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In the porcine model the LigaSure system is a viable option for laparoscopic management of arteries up to 6 mm. and veins up to 12 mm. in diameter.

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We believe this trend toward ureteroscopy is attributable to several factors: improved, smaller rigid and flexible ureteroscopes; the availability of more effective intracorporeal lithotripters (e.g., pneumatic and holmium laser), and the lack of development of lower cost, more effective SWL. This is an unfortunate trend, as we are moving away from the noninvasive treatment that was the hallmark of urolithiasis therapy at the beginning of the last decade toward more invasive endoscopic therapy. Increased research efforts in SWL technology are sorely needed.

In an effort to further evaluate the potential application of laparoscopy to urologic surgery, we explored the feasibility of using this minimally invasive approach for performing a partial nephrectomy. Nine female pigs underwent laparoscopic partial nephrectomy (LPN) utilizing a plastic cable tie (15 mm. x 4 mm. x 1 mm.) to achieve renal ischemia and an Argon Beam Coagulator probe (ABC) (Birtcher Medical Systems) to fulgurate the transected surface. Six weeks after LPN, 6 pigs underwent creatinine clearance, renin level, arteriography, BP samples and were then killed. The renal remnants were weighed and sectioned for histological studies. These studies revealed excellent function of the renal remnant, no AV fistula, and no evidence of renovascular hypertension. LPN is a feasible, repeatable procedure in the pig. Control of the renal hilum, transient parenchymal compression with a plastic cable, and use of the argon beam coagulator are key elements in performing this procedure.

Although adrenal involvement from renal cell carcinoma is rare, removal of the adrenal during radical nephrectomy continues to be standard practice. To assess the actual need for adrenalectomy, we elected to evaluate whether malignant involvement of the adrenal gland could be reliably diagnosed preoperatively by a computerized tomogram (CT) of the abdomen. A blinded retrospective review of preoperative abdominal CT in 157 patients with renal cancer revealed an abnormality of the ipsilateral adrenal gland in 38. Histopathology confirmed malignant involvement of the adrenal in 10 patients. Significantly, all 119 adrenal glands judged to be normal on the preoperative CT were confirmed to be uninvolved by the renal cancer on histopathological study. We conclude that abdominal CT is reliable in the preoperative evaluation of the ipsilateral adrenal gland and assessment of its noninvolvement with renal carcinoma. In such cases adrenal sparing nephrectomy may be considered (76% of our patients). None of these 119 patients had either macroscopic or microscopic adrenal involvement. When the adrenal is not identified, displaced or enlarged on CT (24% of our patients) adrenalectomy should be routinely performed as part of radical nephrectomy. Even in this select group adrenal involvement was present in only 26% of the cases.

We report a case of percutaneous removal of a staghorn calculus that was accomplished in a morbidly obese patient while he was in a full flank position. In this position, the stone could be successfully accessed and fragmented without compromising the pulmonary status of the patient.

To date, laparoscopic urological surgery has largely been limited to diagnostic or ablative procedures. Herein we report our experience with laparoscopic reconstructive surgery to perform an extravesical ureteral reimplantation. Seven anesthetized pigs with iatrogenic ureteral reflux underwent a laparoscopic extravesical ureteral reimplantation. The newly created ureteral tunnel varied from 2 to 4 cm. In 3 pigs, the tunnel was created with tacking staples, while in the other 4 pigs, the tunnel was created with intracorporeal suturing techniques using a 3-zero polyglyconate running suture. The procedure required an average of 132 minutes. There was one anesthetic death. There were no urinary tract infections. At 3 to 8 weeks after reimplantation, the cystograms were repeated on 5 pigs. One of 2 stapled reimplant pigs still had reflux; 1 of 3 sewn reimplant pigs had reflux. At 6 months following the reimplantation, only 1 pig had residual grade I reflux and this was a sutured reimplantation. None of the stapled reimplantations exhibited any residual reflux on the surgical side; however, in 1 animal a submucosal staple was noted at the time of harvest.