F rectal couvelaire catheter. Closure of the anterior wall of the pouch with running suture. Drainage. The specimen is removed through the enlarged port of the camera.

Results: Bloodless 500 cc, the operative time was 8 hours and 30 minutes, the hospital stay was 12 days, with no complication.

Conclusions: Laparoscopic radical cystectomy with mainz rectal pouch diversion in woman is suitable, feasible, safe and effective. However, it should be considered after significant experience with laparoscopic surgery.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic genital sparing radical cystectomy in females the technique that could duplicate the open surgery

Ahmed M. Shoma


Department of Urology, Urology and Nephrology Center, Mansoura, Egypt

Objectives: To show the technique of laparoscopic genital sparing radical cystectomy in females that follows the same steps of open surgery.

Patients and Methods: The patient is placed in lithotomy position with fixation of five ports. The procedure started with bilateral iliac lymphadenectomy. Both ureters are identified, clipped and divided; the peritoneal reflection at the vesicoureterine junction is incised. The plane between the bladder and vagina is dissected till the urethra. The posterior pedicle is controlled and divided using Ligasure instrument. The peritoneum anterior to the bladder is incised and the cave of retzius is opened. The deep dorsal venous complex is ligated and divided. The urethral stump is prepared and divided. Five stitches were taken in the urethral stump in preparation for extracorporeal urethra-ileal anastomosis.

Results: The technique was performed in 2 patients. The mean operative time was 4.1 hours. Conversion to open is required in one.

Conclusion: Laparoscopic genital sparing radical cystectomy could be performed in well selected cases.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic iliac lymphadenectomy could duplicate the principles of open technique during radical cystectomy

Ahmed M. Shoma


Department of Urology, Urology and Nephrology Center, Mansoura, Egypt

Objective: This video demonstrates the technique of iliac lymphadenectomy as an integral part of laparoscopic radical cystectomy for muscle invasive bladder tumors.

Patients and Methods: The patient is placed in supine position. The procedure is done through five ports. Left iliac lymphadenectomy is performed using endo-scissor and endo-forceps with the aid of bipolar forceps. The lymphatics around the iliac artery and vein are dissected followed by removal of the obturator lymph nodes. Right iliac lymphadenectomy is performed in the same manner.

Results: Bilateral iliac lymphadenectomy could be done in 30 patients. The average number of the removed lymph nodes was 14. The mean operative time was one hour.

Conclusion: Laparoscopic iliac lymphadenectomy could duplicate open technique with satisfactory outcome.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic radical cystectomy: A new approach for management of invasive bladder tumors

Ahmed M. Shoma, Nasr El-Tabey, Mahmoud Bazeed


Urology and Nephrology Center, Mansoura, Egypt

Objective: This video film presents the technique of laparoscopic radical cystectomy for the management of muscle invasive bladder tumors.

Patients: The patient is placed in a Trendelenburg position. The procedure is performed through transperitoneal approach after fixation of five ports (5-10 mm in diameter). The bladder is separated from the rectum posteriorly till reaching Denonvillier's fascia. The fascia is incised to separate the prostate from the rectum. Then the lateral bladder wall is freed from the pelvic wall. The lateral pedicles of the bladder and prostate are divided using LigaSureTM. The peritoneum is then incised anterior to the bladder. The deep dorsal vein is controlled by a ligature and divided. The urethral stump is prepared and divided. The mass is then completely freed. Bilateral iliac lymphadenectomy is then performed. A 10cm suprapubic skin incision is done and the specimen is removed. An ileal W neobladder is reconstructed and the ureters are anastomosed to the pouch through the same incision. The pouch is introduced to the abdominal cavity and the skin incision is closed. The urethra-ileal anastomosis is completed by laparoscopy using intracorporeal free hand suturing.

Results: Thirty one cases with invasive bladder tumors were managed by laparoscopic radical cystectomy. All, apart from 2, were successfully performed. The mean operative time was 3.9 hours.

Conclusion: Laparoscopic radical cystectomy is technically feasible. However, an increasing number of patients and a longer period of follow up are required for accurate assessment of this technique.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Assessment of the role of laparoscopy in the management of upper urinary tract tumors

Ahmed M. Shoma, Ibrahim Eraky, Ahmed El-Nahas, Nasr El-Tabey, Hamdy El-Kappany


Urology and Nephrology Center, Mansoura, Egypt

Introduction and Objectives: Laparoscopy has been widely used for management of uro-oncologic disorders in the last decades. Thus, the results of laparoscopic management of upper urinary tract tumors in our institute are presented.

Patients and Methods: Between 1996 and 2005, 53 patients with upper urinary tract tumors were managed by laparoscopy. They included 45 patients with parenchymal renal tumors, and 8 with renal pelvis tumors. Laparoscopic radical nephrectomy was performed for the locally confined renal tumors (T1-2, N0, M0) in 35 patients while 10 had T3a, N0-2, M0 renal masses. Seventeen patients had lesions >7 cm in their largest diameter. Total nephroureterectomy with bladder cuff excision performed exclusively by laparoscopy was done for eight cases with T1-2, N0, M0, renal pelvis tumors. Success rate, operative time, morbidity, mortality and short-term outcome were assessed for these procedures.

Results: Laparoscopic radical nephrectomy was performed through transperitoneal approach in 41 cases while retroperitoneoscopy was used in 4. The procedures were successfully completed in 44 patients (98%). The mean operative time was 3.2 hours. Two patients required intraoperative blood transfusion. No reported major complications apart from postoperative development of arterial fibrillation in one patient. The mean operative time for the laparoscopic nephroureterectomy with bladder cuff excision was 3.2 hours. All the procedures were successful; the average blood loss was 120cc. One patient develops port site metastasis and distant metastasis one year after the procedure.

Conclusion: Laparoscopy could be effectively used for management of upper urinary tract tumors with satisfactory outcome and low morbidity and mortality.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic radical cystoprostatectomy: A new approach for muscle invasive bladder tumors: Initial outcome and shor term follow up

Ahmed M. Shoma, Nasr El Tabey, Khaled El Kohlany, Mahmoud A. Bazeed


Urology and Nephrology Center, Mansoura, Egypt

Objective: We present the results of laparoscopic radical cystoprostatectomy with bilateral pelvic lymphadenectomy and evaluate the short term oncologic and functional outcome.

Methods: Between November 2002 and July 2005, 30 patients with muscle invasive bladder tumors were managed by radical cystoprostatectomy with bilateral pelvic lymphadenectomy performed exclusively by laparoscopy. The mass was extracted intact via a small suprapubic incision. Through this incision, orthotropic ileal reservoirs and ileal loop conduits were reconstructed extra-corporeally in 26 and 4 cases respectively. The operative time, success rate, blood loss, number of lymph nodes removed and morbidity were recorded. Also, continence state and tumor recurrence were assessed during the follow up period.

Results: The procedures were completed by laparoscopy in 27 patients (90%). Conversion was reported in 3 cases due to vascular injury (2) and difficult urethroileal anastomosis (1). The number of the removed lymph nodes ranged from 4 to 30. The average operative time for cystectomy and lymphadenectomy were 3.95 hours. The mean blood loss was 675 ml. Only 8 cases (27%) required one unit of blood for each. Vascular injury was recorded in 4 that often occurred during lymphadenectomy. A bleeding from deep dorsal vein (1) and right external iliac vein (1) were controlled by laparoscopy using intracorporeal sutures. Two patients with injury of external iliac artery (1) and vein (1) required conversion to open surgery. Postoperative major complications were recorded in 3. All were related to the diversion step. They included pouch-cutaneous fistula (1), leakage from uretero-ileal anastomosis (1), and pouch-rectal fistula (1). No recorded mortality. The follow up ranged between 3 and 20 months (mean = 10 ± 3.4). Twenty one patients (80%) are living free of the disease. Four developed distant metastasis and one had local recurrence. All patients with orthotopic diversion were continent by the day while 6 (25%) had nocturnal enuresis.

Conclusions: Laparoscopic radical cystoprostatectomy is technically feasible with accepted operative time blood loss and morbidity. Most of the complications are related to lymphadenectomy step and diversion. Continence state and early oncologic outcome look promising.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Minimally invasive technique in pediatric urology past - present - future

Jeff-Stephane Valla


President of, French Society of Pediatric Urology, Vice-President of International Endoscopic Pediatric Group, Pediatric Urologist Laparoscopic Endourology Surgeon, Fondation Lenval, Pediatric Surgery, Nice, France

The history of laparoscopy in pediatric urology began in 1976, when CORTESI published the first paper about using a laparoscope in order to localize intra abdominal testis. During 14 years, this diagnostic procedure remained few used and only five articles have been published.

The advent of laparoscopic cholecystectomy in the early nineties engendered a cultural change in the mind of general adult surgeons; but pediatric surgeons were much more cautions at the beginning and pediatric urologist often reluctant! However, using laparoscopy for diagnostic purpose or for simple therapeutic procedure (gonadectomy, varicocelectomy, total nephrectomy) progressively became admitted between 11995 and 2000; the medical literature reflects this evolution: More than 300 articles on intra abdominal testis, 190 on varicocele, 120 on nephrectomy. Reconstructive surgery like pyeloplasty, ureteral reimplantation, ureterocelectomy and other advanced procedures is practiced today only by few teams around the world. That represents a new step for pediatric urologist; we will report our preliminary experience about 40 pyeloplasties and 70 Cohen procedures.

However, many problems remain to be solved and act as a brake upon expansion of MIS in pediatric urology:

  • The advantages of MIS haven't yet been demonstrated according to the criteria of Evidence Based Medicine
  • MIS is technically demanding, the learning curve is long
  • Indications for using MIS in pediatric urology are not very frequent
  • Tutoring is difficult with laparoscopy.


So even after more than 10 years, MIS remains little expanded in the field of Pediatric Urology. Our community has to think about how to reduce these limitating factors because it is worth for children to reduce as much as possible all the damaging side effects of surgery.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic orchiopexy: Procedure of choice for the non palpable suprainguinal abdominal testis

Ahmed M. Shelbaia, Ahmed M. El Nashar, Ali Hussein, Hashem Rashwan


Department of Urology, Cairo University Hospitals and Suez Canal University, Egypt

Objective: To evaluate the procedure of laparoscopy in the management of undescended testis.

Patients and Methods: Between May 2000 and January 2003, 22 male patients were selected with non-palpable suprainguinal abdominal testes were subjected to laparoscopic orchiopexy at Urology Departments of Cairo University Hospitals and Suez Canal University Hospital. Their ages ranged from 18 months and 18 years. Laparoscopy was performed by the closed method, the following parameters were assessed:

  • Any complications during the procedure
  • Laparoscopic findings: size of the testis, location, patency of the internal ring, caliber or the vessels and vas and any other congenital anomalies
  • Histopathology of testicular biopsy from old age patients.


Follow up of the patients after discharge from the hospital every 3 months for one year by clinical examination and scrotal sonography.

Results: 16 successful laparoscopic orchiopexy were performed and the testis was in good position with no complications, except one case, the patient developed testicular atrophy, two patients underwent laparoscopically assisted orchiectomy, blind ended vessels and vas with closed internal ring was found in 4 cases and inguinal exploration is not necessary as viable testicular parenchyma is rarely found.

Conclusion: We found that laparoscopy is the most accurate practical way for localizing the site of a non-palpable testis especially if other non invasive imaging modalities failed to localize the exact site of the non-palpable testis. Laparoscopy not only used for diagnosis but also used as a therapeutic procedure for treating impalpable testis. We concluded that laparoscopic orchiopexy is considered the most suitable tool for the management of non-palpable suprainguinal abdominal testis.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic management of non-palpable testis at King Fahd Armed Forces Hospital - Jeddah

Raboei Enaam, Salaheldin Syed, Luoma Reijo


Department of Urology, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia

The purpose of diagnostic laparoscopy in the management of the non-palpable testis is to answer the questions regarding testicular presence and location to plan overall surgical management with low incidence of complications.

We reported our experience with diagnostic and therapeutic laparoscopic management of non-palpable testis in forty-four patients (total of 50 testes). The age of the patients ranges from 6 months to 12 years old. We retrospectively reviewed the medical charts of these patients over four years period.

At laparoscopy, 6/50 (12%) testes were absent or atropic. Standard orchidopexy was done for 23 testes which were located either outside the abdominal cavity or at the internal ring, out of which, two testes were located intra-abdominally (IA) due to technical problem. Three patients underwent laparoscopic orchidopexy and two patients underwent one stage Fowler-Stephens procedure. Eighteen high IA testes (>3 cm from internal ring) underwent two stage Fowler-Stephens orchidopexy.

At follow up, ninety three percent (6 months to 3 years old) of the testes are of acceptable size and in normal scrotal position. One atrophic testis (2.3%) was found in the scrotum after the two stage Fowler-Stephens procedure.

The low incidence of complications and ninety three percent success rate encourage us to make laparoscopic exploration for non-palpable testes as our procedure of choice in diagnosing and to consider one stage Fowler-Stephens procedure or laparoscopic orchidopexy in treating non-palpable testes in the future.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Laparoscopic partial nephrectomies and nephrectomies can be accomplished safely in the very young child

Hamdan Al Hazmi, Ricardo Gonzalez, Anne-Marie Houle, Diego Barrieras, Julie Franc-Guimond


CHU Sainte-Justine, Division d'Urologie Pediatrique, Universite de Montreal and AI duPont Hospital for Children, Division of Pediatric Urology, Thomas Jefferson University, Wilmington, Delaware, USA

Purpose: Laparoscopic renal surgery is an effective treatment for nonfunctioning renal units, although its role in the very young is still largely undetermined. Our objective was to evaluate the efficacy and safety in a large series of laparoscopic procedures done in young children whom underwent nephrectomies or partial nephrectomies.

Materials and Methods: 41 laparoscopic procedures were performed in children less than 2 years (26 less than 1). The diagnosis were hydronephrosis in 7, multicystic/dysplastic kidneys in 6, nonfunctioning upper poles in 17 (2 upper pole UPJ obstruction, ectopic ureters with or without ureteroceles in 4 and 11), nonfunctioning lower poles in 4 or miscellaneous in 7.

Results: 20 total and 21 partial nephrectomies (17 upper, 4 lower) were performed laparoscopically in 23 females and 18 males. Mean age and weight were 9.89 months (2-23 months) and 8.47 kg (4-13.7 kg). 23 procedures were done transperitoneally vs. 18 retroperitoneally. Three ports (3-5 mm) were used in all except 2 (4 ports). The mean operative duration was 160 minutes. There were no intraoperative complications (surgical and anesthetic) including no transfusion. 7 cases done retroperitoneally were converted due to technical challenges (port leakage, poor visibility, peritoneal tear). The mean hospital stay was 2.15 days. Postoperative complications included an omental hernia and a urinoma.

Conclusions: Laparoscopic renal surgery can be carried out safely and effectively in young children and may avoid the morbidity of an open procedure. Transperitoneal approach or retroperitoneoscopy can be done but the latter approach is more challenging in a very young population.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Laparoscopic orchidopexy: The easy way to go

Hamdan Al Hazmi, Julie Franc Guimond, Anne-Marie Houle, Diego Barrieras


CHU Sainte-Justine, Division d'Urologie Pediatrique, Universite de Montreal and AI duPont Hospital for Children, Division of Pediatric Urology, Thomas Jefferson University, Wilmington, Delaware, USA

Purpose: Intra-abdominal testes represent less than 10% of cryptorchid testicules, yet they are the most challenging to correct. In the last 15 years, the 2-stage Fowler-Stephens orchidopexy has gained wide acceptance. The traditional approach includes laparoscopic or open clipping of the testicular vessels (first stage) and open inguinal orchidopexy (second stage). We present our experience with 2-stage orchidopexy with both stages done through a laparoscopic approach.

Materials and Methods: Between 1999 and 2003, we reviewed patients operated for intra-abdominal testis using a two stage laparoscopic orchidopexy with a minimum of one-year follow up. In this study, success is defined as a non-atrophic intrascrotal testis. 15 patients met the inclusion criteria and none was lost to follow up.

Results: In the 15 patients, 11 had a unilateral intra-abdominal testis and 4 had bilateral cryptorchidism, with one of the two testes intra-abdominal. First stage was done at a mean age of 32 months and the average time between the two stages was 9.7 months. All procedures (31) were done as an outpatient. Only 2 complications occurred, one scrotal hematoma and one redo first stage because of inappropriate clipping noticed at the time of planned second stage. The success rate is 93.3% (14/15). All testicules are intrascrotal and all testicules but one had maintained pre-operative volume.

Conclusions: 2-stage laparoscopic orchidopexy is a fairly easy surgical procedure with minimal morbidity and high short term success rate. A larger cohort of patient with long term follow up is needed to substantiate these findings.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Adult laparoscopic varicocele ligation using methyline blue lymphatic mapping: Early results

Ayman Adwan, Danny Rabah


Department of Surgery, Division of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Objectives: To evaluate the outcome and feasibility of injecting methyline blue intraoperatively aiming to preservation of lymphatic vessels during laparoscopic varicocelectomy and its impact on the rate of complications.

Patients and Methods: Twelve patients were included in the study with age range between 20 to 45 years (mean age is 30 years) out of which two patients were complaining of primary infertility and the rest were complaining of scrotal pain. Six of them had bilateral varicocele and the rest were unilateral. All of them had preoperative ultrasonogrphy which showed grade two to three varicocele. All of them underwent laparoscopic ligation of varicocele via 3 ports with scrotal injection of methyline blue. All received general anesthesia. After surgery the patients were followed up in one and six months for detection of varicocele recurrence, formation of hydrocele, testicular pain, atrophy and pregnancy.

Results: The operative time was ranging from 15 to 30 minutes (the mean was 22 minutes). There was no intra operative complication or bleeding. There was good visualization of the lymphatic vessels and cut short our operative tune by identifying the varicocele and divide it. None of them needed to be converted to open surgery. There was no scrotal or systemic reaction from the dye. All the patients left the hospital in the same day and only 2 patients needed morphine as analgesia and the rest received NSAID. At one month follow up, out of 12 patients 2 developed hydrocele one side, these two patients had bilateral varicocele preoperatively, one patient had persistent varicocele, one patient developed inguinal pain. At six months follow up still the two patients with hydrocele but not increasing in size and asymptomatic. The patients who had persistent varicocele needed to do angioembolization. Ultrasonography which was done at six months showed no change in the size of the both testes.

Conclusion: Use of methyline blue in laparoscopic ligation of varicocele contribute in avoiding lymphatic vessels ligation but does not fully preserve them and its rule in preventing hydrocele formation still controversial as we had 2 out of 12 patients with hydrocele formation.

Presented at the: 19 th Saudi Urological Conference

King Khalid University Hospital, Riyadh

26 February to 01 March 2007

Laparoscopic partial nephrectomy using renal artery perfusion for cold ischemia: Functional and oncological outcome

F. Nassar, C. Ghysel, K. Leeb, G. Janetschek


Department of Urology, Elisabethinen Hospital, Linz, Austria

Aim of the Work: We present our series on the safety and long term oncological and functional outcome of laparoscopic partial nephrectomy using renal artery perfusion for cold ischemia.

Patients and Methods: Of 128 patients having undergone laparoscopic partial nephrectomy in our center between August 2000 and November 2007, 31 were performed using cold ischemia are included in this study. Mean age was 58 years (range 22-80). Mean tumor size was 2.68 cm (range 1-5 cm). 6 patients had a solitary kidney, 8 tumors were hilar. Cold perfusion was achieved through renal artery catheterization followed by intra-operative artery clamping and perfusion with 4oC Ringer lactate solution with mannitol.

Results: Mean ischemia time was 40.8 min. (range 25-101 min). Mean estimated blood loss was 275 ml (range 50-100 ml). 3 patients converted to open surgery prior to induction of cold ischemia, 1 of these patients was due to difficulties in identifying the renal tumor in the absence of laparoscopic ultrasound. The two others were because of excessive sclerotic fat surrounding the kidney. 3 postoperative complications occurred including leakage from pyelo-calyceal system, pancreatitis and pulmonary embolism; none were related to cold perfusion. Nuclear scans showed functional kidney moiety in all but one case, where the kidney was lost due to intimal lesion of the renal artery, additionally; no difference in peak concentration times was documented between the operated and non operated side. Outcome revealed 100% tumor specific survival for 45 months median follow up.

Conclusion: Intra-operative cold ischemia for laparoscopic partial nephrectomy using arterial perfusion is safe and feasible. It constitutes a viable alternative for complex tumors where ischemia time is expected to exceed 30 min. we provide proof of principle confirming protective effect of cold perfusion to prevent parenchymal damage. The mechanism of this protection is twofold: Cooling of the kidney and continuous washout of toxic radicals.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University, Tabuk

18-20 March 2008

Retroperitoneal laparoscopic procedures for ureteric stones

E. Elmalik, K. Al-Rumaihi, K. Assadiq, A. Al-Ansari


Department of Urology, Hamad General Hospital, Doha, Qatar

Aim of the Work: To present the technique of RLP and our preliminary data in using the procedure, especially for stones.

Patients and Methods: Patients with large upper ureteric stones deemed to be difficult to clear by ESWL or endourological procedures were chosen to have their stones cleared by RLP as a minimally invasive alternative to open surgery. A couple of minutes video clip will be projected to show the procedure.

Results: 32 RLP were performed. The indicators included 28 upper ureteric stones, 2 renal cysts and two simple nephrectomies. There were 30 males and two females. Ages ranged between 26 and 50 (mean 41 years). The conversion rate was 15%. Operative time ranged from 40 to 130 minutes (mean 94 minutes). Stone clearance was 100%. There were no major complications (vascular or bowel injury, major bleeding). Minor complications occurred in 20% of cases (peritoneal tears, surgical emphysema, port infection or hematoma, prolonged drainage).

Conclusions: RLP is a useful technique especially for surgeons who perform in the retroperitoneal space. Its learning curve and rate of complications is comparable to classical laparoscopy with the added benefit of avoidance of entry to the peritoneal space with its attendant risks.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University, Tabuk

18-20 March 2008

Laparoscopic excision of pelvic mass

K. Othman, A. Zahrani


King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Aim of the Work: Cryptorchidism is a relatively common condition seen in pediatric age group. However, it is uncommonly seen in adulthood.

Patients and Methods: We have here 46 years old male patient presented with primary infertility. On examination, he had bilateral undescended testicles. Right one was non-palpable and left one was inguinal. CT abdomen and pelvis showed 12 cm right pelvic mass representing tumor in the right undescended testis. HCG was elevated. Patient underwent laparoscopic exploration and removal of this mass.

Results: Operative time was 1 hr and 40 min. minimal blood loss. No intra or postoperative complication. Patient discharged home the next day. The histopathology result was pure seminoma.

Conclusion: Laparoscopic excision of pelvic testicular neoplasm is safe and feasible and should be considered as compared to open approach.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University, Tabuk

18-20 March 2008

Survey of urological laparoscopic practice patterns in Saudi Arabia

D. Rabah, N. Abumostafa


Department of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Objective: Laparoscopic surgery is taking a greater role in the treatment of many urological diseases. We performed a survey aimed at defining laparoscopic practice patterns among urologists in Saudi Arabia.

Materials and Methods: In March 2007, detailed questionnaires about urological laparoscopic practice patterns were distributed to 352 urologists working in Saudi Arabia.

Results: The overall response rate was 42%. A total of 21% of certified urologists in Saudi Arabia performed no laparoscopy, 24.8% devoted less than 5% of their practice and 54.3% devoted 5% or more of their practice time to laparoscopic surgery. Of the respondents 27.5% stated that they had adequate training during residency to perform laparoscopy. Both age and time in practice were inversely related to amount of time devoted to laparoscopy (P = 0.0001). 32.9% of the urologists who were devoting 5% and more of their OR time to laparoscopy were in university hospitals (academia). Urologists in Ministry of Health (MOH) were the least to perform significant volume of laparoscopy among urologists in governmental hospitals sectors. The two most important reasons mentioned for doing laparoscopy were faster recovery period and reduced morbidity. The most laparoscopic procedures according to proportion of urologists who can perform laparoscopic surgery were varicocelectomy 38%, simple nephrectomy 27%, renal cyst decortications 23%, adrenalectomy 20%, radical nephrectomy 20%, pyeloplasty 18%, and orchidopexy 17%.

Conclusion: Urological laparoscopic practice in Saudi Arabia still in early stages. Accordingly, more laparoscopic procedures should be implemented in the local training programs.

Presented at the: 21 st Saudi Urological Conference

North West Armed Forces Hospital, Tabuk

14-16 April 2009

Laparoscopic boari flap ureteroneocystostomy for treatment of ureterovaginal fistula

A. Al-Kandari, A. Ibrahim, Y. Elshebiny, I. McGill


Urology Division, Adan Hospital, Kuwait, Department of Urology, Cleveland Clinic Urologic Institute, Cleveland, OH, USA

Aim of the Work: The Boari flap is a viable alternative for ureteral reconstruction when long defects of the ureter must be bridged to the bladder. We present our video of laparoscopic Boari flap ureteroneocystostomy for treatment of ureterovaginal fistula.

Patients and Methods: Laparoscopic Boari flap ureteroneocystostomy was performed in an adult female patient with a ureterovaginal fistula developed after abdominal hysterectomy. After mobilization of the ureter, the transected ureteral end was spatulated, fashioning of a Boari flap from the bladder, fixing it to the psoas muscle, direct anastomosis of the ureter to the flap, placement of a stent and closure of the flap over the stent was done.

Results: Operative time was 174 minutes. No postoperative complications were encountered.

Conclusion: Laparoscopic bladder flap (Boari) ureteroneocystostomy technique can be performed successfully for treatment of long ureteric defects as those encountered in cases of ureterovaginal fistula.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University, Tabuk

18-20 March 2008

Laparoscopic versus open donor nephrectomy comparative study in the transplant unit at King Faisal Specialist Hospital and Research Centre, Jeddah

A. Awad, A. Anaam, H. Saada, A. Al Shareef


King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia

Objective: Laparoscopic donor nephrectomy (LDN) is considered the preferred method for potential donors; we report our experience at King Faisal Specialist Hospital Transplant Unit, of 42 cases of Laparoscopic Donor Nephrectomy and comparing them with 80 cases of open donor nephrectomy (ODN). This study was designed to investigate the efficacy and safety of laparoscopic donor nephrectomy (LDN) in both the donors and the recipients.

Patients and Methods: A total of 122 cases of donor nephrectomy were performed from 2003 to 2008, of those 42 patients done by laparoscopy (LDN) and 80 cases done by open procedure (ODN).

Results:



Conclusion: Laparoscopic donor nephrectomy (LDN) is a safe minimally invasive procedure that gives good quality organs as the open procedure.

Presented at the: 21 st Saudi Urological Conference

North West Armed Forces Hospital, Tabuk

14-16 April 2009

The outcome of laparoscopic radical nephrectomy for localized renal cell carcinoma, King Faisal Specialist Hospital and Research Centre experience between 2002 and 2007

Abdullah Al Enizi, Hassan Al Zahrani, Khalid Al Othman, Mohammed Al Otaibi


King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To report the experience of KFSH&RC with Laparoscopic Renal Nephrectomy (LRN) for Renal Cell Carcinoma (RCC) with a minimum follow up of 2 years.

Methods: All cases of LRN for radiologically suspected RCC between July 2002 and December 2007 were included. The data were collected retrospectively and included patient's demographics, clinical presentation, co-morbidities, laboratory and imaging studies, operative data, postoperative immediate and late complications, histology results, cancer control and renal function on their last follow up.

Results: Fifty two (52) patients were scheduled for LRN including 31 males and 21 females with a mean age of 56 year (21-78). Forty patients (77%) had an incidental finding, 6 (11%) had pain, 4 (8%) had hematuria and 2 patients (4%) during follow up for other malignancy. Fifty one patients had normal preoperative creatinine and one patient was on hemodialysis. Forty seven patients had enhancing solid lesions and 4 had complex cysts with size ranging from 3.5 to 12 cm (mean 7.2 cm). Thirty four patients (65%) had other co-morbidities. All cases were done with a transperitoneal approach and intact specimen retrieval. Five cases were converted to open, 4 due to failure to progress and 1 due to vascular injury. The operative time ranged from 75 to 320 minutes (mean 170 min) and was getting less with experience. Blood loss ranged from less than 50 cc to 1250 cc (mean 120 cc). Two patients received blood transfusion. One patient was taken back to OR due to massive bleeding and admitted to ICU. One patient died on the 3rd postoperative day from pulmonary embolism. One patient developed immediate renal impairment and had renal transplant 3 years postoperatively. The mean postoperative hospital stay was 5 days (3-14 days). One patient had incisional hernia and 2 had temporary orchalgia. The histopathology showed RCC in 41 patients, 3 oncocytoma, 1 mucinous tubular cell carcinoma, 2 hydatid disease, 1 synovial sarcoma, 1 AMI, 2 benign cysts and 1 renal hypertrophy. All margins were negative and pathological stage was: pT1a 4, pT1b 20, pT2 16, pT3b 1. Of the RCC cases 5 patients lost follow up and 2 of the other 36 developed metastasis and died of their disease at 22 and 27 months. The synovial sarcoma patient had recurrence and died of her disease 5 months later. The DFS at a mean follow up of 56 months (24 to 90 months) for the RCC patients is 94%. Follow up on renal function was available on 42 patients. One patient developed ESRD and had renal transplant, 6 patients had renal impairment with drop of their eGFR to less than 50%. They all had DM.

Summary and Conclusion: Our experience with LRN for localized RCC matches the reported literature from other centers worldwide with cancer control and renal function outcome. While LRN I s a standard procedure for localized RCC, NSS sho7uld be considered for T1 lesions if technically feasible.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Laparoscopic pyelolithotomy for partial staghorn stones

Ahmed Jalal Al Sayyad, Abdulmalik Al Tayeb


Department of Urology, King Abdulaziz University, Jeddah, Saudi Arabia

Introduction: To confirm the feasibility and safety of laparoscopic pyelolithotomy in partial staghorn stones.

Methods: 17 patients underwent laparoscopic pyelolithotomy for partial staghorn stone included in a prospective study at King Abdulaziz University Hospital in the period between May 2007 until February 2009. Preoperatively, all patients had blood work, urine culture, ultrasonography and CT renal stone study. Inclusion criteria included stones with largest diameter of more than 25 mm (measure by CT), branching into one or more group of calices, and no contraindication for laparoscopic surgery. All patients underwent cystoscopy, DJ stent insertion prior to the procedure, while prophylactic antibiotics provided for all the patients with or without positive urine culture.

Results: All patients were completed laparoscopically where none required conversion to open surgery or developed intraoperative complications. The largest diameter of the stones varied between 29 and 48 mm with mean diameter of 41 mm, and the number of stones removed was 1-4 with mean of 1.3. The mean operative time was 175 minutes (range 125-240 minutes) and the estimated blood loss was 20-150 ml with mean of 49 ml. All patients cleared from their stones except 2 patients had small residual stones of 5 mm and 7 mm which were managed later by ESWL. One patient developed ileus, postoperatively.

Summary and Conclusion: Laparoscopic removal of partial staghorn stones is safe and feasible and has an equal outcome to open surgery.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Laparoscopic donor nephrectomy, King Fahad Specialist Hospital experience

Ibrahim Abdulkarim Al Oraifi, Hanan Al Ghamdi


Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia

Introduction: Laparoscopic donor nephrectomy became the standard of care in many international transplant centers. We recently adopted this in our new transplant center as our routine procedure for living donor nephrectomies.

Methods: We performed 10 laparoscopic donor nephrectomies using the transperitoneal approach. Full explanation of the procedure will be shown in the video.

Results: No open conversion, no blood transfusion and no complications were encountered. All patients have normal renal function.

Summary and Conclusion: Our results of laparoscopic donor nephrectomies are comparable to international series and we believe that the procedure is safe in our hands with less morbidity to our patients.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Laparoscopic transperitoneal ureterolithotomy for impacted proximal ureteric stones

Ahmed J. Al Sayyad, Ashraf J. Abusamra


Department of Urology, National Guard Hospital, Jeddah, Saudi Arabia

Aim: Large impacted proximal ureteric stones constitute a management dilemma to the practicing urologist. We reviewed our experience of laparoscopic ureterolithotomy for this special type of stones.

Methods: Retrospective chart review was carried out for all patients who underwent laparoscopic ureterolithotomy at our institutions over the last 2 years. Exclusion criteria included: stones <2 cm in size, lower ureteric stones and follow up duration <6 months.

Results: Twelve (12) patients were identified (9 men and 3 women). Mean age was 53 years (31-67). Mean stone largest dimension was 3.9 cm (2.1-6.2). Mean number of stones was 1.4 (1-3). Operative time ranged from 40 to 150 minutes with mean of 62 minutes. Mean blood loss was 30.8 mm (20-90). Hospital stay ranged from 1 to 5 days with a mean of 2.5 days. Mean duration of ureteric stenting was 7.2 week (4-12). We achieved 100% stone clearance rate. Mean follow up duration was 14 months (6-30). Postoperative complications included ureteric stricture which developed in 2 patients; it developed 6 months postoperative in one patient and 15 months in the other.

Summary and Conclusion: Laparoscopic ureterolithotomy is a safe and reliable procedure for this special group of patients with an excellent success rate. The need for long term follow up cannot be overemphasized.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Laparoscopic vs open nephroureterectomy for upper tract urothelial tumors, outcome and cancer control difference: Single centre experience

Mahmoud Sherief, Khalid Al Othman, Ali Al Zahrani, Hassan Al Zahrani, Mohammed Al Otaibi


King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objectives: Upper tract urothelial carcinoma (UTUC) is not a common disease, accounts for 5-10% of all renal tumors and 5-6% of all urothelial tumors. Nephroureterectomy (NU) has been the standard of care for UTUC. Since 1991, conventional open NU is being replaced by laparoscopic nephroureterectomy (LNU) as a treatment option for UTUC. It is increasingly being used instead of open nephroureterectomy (ONU) but the evidence of equal oncologic effectiveness is still lacking. We reviewed our experience at KFSH&RC regarding perioperative outcome and the oncologic outcomes in both LNU versus ONU.

Patients and Methods: This is a retrospective comparative study for patients between years 2000 and 2008 with UTUC treated at our institution underwent nephroureterectomy either open or laparoscopic. Thirty seven (37) patients with non-metastatic UTUC were enrolled. Patient's full chart data were reviewed. Twenty (20) patients open (Group I) and seventeen (17) patients laparoscopic (Group 2). Standard preoperative evaluations were done for the diagnosis and localization of the upper tract tumors. Both open and laparoscopic procedures were done in the standardized technique. End points of the study outcomes including perioperative and oncologic outcomes were reported.

Results: Both groups are matched regarding age, sex and performance status. Operative times were comparable, while mean blood loss and hospital stay were significantly lower in Group 2; 882.5 ml versus 523 ml and 9.2 days verus 5.9 days, respectively. In a median follow up of 46 months, local recurrence was comparable but more in ONU. Bladder recurrence was higher in LNU; 12 versus 7 patients. Time to recurrence was shorter in LNU; 15.2 months versus 20.7 months. Over-all survival is comparable but in favor with LNU, 71% for LNU versus 63% for ONU. The limitations of our study include the small sample size and the personal choice of laparoscopic technique.

Conclusion: Although perioperative outcomes are in favor of LNU, it has a higher bladder recurrence rate. Larger number of patients in a randomized controlled study would be appreciated.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Transperitoneal laparoscopic right adrenalectomy for pheochromocytoma

Hassan Al Zahrani, Mohammed Al Otaibi


King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: The aim is to describe the technique of transperitoneal right laparoscopic adrenalectomy for pheochromocytoma.

Methods: A 67 year old male was referred to us a 6.7 cm right adrenal mass. His endocrinologic evaluation showed pheochromocytoma. After control of his blood pressure, he was scheduled for right laparoscopic adrenalectomy.

Results: Patient was positioned with his right side up at 60 degrees. Pneumoperitineum was established with a veress needle. Four ports were used, 1 for camera, 2 working and 1 for liver retraction. The hepatic flexure was mobilized and duodenum cocharized to expose the IVC. The mass was separated from the right upper pole. Adrenal veins were identified and clipped medially and inferiorly. The mass was dissected from its lateral and superior attachments and then removed intact in an endocath bag. Blood loss was 200 cc. The patient did well postoperatively and was discharged in good condition on post operative day 2.

Summary and Conclusion: Laparoscopic adrenalectomy is the standard of care for adrenal masses that requires excision and size up to 10 cm in many centers worldwide. It offers patients minimal morbidity and excellent recovery.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Left laparoscopic simple nephrectomy for large hydronephrotic kidney crossing the midline

Mohammed Al Otaibi, Hassan Al Zahrani


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To describe the technique of laparoscopic simple nephrectomy for large hydronephrotic kidney.

Materials: A 26-year old male presented to local hospital with high blood pressure. On evaluation, he was found to have severely hydronephrotic left kidney that was crossing the midline. It was 25 cm in largest diameter. The kidney was non-functioning.

Result: Left laparoscopic simple nephrectomy was done using classical 3 ports technique. Open hasson technique was done to insert the camera port. The kidney was partially drained using percutaneous needle aspiration under direct vision. After controlling the hilum, the kidney was opened and drained completely. The rest of the dissection was carried on and the kidney was removed from 2 cm incision.

Conclusion: Laparoscopic nephrectomy should be tried in all simple nephrectomies for hydronephrotic non-functioning kidney. The size of the kidney could be managed by partially draining the kidney until the dissection is completed.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Step by step technique of laparoscopic sacrocolpopexy

Ahmed Al Zahrani, Romeo Stefanescu, Vardi Adam, Salim Taleb, Aurel Messas


Department of Urology, Max Fourestier Hospital, France

Introduction: Genito-urinary prolapsed is a common disease that requires a global approach which includes all the compartments. Sacrocolpopexy with anterior and posterior mesh allows an anatomical restoration with preservation of the sexual function.

Materials and Methods: Between 2004 and 2010 more than 120 cases of laparoscopic sacrocolpopexy were done by different surgeons in our center. We have established our own steps of intervention following the standard technique of these procedures.

Results: The laparoscopic approach is a modern and efficient answer for this functional surgery. It combines the advantage of a similar technique to the open route compared to the vaginal approach, without the need for a large abdominal incision, abdominal packing and extensive bowel manipulation.

Conclusion: The surgical techniques described can help maximize the accuracy and safety of this procedure and minimize the steep learning curve usually associated with laparoscopic abdominal sacrocolpopexy.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21-24 February 2011

Laparoscopic repair of vesicovaginal fistula

Ahmed Al Zahrani, Romeo Stefanescu, Adam Vardi, Salim Taleb, Aurel Messas


Department of Urology, Max Fourestier Hospital, France

Introduction: The objective of this presentation is to demonstrate the advantages of the laparoscopic approach in the treatment of complex vesico-vaginal fistula.

Materials and Methods: We have in the operating room two laparoscopic columns. The patient is placed supine with legs apart, arms to the body. A laparoscopic column is placed between the legs of the patient while the other one is prepared toward the head of the patient in case of mobilization of ementum is needed. After the bladder has been opened each edge of the bladder wall was suspended to the anterior abdominal wall to facilitate exposure. A urinary catheter is inserted into the vagina and the balloon is inflated to inject blue serum and identify any fistulas. Each fistula was spotted by a coagulation point. The use of LigaSure® can help in the mobilization of the ementum.

Results: This 10 minutes film demonstrate each time of this intervention.

Conclusion: The laparoscopic approach allows the treatment of complex vesico-vaginal fistulas and systematic interposition of omentum between the bladder suture lines and vagina which has a major advantage because of the wide median laparotomy necessary to achieve the same treatment in the open approach.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21-24 February 2011

Laparoscopic ureterolithotomy of huge ureteral stone

Khaled Al Kohlany, Khaled Baker


Department of Urology, Medical College, Sanava University, Yemen

Introduction: Uro-laparoscopy is recently started in Yemen. We started with simple procedures such as varicocelectomy and ureterolithotomy.

Materials and Methods: In this video presentation we show one patient with huge (6 × 3 cm) ureteral stone removed by laparoscopic surgery. DJ stent was inserted prior to operation. It was not suitable for endoscopic surgery and the only alternative was open surgery.

Results: The procedure was successfully performed with no intraoperative or postoperative complications. Operative time was 120 minutes. Hospital stay 3 days.

Conclusion: Laparoscopic ureterolithotomy is a good alternative to open surgery in removal of large ureteral stones not suitable for ESWL or endoscopic removal.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21-24 February 2011

Laparoscopic single port simple nephrectomy King Khailid University Hospital early experience

Danny M. Rabah, Mohamed M. Gadelmoula, Majid M. Al Aqeeli


Department of Urology, King Khailid University Hospital, Riyadh, Saudi Arabia

Introduction: Laparo-endoscopic Single Site (LESS) is an appealing yet technically challenging procedure. Many surgeries were reported in literature to be performed using LESS. Herein, we present our early experience in using LESS in KKUH.

Materials and Methods: 41 y.o. lady post-emergency C/S in another hospital, complicated with left ureteric injury and a non-functioning kidney. Came to KKUH for further management, LESS was performed as follows

  • Single Port inserted through a 3-cm incision using open technique
  • Pneumoperitoneum was created
  • Reflection of the colon
  • Mobilization of lower pole
  • Identification and traction of the ureter
  • Aspiration of the hydronephrotic kidney
  • Control of the renal pedicle
  • Mobilization of the upper pole
  • Extraction of the kidney using Endobag
  • Abd wal closure in layers.


Results: Operative time was 3½ hrs with no intraoperative complications. Estimated blood loss was 200 cc. Postoperative analgesia requirement was minimal and patient was tolerating orally on Day 1 post-op. And patient was discharged in an excellent condition on Day 3 post-op and was happy with the cosmetic outcome.

Conclusion: LESS seems to have minimal postoperative analgesia requirement and apparently a better cosmetic outcome. However, it's technically challenging, especially in the early experience. It has a longer operative time, more expensive instruments compared to the conventional Laparoscopy making it less feasible.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21-24 February 2011

Laparoscopic donor nephrectomy, King Faisal Specialist Hospital, Dammam experience

I.A. Al Oraifi, Hanan Al Ghamdy, M.A. Aggamy


Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia

Introduction: Laparoscopic donor nephrectomy became the standard procedure for donor nephrectomy in many centers all over the world. We adopted that in the year 2009 to be a routine procedure for living related donor nephrectomies.

Methods: We performed 31 laparoscopic donor nephrectomies using the transperitoneal approach and removing the left kidney. Full explanation of the procedure will be shown in the video.

Results: 2 open (6.45%) conversions, one because of bleeding time from a lumbar vein and another because of a loaded left colon which couldn't be cleared with sigmoidoscopy intraoperatively. All graft was functioning normally in the immediate post-operative period and thereafter. Mean operative time was 180 min. and blood loss was minimal. Warm ischeamic time was 2.8 min.

Conclusion: Our results of laparoscopic donor nephrectomy are comparable to the internationally published series and we believe that the procedure is safe in our hands with less morbidity to our patients.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21-24 February 2011

Laparoscopic de-roofing of a renal cyst

Ibrahim Al Oraifi, M.A. Aggamy


Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia

Introduction: We believe that this laparoscopic technique is a significant advance in urological surgical management and may be a better option for symptomatic, recurrent, simple renal cysts. We used laparoscopy in a selected patient to unroof a huge renal cyst.

Purpose: We document our experience with laparoscopic cyst decortications for renal cysts.

Materials and Methods: 25-year old female patient was diagnosed to have a huge right renal cyst 9x9x25 cm. The patient was scheduled for laparoscopic right de-roofing of the renal cyst. A ureteral catheter was inserted to check if there are any communications between the pelvi-caliceal system and the cyst by injecting methylene blue through the catheter, the procedure was performed via 3 ports trans-peritoneal approach. The ligasure was applied to coagulation and cutting, at the end we covered the de-roofed surface with an omentum.

Results: Operative time was 80 minutes and the blood loss was very minimal. The procedure was minimally traumatic, morbidity was negligible and the patient was discharged from the hospital the morning.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21-24 February 2011

Laparoscopic donor nephrectomy for 99 cases: Our experience

Hosam S. Al Qudah, Omar Siddiki, Hisham Abu Taha, Tariq Tassadaq, Ahnaf Bataynah, Sameh Murad, R.N. Ahmad Shurman


Department of Urology, Saad Specialist Hospital, Saudi Arabia

Introduction: Laparoscopic donor nephrectomy was introduced for the first time in 1996. During these years it gained popularity in many transplant centers around the world. We wanted to present the experience of our charity program in this field.

Materials and Methods: Retrospective chart review of all the transplant cases (recipients and donors) since January 2006 was done. We collected data on donor's age, sex, relation with the recipient, nationality, ischemia time and complications. For the recipients we added the kidney function.

Results: 99 living kidney transplants were done. Five cases were living unrelated. All donors were completed laparoscopically except one case that was converted to open for bleeding control. Donors' mean age was 32 (19-51) year and male to female ratio was 2.9:1. Recipients mean age was 35 (range 10-59) year with male to female ration of 2:1. There were no reported major donor complications except one donor who needed repair of a strangulated hernia on first post operative day. Minor complications included ileus in 5 patients and wound infection in two patients. Recipients' major complications included one graft primary non-functioning and five cases of delayed graft function (three patient had ATN and two had acute rejection). 3 cases of urine leak treated with re-implantation and two cases of urinary tract infection. Lymphocele reported in four cases. Wound infection was found in three cases. All kidneys except two were functioning in the last follow up.

Conclusion: Laparoscopic donor nephrectomy is a safe and reliable alternative for open surgery.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21-24 February 2011

Uro-laparoscopy in Yemen - to start late better than never

Khaled Al Kohlany, Morshed Salah, Khaled Baker


Department of Urology, Medical College, Sana'a University, Yemen

Introduction: Although there are great advances and achievements in uro-laparoscopy worldwide, it is still not well developed and organized in Yemen. Sporadic cases are done here and there by urologists or surgeons in the year 2009 among the activities of the 3rd Yemeni Urological Conference, a teaching course with training on animals was organized with help of Saudi Urological Association. After this course, laparoscopic procedures started in different hospitals. In this presentation we will show our initial experience in doing uro-laparoscopic procedures in Yemeni urological practice.

Materials and Methods: Laparoscopic team was created by 3 motivated urologists from different hospitals with reasonable background in laparoscopic surgery. Organized uro-laparoscopic procedures have been started in General Military Hospital where modern laparoscopic equipment was provided.

Results: Between May and November 2010, 32 laparoscopic varicocelectomies (20 unilateral and 12 bilateral), 5 ureterolithotomies and 3 nephrectomies have been done successfully. No conversion to open surgery and no major intra or postoperative complications. Mean operative time for unilateral varicocelectomy was 19.55 minutes (range 10-35 minutes), for bilateral varicocelectomy was 29.41 minutes (range 20-40 minutes), for ureterolithotomy was 110 minutes (range 90-130 minutes) and for nephrectomy was 120 minutes (range 115-130 minutes).

Conclusion: Although late, uro-laparoscopic surgery started in Yemeni urologic practice with a reasonable outcome. Proper laparoscopic equipment and motivated laparoscopic team are essential for successful outcome.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21-24 February 2011

Radical nephrectomy with robot Da-Vinci surgical system

Dogra Prem Nath, N.P. Gupta, A.K. Hemal


Department of Urology, King Faisal University, Al Ahsa, Saudi Arabia

Computer assisted robotic surgery (CAS) has established its role in radical prostatectomy, pyeloplasty, adrenalectomy, radical cystectomy and repair of V.V.F., U.V.F., etc. After gaining initial experience and confidence, we explored the feasibility of CAS in radical nephrectomies, whether the procedure can be successfully accomplished.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University, Tabuk

18-20 March 2008

Iatrogenic pelviureteric junction obstruction obstruction

A. Elshennawy


Department of Urology, King Fahd Hospital, Al Baha, Saudi Arabia

Case Report: Nine years old boy was subjected to pyelolithotomy for right staghorn stone one year ago. He was presented a month ago with right loin pain, microhematuria and urinary tract infection. Excretory urography showed multiple right renal stones with pelviureteric junction obstruction. He was subjected to right percutaneous nephrolithotomy and endopyelotomy with antegrade JJ stent insertion.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University, Tabuk

18-20 March 2008

Robotic partial nephrectomy for renal cell carcinoma, King Faisal Specialist Hospital and Research Centre early experience

Hassasn Al Zahrani, Mohammed Al Otaibi, Waleed Al Khudair


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To report the outcome of our early experience with robotic assisted partial nephrectomy for renal cell carcinoma.

Methods: All cases scheduled for robotic partial nephrectomy for radiologically suspected renal cell carcinoma (RCC) were analyzed. Data included patients' demographics, clinical presentation, comorbidities, laboratory and imaging studies, operative approach, warm ischemia time, total operative time, blood loss, blood transfusion, intra and post operative complications, pathology results and margin status and renal function.

Results: Between October 2008 and January 2010, 6 patients had 7 robotic partial nephrectomies for RCC in our hospital. There were 3 females and 3 males. The mean age was 46 year (32-63). They all had asymptomatic incidental solid unilateral lesions in 5 patients and bilateral in 1 patient. All had normal preoperative renal function. All cases were completed as planned with no complications or conversion. Warm ischemia time mean time was 20.4 min (15-36). Mean blood loss was 85 cc (less than 50-200). No blood transfusion was given. No post operative complications. Pathology results showed RCC in all cases (5 clear cell type, 2 papillary). There was one positive surgical margin, renal function was comparable postoperatively to the preoperative finding.

Summary and Conclusion: Our initial experience with robotic partial nephrectomy for RCC is encouraging and proved the international trend of the acceptance of this modality for nephron sparing surgery (NSS). We recommend referring potential cases for NSS to centers with minimally invasive surgery experience.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Robotic pyeloplasty for pelviureteric junction obstruction obstruction in adults, King Faisal Specialist Hospital and Research Centre 5 years experience

Ahmed Al Enezi, Hassan Al Zahrani, Mohammed Al Otaibi, Khalid Al Othman, Waleed Al Khudair


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To report the perioperative and clinical and functional outcome of robotic assisted pyeloplasty in the treatment of pelviureteric junction obstruction (PUJ) in adult patients at King Faisal Specialist Hospital and Research Centre, Riyadh.

Methods: All cases scheduled for robotic assisted pyeloplasty between September 2004 and June 2009 were included. The data were collected retrospectively and analyzed for patient's demographics, clinical presentation, laboratory, and imaging studies. The operative approach, time, complications and techniques were analyzed. Post operative complications and need for unplanned procedures were recorded. Clinical and functional outcome was assessed and success was defined as pain resolution or improvement that needed no use of analgesia with or without improved drainage or differential function on renal scan. Failure was defined as persistence of pain or deterioration of renal scan or both.

Results: Thirty six patients were scheduled for robotic assisted pyeloplasty with a mean age of 34 year (14-52). There were 22 females and 14 males. Pain was the presenting complain in 30 cases (83%), stones in 4 (11%) and infection and hematuria in 2 (6%). Thirty one cases had primary PUJ and 5 had previous repair (4 endopyelotomy and 1 laparoscopic pyeloplasty). One patient had bilateral PUJ and one had an L-shaped fused kidney. All patients had normal renal function preoperatively. Diuretic renal scan showed obstruction in 32 cases. Cystoscopy with retrograde and stent placement prior to repair was done in 19 cases and 17 had stent placed antegradely during the robotic repair. All cases were done with a transperitoneal approach and there were no major intraoperative complications or conversion. The proximal end of one stent was broken during manipulation. Simultaneous stone extraction was successful in 2 cases. Anterior crossing vessel was found in 21 cases (58%). Twenty eight repairs were done with dismembered pyeloplasty, 5 YV plasty and 3 fengerplasty. The mean operative time excluding the cystoscopy part was 230 min (150-310). Blood loss was minimal in all cases. One patient developed ileus, atrial fibrillation and pulmonary embolism and was discharged in good condition on post operative day 22. One patient was taken the second day post operatively for ureteroscopy for migration of stent. One patient had a urine leak and a nephrostomy tube was inserted. The mean post operative hospital stay was 3.6 days (2-22). Renal scan was done in all cases at 3-6 months of follow up. At a mean follow up of 27 months (6-57), pain disappeared in 22 cases (61%), improved in 10 (28%) and 4 patients had persistent pain. Failures with need for further repair were done in 3 patients at 3, 26, and 44 months after repair.

Summary and Conclusion: Robotic assisted pyeloplasty combines the advantages of minimally invasive surgery, open technique and information technology in the treatment of PUJ obstruction. Our experience supports the reported literature that this procedure is the standard of care.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Robotic bladder diverticulectomy

Ahmed Jalal Al Sayyad


Department of Urology, King Abdulaziz University, Jeddah, Saudi Arabia

Bladder diverticulum can be congenital or acquired secondary to outlet obstruction and often become a dilemma to treat. I report my experience with a case of robotic diverticulectomy for a BPH patient who used to have severe LUTS and after surgery and the use of alpha blockers, he improved significantly. Robotic diverticulectomy got all the advantages of MIS beside the 3D, HD vision and the ability to reach difficult regions in the pelvis.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Robot-assisted laparoscopic repair of ureteropelvic junction obstruction due to a crossing vessel

Mohamed Aly Aggamy, Adel Al Dayel, Mohamed Gomha


Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia

Introduction: Pyeloplasty is a well established procedure in urology. Robot-assisted laparoscopic pyeloplasty was introduced since about 5 years. We provide in this video, details of surgical management of sub-pelvic obstruction due to crossing vessel using DaVinci Robot.

Methods: In this video, we present a robot-assisted laparoscopic pyeloplasty using DaVinci robot which provides movement freedom in six directions in addition to 3D vision. Under GA, and in lithotomy position left DJ stent was placed. The patient was repositioned and abdominal insufflations with versus needle was performed, then the robotic ports were developed and another 11 Fr port for assisting caudal to the camera in the midline. Mediocolic incision of the mesentery then the ureter was identified and the renal pelvis was dissected to show a crossing vessel, which was dissected carefully and elevated from the pelviureteric junction. The pelviureteric junction was divided and placed in front of the blood vessel, the DJ stent was readjusted, ureter and renal pelvis were splitted, spatulated and re-anastomosed with 5/0 vicryl in an interrupted fashion. The operative findings and procedure are shown in the video.

Results: The operative time was 2 hours and 15 minutes. Blood loss was less than 100 ml. There was no intraoperative or postoperative complication.

Summary and Conclusion: We conclude that robotic pyeloplasty results are comparable to those of surgery with less morbidity. However, special knowledge of robotic surgery is necessary to provide the patient with a safe and effective minimally invasive alternative to open pyeloplasty.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Robotic-assisted ureteric reimplantation in adults

Waleed Al Khudair, Mohammed Al Otaibi, Hassan Al Zahrani


King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To describe the technique of robotic assisted ureteric reimplantation in three (3) adults.

Methods and Materials: Three (3) adult patients (15-26 year old) presented with unilateral ureterovesical stenosis, 2 left and 1 right.

Results: The video will illustrate patient position, ports placement, ureteric dissection, stenting and the ureterovesical anastomosis. All cases were completed as scheduled without complications. The operative time ranged from 105 to 140 minutes. Stents were removed 4-6 weeks after surgery. All patients were well on follow up visits.

Summary and Conclusion: Robotic assisted ureteric reimplantation simplified the minimally invasive approach and gives the patient all the advantages of minimally invasive surgery.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Bilateral robotic-assisted laparoscopic dismembered pyeloplasty using the same ports

Hassan Al Zahrani, Mohammed Al Otaibi, Waleed Al Khudair


King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To describe the technique and feasibility of bilateral simultaneous robotic-assisted laparoscopic dismembered pyeloplasty using the same ports.

Methods: A 28-year old male patient was diagnosed with bilateral pelviureteric obstruction. The 3 arms DaVinci System was used. A 12 mm camera port was placed at the umbilicus. An 8 mm port was placed midway between the umbilicus and the xiphoid process and used for the robotic arm in both sides. Another two (2) 8 mm ports were placed 2 inches lateral to the midline midway between the umbilicus and symphysis pubic in each side. They were used exchangingly for the robotic arm and assistant port. A 3 mm port was placed between the camera and the midline cranial port and used for the double J stent insertion on both sides. The left side was done first with left side up at 60 degrees and then the patient was repositioned for the right side.

Results: The left dismembered pyeloplasty was done through a mesocolic approach with stent placed antegradely. A right side dismembered pyeloplasty was performed with antegrade stent placement. The total procedure including repositioning lasted 4 hours. It was finished as planned with no intraoperative complications. The patient was discharged home 2 days after surgery and stents were removed 6 weeks later.

Conclusion: Bilateral simultaneous robotic-assisted laparoscopic dismembered pyeloplasty using the same ports for both sides is feasible in selected patients with bilateral PUJ obstruction and thin body built.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Lymphangioma of bladder managed with robotic-assisted laparoscopic partial cystectomy

Mohammed Al Otaibi, Hassan Al Zahrani, Waleed Al Khudair


King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To describe a technique of robotic-assisted laparoscopic partial cystectomy for a bladder tumor.

Methods: A 29-year-old female was evaluated for gross hematuria and found to have a supravesical mass that was not invading bladder mucosa. Endoscopic biopsy showed no evidence of malignancy. Patient was placed in extended Trendelenburg position. A 12 mm camera port was placed above the umbilicus at midline. Two 8 mm ports were placed lateral to the rectus and 2 inches below the umbilicus. A 10 mm assistant port was placed lateral to the rectus at the umbilicus level on the left side. Bladder filling with saline through the catheter was done to delineate the relation of the mass to the bladder. After complete mobilization of the mass, 2 stay sutures were placed 1 cm away from the lateral edge of the tumor. Using 1 cm margin, the tumor was excised. The bladder wall was thereafter closed in 2 layers using 3-0 monocryl for the mucosa and 2-0 PDS for the detrusor and serosa. A JP drain was placed.

Results: Procedure was completed in 2 hours with minimal blood loss and no complications. The tumor was placed in endocath bag and removed by enlarging the camera port. A cystogram on post operative day 6 showed no leakage and was discharged in good condition. The histopathology showed a lymphangioma.

Conclusion: Robotic-assisted laparoscopic partial cystectomy offers all the advantages of minimally invasive surgery with the extra advantage of the robotic system of precise dissection, excision and reconstruction.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Robot-assisted laparoscopic repair of vesicovaginal fistula post hysterectomy

Mohamed Aly Aggamy, Adel Al Dayel, Mohamed Gomha


Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia

Introduction: Vesico-vaginal fistulae due to hysterectomy is not uncommon problem. Open surgical approach is still representing the gold standard although the laparoscopic technique is less invasive; it is not widely used because of the demand for specialized expertise. The robot-assisted laparoscopic repair emerged as valid alternative for the laparoscopic technique as it combine the shorter learning curve with the minimally invasiveness. We are presenting in this video a fistula repair procedure using DaVinci Robot.

Methods: The procedure performed transperitonealy using DaVinci® Robot assisted laparoscopy to treat a vesicovaginal fistula in a 36 year-old lady that was discovered three months after hysterectomy. Cystoscopy revealed a 1.5 cm wide opening positioned highly in the posterior wall of the bladder. Patient was positioned in the lithotomy position with a 60-degree Trendelenburg. Then the three trocars of the robot were inserted followed by a fourth one for the assistant. The procedure was started with dissecting the peritoneum from the dome of the bladder through longitudinal incision of the bladder dome and extended down to the fistulous opening. The vesical wall was separated from the vagina, and closed in to layers then the vaginal wall was closed.

Results: The operative time was 3 hours and 35 minutes. Blood loss was minimal; there were no intra operative complications. Post operative course passed smoothly. Patient was seen in three months after the procedure and she was doing fine.

Summary and Conclusion: Robotic-assisted laparoscopic repair of the vesicovaginal fistula is feasible and comparable to open surgery with early recovery and short hospital stay.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Robotic-assisted laparoscopic salvage radical prostatectomy after radical radiotherapy

M.A. Aggamy, Mohamed A. Gomha, Alexander Motrie


Department of Urology, King Fahd Specialist Hospital, Dammam, Saudi Arabia

Introduction: Recurrence of prostatic cancer after radical radiotherapy can be cured by salvage radical prostatectomy if it is localized to the prostate. Salvage prostatectomy is, however, technically more difficult and is associated with a high rate of incontinence. The aim of this video is to show the feasibility of robotic-assisted laparoscopic salvage radical prostatectomy.

Methods: A 55-year-old man was diagnosed as prostatic carcinoma by TRUS prostatic biopsy. His PSA was 41 ng/ml and clinical stage was T2b NO MO. Patient was initially treated in Dec 2007 by radical radiotherapy (72 Gy) and adjuvant/neoadjuvant hormonal therapy. Patient has a nadir PSA of 1.3 in June 2008 and then he has relapse with PSA 26 ng/ml in Feb 2010. Bone scan and CT showed no evidence of metastases. He then underwent robotic-assisted laparoscopic prostatectomy. Operative parameters, operation time, estimated blood loss, conversion to open surgery rate, blood transfusion, transurethral catheter time and functional outcome were reviewed.

Results: The procedure was somehow difficult because of the effect of radiation on tissue planes but was feasible there was no need for conversion to open surgery or transfusion. Operation time was 180 minutes. No intraoperative complications were reported. Total transurethral catheter duration was 10 days. Histopathology of the removed specimen showed negative margins. Patient was continent 2 month postoperatively.

Conclusions: Robotic-assisted laparoscopy radical prostatectomy after failed radiation therapy is a safe and efficient method of treatment.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21-24 February 2011

Robot assisted laparoscopic radical nephrectomy for a large renal-cell carcinoma

M.A. Aggamy, Riyadh Al Mousa, Alexandre Motrie


Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia

Introduction: Laparoscopy has become a standard modality for most renal tumors; Robotic technology may facilitate such complex procedures, due to the flexibility of the robotic wrested instruments.

Objective: This film presents the first case of robotic assisted laparoscopic radical nephrectomy in our institute.

Methods: A 48 year-old man who had a 11 cm × 8 cm × 10.5 cm lesion occupying the lower and the middle zones of the right kidney. Patient was placed in right decubitus position a 12 mm opti-port trocar was placed to the right of the umbilicus, two assistant ports were placed and a fourth 8 mm port was placed to start a precise dissection of the kidney with Gerorta's fascia, ligation of renal vessels with clips then the ureter was ligated and cut to complete the nephrectomy with good hemostasis, one drain was left, the specimen was removed through a right iliac fossa incision.

Results: Operative time was 180 minutes. Postoperative length of stay was 3 days. There were no complications, transfusions, or re-admissions.

Conclusions: Our initial experience demonstrates that robotic assisted laparoscopic radical nephrectomy is feasible even in such huge renal mass.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21-24 February 2011

Retroperitoneal laparoscopic partial nephro-ureterectomy in infants and children: Analysis of risk factors and age related

Hamdan Al Hazmi, Haytham Badawy, Yves Aigrain, Alaa El Ghoneimi


Department of Pediatric Surgery and Urology, Hospital Robert Debre, AP-HP, University Paris VII, Paris, France

Purpose: Laparoscopic partial nephrectomy is a technically demanding procedure. Recently, there is an arising concern on the risk and outcome specific manner young children to evaluate their specific risk and the operative steps to define the optimal technique to avoid complications.

Material and Methods: Between 1997 and 2006, 29 partial nephro-ureterectomies were done, 21 upper poles (UPN) at mean age of 36 months (3-156) and 8 lower poles (LPN) at 39 months (1-121). The lateral retroperitoneal approach was used in all cases. Routine follow up with renal ultrasound and Doppler of the remaining moiety were done. Since five years the technique is standardized to reduce complications: Kidney is kept attached to peritoneum, pathological ureter is kept dilated by ligature at the methelyne blue injection in cases of LPN or atypical UPN.

Results: Our first patient, aged 7 year, had early postoperative renal artery thrombosis after UPN and had total nephrectomy. Among the 10 UPN done in children under 1 year, none had complications, and one needed conversion in our first year of experience to identify the line of parenchymal section. 3 children underwent LPN under one year, none had complications and no conversion even for 60 mm dilated pelvis in one (75-180) for UPN. All children had a well vascularized remaining moiety after a mean follow up of 36 months (6-60).

Conclusions: Partial nephro-ureterectomy remains a challenging laparoscopic procedure. The main limiting factor is the learning curve and not the age at surgery. We have learned from our early complications that few tips are necessary to make the retroperitoneal approach easier and safer. The procedure is now standardized and safely feasible.

Presented at the: 19 th Saudi Urological Conference

King Khalid University Hospital, Riyadh

26 February to 01 March 2007

Laparoscopic retroperitonoscopic nephrectomy: Is it difficult to perform?

H. Al Hazmi, K. Fouda


Department of Surgery, Division of Pediatric Urology, King Saud University, Riyadh, Saudi Arabia

Objective: Laparoscopic renal surgery is an effective treatment for non-functioning renal units which need to be excised. This can be approached either transperitoneally or retroperitoneally. Our objective was to evaluate our experience with retroperitonoscopic approach in children who underwent nephrectomies or partial nephrectomies.

Materials and Methods: We retrospectively reviewed our experience with 39 laparoscopic procedures that were performed in our center from 2004 to 2008. We reviewed the demographic data, age at surgery, indications, operative time, surgical complications, conversion to open surgery, and post operative complications.

Results: 37 total and 2 partial nephrectomies (upper pole) were performed laparoscopically in 18 females and 21 males. Mean age was 36 months (24-120 months). The diagnosis was severe PUJO in 8, multicystic/dysplastic kidneys in 10, non-functioning kidneys secondary to high grade vesicoureteral reflux in 16, secondary to staghorn stone in 3 non-functioning upper poles in 2 (upper pole with ureteroceles). All procedures were done retroperitoneally. The mean operative duration was 160 minutes. There were no intra-operative complications (surgical or anesthetic), no transfusions, no conversion to open surgery and no postoperative complications. The mean hospital stay was 2.15 days.

Conclusion: Laparoscopic retroperitonoscopic renal surgery can be carried out safely and effectively in children as recommended in open surgery, but with avoidance of the morbidity of an open procedure. It is still is more challenging. It needs excellent imagination of the retroperitoneal space and a longer learning curve. The advantage of retroperitonoscopy is preserving the virginity of the peritoneum which is the classical approach in open surgery.

Presented at the: 21 st Saudi Urological Conference

North West Armed Forces Hospital, Tabuk

14-16 April 2009

The utility and role of robot in pediatric urology King Khalid University Hospital experience of first 24 cases

Mahmoud S. Trbay, Khalid Fouda, Hamdan Al Hazmi, Ahmad Elderwy, Abdulmoneim Gomha


Department of Surgery, Unit of Urology, Pediatric Urology Service, College of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia

Purpose: Evaluate the safety, feasibility and utility of the minimally invasive robotic surgery in different pediatric urology procedures performed in our institution.

Methods: Retrospectively, we reviewed the medical record of all patients underwent robotic surgery between October 2006 and October 2009. The type of the urological procedure, demographic, preoperative, intra operative and post operative data were compared.

Results: Twenty four (24) patients (18 boy and 6 girl) with mean age of 7.28 years ± 3.6 (range between 9 months and 13 years) were subjected to different robotic assisted laparoscopic urologic procedure during this period. Dismembered pyeloplasty was the main surgical procedure (12-50% patients), followed by simple nephrectomy in 5 (20%), then upper pole hemi-nephrouretrectomy and resection of pelvic Mullerian remnants in 2 (8.3%) patients for each and excision of bladder diverticula and urethrolithotomy and resection re-anastomosis of retrocaval ureter in one for each. No conversion to open surgery was recorded. No blood transfusion was indicated. Mean operative time was 176.8 minutes ± 42 (110-250). Mean hospital stay was 2.08 days ± 0.77 (range 1-4). 11 out of 12 patients with pyeloplasty (5 were recurrent after open surgery), showed good functional outcome. One patient showed deterioration of the hydronephrosis after redo- robotic pyeloplasty and he was managed by laparoscopic ureterocalycostomy.

Summary and Conclusion: Robotic surgery in pediatric urology is an evolving technology which is safe and effective. An enormous variety of cases can be safely performed including complex cases in small children. The ideal application of the robot in the pediatric population is in procedures requiring delicate suturing such as reconstructive procedures. Simple operations such as nephrectomies have minimal advantages apart from training purpose. Ultimately, the efficacy and role of robotic surgical systems need to be explored by further prospective studies.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Percutaneous insertion of a stent in laparoscopic pyeloplasty: A new technique

A. Al Zahrani, F. Al Modhem, R. Jednak, M. El Sherbiny, J-P Capolicchio


McGill University Health Centre, Montreal Children's Hospital, Montreal, Quebec, Canada

Objective: Multiple techniques of urinary stenting during laparoscopic pyeloplasty have been described, but all have drawbacks. Retrograde double-J stenting has the disadvantage of requiring repositioning of the patient and a second procedure for removal of the stent. Antegrade double-J stenting is often frustrated by inability to bypass the ureterovesical junction, especially in children. Percutaneous, endoscopy-guided nephrostomy can be difficult once the collecting system is open and collapsed. We describe a novel, percutaneous antegrade technique which overcomes these difficulties.

Materials and Methods: Once suturing of the posterior anastomotic suture line is complete, a Chiba needle is passed percutaneously across the anterior wall of the renal pelvis. A guide wire is inserted through the needle trocar followed by, after trocar removal, an angiocatheter insertion over the guide wire and through the flank. A percutaneous pyelo-ureteral stent is passed through the angiocatheter, over the guide wire and across the wall of the renal pelvis. The guide wire is withdrawn and the distal tip of the stent then advanced to the mid-ureter. The remaining posterior suture line is then closed and the system tested for leaks. The stent is capped on postoperative day 1 and removed in the office postoperative day 10.

Results: We have utilized this technique in 7 patients thus far, mean age is 7.4 years (range 5-10 years). Six were in a single system and 1 in a lower moiety pyeloplasty. The procedure was quick with no difficulties encountered in terms of passing the needle, guide wire, or stent. No intra-operative or postoperative complications were noted.

Summary and Conclusion: The antegrade pyelo-ureteral stent is easily and quickly inserted. Further experience with a larger number of cases is needed.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010



 
 
    Tables

  [Table 1]



 

Top
 
  Search
 
    Similar in PUBMED
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Article Tables

 Article Access Statistics
    Viewed1540    
    Printed14    
    Emailed0    
    PDF Downloaded1290    
    Comments [Add]    

Recommend this journal