George Chow - Academia.edu (original) (raw)

Papers by George Chow

The Journal of Urology, Aug 1, 1998

We determined the immediate efficacy of contemporary urological intervention for cystine stones a... more We determined the immediate efficacy of contemporary urological intervention for cystine stones and the impact of such intervention on the subsequent rate of recurrent stone formation. A total of 31 cystinuric patients underwent selected intervention for 61 stone events. Patients were subsequently followed at 6 to 12-month intervals while being treated with standard medical therapy. Logistic regression models were used to correlate potential risk factors with the efficacy of the intervention in achieving a stone-free status. Kaplan-Meier estimates of the probability of recurrence-free survivals at 1 and 5 years were generated, and risk factors for stone recurrence were analyzed using the log rank test. Overall stone-free rate was 86.9%, which was not significantly influenced by the initial stone burden or type of intervention selected. The probability of recurrence-free survival at 1 and 5 years was 0.73 and 0.27, respectively, and again this probability was independent of initial stone burden or type of intervention selected. Urinary cystine levels before intervention and post-procedure residual stone status also failed to impact significantly on the risk of recurrence. However, a stone-free result, in contrast to residual stones, prolonged the mean time to stone recurrence from 346 to 1,208 days. While cystine stones are not amenable to all currently available minimally invasive therapeutic modalities, high stone-free rates can be achieved without the need for open surgery and as such cystinuric patients clearly benefit from contemporary intervention. When such intervention is used selectively, with consideration given primarily to stone burden and location, rates of recurrence will relate primarily to the natural history of the medically treated cystinuric patient, and not the type of intervention applied.

International Journal of Urology, Aug 24, 2015

To evaluate the long-term outcomes and potential predictors of treatment failure after robotic sa... more To evaluate the long-term outcomes and potential predictors of treatment failure after robotic sacrocolpopexy. We identified 70 consecutive patients from 2002 to 2012 with symptomatic post-hysterectomy vaginal vault prolapse that underwent robotic sacrocolpopexy. Multiple clinical and surgical variables were evaluated for potential association with treatment failure, which was defined as any repeat operation for recurrent prolapse or mesh-related complications. The median age at surgery was 67 years (interquartile range 59-74 years) and median follow up was 72 months (interquartile range 39-114 months). Overall, six out of 70 patients (8.6%) underwent a total of six secondary surgeries, including four for recurrent prolapse (two anterior repairs, one posterior repair, one apical) and two mesh complications. No patient-related factors were associated with the risk of repeat surgery: age (P = 0.45), diabetes mellitus (P = 0.24), tobacco use (P = 0.61) or prior prolapse surgery (P = 0.1) on univariate analysis. Freedom from repeat prolapse surgery or surgery for mesh complication was 98% at 1 year, 95% at 3 years and 90% at 6 years. At last follow up, 80% of patients reported that they would or probably would recommend robotic sacrocolpopexy to a family member or friend. Robotic sacrocolpopexy is associated with excellent long-term outcomes. Recognition of long-term success is important for preoperative patient counseling.

Journal of Endourology, Dec 1, 2000

A shortage of kidney donors has contributed to the interest in laparoscopic live-donor nephrectom... more A shortage of kidney donors has contributed to the interest in laparoscopic live-donor nephrectomy. Three transperitoneal ports are used, as is an AESOP robot. To maintain urine flow, the donor is kept volume expanded during the procedure, and the pneumoperitoneum pressure is minimized. The most critical and hazardous part of the surgery is dissection of the renal artery and vein. Abundant periureteral tissue should be left to protect the blood supply. Harvest of the right kidney is more difficult. Placing the extraction incision in the right upper quad¬ rant and using a Satinsky clamp instead of a stapling device at the origin of the renal vein will provide maximum venous length and help prevent postoperative thrombosis of the allograft. In the first 175 laparoscopic renal har¬ vest procedures at Johns Hopkins, the complication rate was 14%, the rate of open conversion was 2%, and 3% of the patients required transfusions. These rates improved with experience. There was no significant difference in the performance of the allografts or the recovery of the recipients from what is seen after open kidney har¬ vest Wider acceptance of laparoscopic renal harvest will increase the number of donors and will be helped by development of methods and devices that shorten the learning curve.

Journal of Endourology, Oct 1, 2006

Background and Purpose: The classic standard for surgical repair of ureteropelvic junction (UPJ) ... more Background and Purpose: The classic standard for surgical repair of ureteropelvic junction (UPJ) obstruction has been open pyeloplasty, with a 95% success rate. Antegrade endopyelotomy is a less-invasive option with a slightly lower success rate. However, recent data call into question the long-term durability of UPJ repair. We present the long-term success of treatment of UPJ obstruction comparing these two modalities. Patients and Methods: We reviewed the medical records of patients undergoing percutaneous antegrade endopyelotomy or open and laparoscopic pyeloplasty for UPJ repair in our practice from 1988 to 2004. Success was defined as both radiographic and symptomatic improvement. We evaluated the impact of preoperative factors, including prior surgical repair, crossing vessels, renal function, and calculi, on success. Results: The estimated 3-, 5-, and 10-year recurrence-free survival rates for the endopyelotomy group (N ‫؍‬ 182) were 63%, 55%, and 41%, respectively, compared with 85%, 80%, and 75% for the pyeloplasty group (N ‫؍‬ 175; P Ͻ Ͻ 0.001). Of the failed endopyelotomies undergoing salvage open repair, 8 of 26 (31%) had crossing vessels. Poor renal function and previous failed pyeloplasty decreased success in the pyeloplasty group. Variation from standard cold-knife incision adversely affected endopyelotomy success. Conclusions: Long-term success rates after both endopyelotomy and pyeloplasty are worse than previously reported. Although most failures in both groups occurred within 2 years, failures continue to appear after 5 and 10 years, and patients should be followed accordingly. In view of these results of endopyelotomy, laparoscopic pyeloplasty may prove to be the preferred minimally invasive approach to repair UPJ obstruction.

Urology, Feb 1, 2004

... David S. Di Marco a , George K. Chow a , Matthew T. Gettman a and Daniel S. Elliott Correspon... more ... David S. Di Marco a , George K. Chow a , Matthew T. Gettman a and Daniel S. Elliott Corresponding Author Contact Information , a. ... Technical considerations. The procedure combines the use of standard laparoscopy with the daVinci robotic system. ...

World Journal of Urology, Mar 24, 2006

Currently, there has been limited reporting and research in the female urology and gynecological ... more Currently, there has been limited reporting and research in the female urology and gynecological literature concerning the use of robotics. To date, robotics have been utilized only for the treatment of three benign gynecologic conditions: benign hysterectomy; repair of vesicovaginal fistula; and sacrocolpopexy which is a treatment for posthysterectomy vaginal vault prolapse. We describe a novel minimally invasive technique of vaginal vault prolapse repair and present our initial experience. The surgical technique involves placement of five laparoscopic ports: three for the daVinci robot and two for the assistant. A polypropylene mesh is then attached to the sacral promontory and to the vaginal apex using Gortex sutures. Thirty-one patients underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution in the past 24 months for severe symptomatic vaginal vault prolapse. Complications were limited to mild port site infections in two patients, which resolved with oral antibiotic therapy. While our early experience utilizing robotic repairs in female urology and gynecology is encouraging, long-term data are needed to confirm these findings and establish longevity of the repair.

Mayo Clinic Proceedings, Apr 1, 2006

American Journal of Surgery, Oct 1, 2004

Transabdominal sacrocolpopexy is an excellent treatment option for patients with high-grade vagin... more Transabdominal sacrocolpopexy is an excellent treatment option for patients with high-grade vaginal vault prolapse, with long-term success rates ranging from 93% to 99%. However, it is associated with increased morbidity compared with vaginal repairs. In this article, we describe a novel minimally invasive technique of vaginal vault prolapse repair and present our initial experience. The surgical technique involves placement of 4 laparoscopic ports, 3 for the surgical robot and 1 for the assistant. A prolene mesh is then attached to the sacral promontory and to the vaginal apex using nonabsorbable expanded polytetrafluoroethylene sutures. At the end of the case, the mesh material is covered by the peritoneum. A total of 20 patients underwent a robot-assisted laparoscopic sacrocolpopexy at our institution in the past 18 months for severe symptomatic vaginal vault prolapse; 8 of the 20 (40%) underwent a concomitant anti-incontinence procedure. Mean follow-up was 5.1 (range, 1-12) months and mean age was 66 (range, 47-82) years. The mean total operative time was 3.2 (range, 2.25-4.75) hours. Of these patients, 1 was converted to an open procedure secondary to unfavorable anatomy. All but 1 patient, who left on postoperative day 2, were discharged from the hospital after an overnight stay. Complications were limited to mild port-site infections in 2 patients, which resolved with oral antibiotic therapy. Recurrent grade 3 rectocele developed in 1 patient, but there was no evidence of cystocele or enterocele. Significant incontinence (Ͼ1 pad/day) was present in 2 patients. All 18 patients reported being satisfied with the outcome of their surgery and all 10 would recommend it to a friend. This novel technique for vaginal vault prolapse repair combines the advantages of open sacrocolpopexy with the decreased morbidity and improved cosmesis of laparoscopic surgery. It is associated with decreased hospital stay, low complication and conversion rates, and high rates of patient satisfaction. Although our early experience is encouraging, long-term data are needed to confirm these findings and establish longevity of the repair.

Urology, Dec 1, 1999

Objectives. To determine whether a high versus a dependent ureteral insertion significantly affec... more Objectives. To determine whether a high versus a dependent ureteral insertion significantly affects the outcome of endopyelotomy for management of ureteropelvic junction (UPJ) obstruction. Methods. Sixty patients with UPJ obstruction were treated with an endopyelotomy by way of either an antegrade percutaneous approach (n ϭ 36) or a retrograde hot-wire balloon incision (n ϭ 24). In these 60 patients, the ureteral insertion was high on the renal pelvis in 19 (32%), dependent in 25 (42%), and indeterminate in 16 (26%). Intravenous urography was performed 4 to 6 weeks after stent removal (8 to 12 weeks after endopyelotomy) and then at 6 to 12-month intervals. Success of the procedure was defined as resolution of symptoms and decrease in hydronephrosis compared with pre-endopyelotomy studies. Results. With a follow-up range of 2 to 41 months (mean 10.3), the overall success rate was 80%. This rate was independent of whether the procedure was performed in an antegrade or retrograde fashion. A successful result was achieved in 15 (78.9%) of those with a high insertion, 19 (76%) of those with a dependent insertion, and 14 (87.5%) of those with an equivocal insertion; these differences were not statistically significant (P ϭ 0.72). Conclusions. The type of ureteral insertion (ie, high versus dependent) had no significant impact on the outcome of endopyelotomy by way of either a percutaneous or retrograde approach. As such, these anatomic variations need not play a role in a decision-making algorithm for contemporary management of UPJ obstruction.

Transplantation, Oct 1, 2001

Laparoscopic donor nephrectomy is gaining increasing popularity because the procedure helps reduc... more Laparoscopic donor nephrectomy is gaining increasing popularity because the procedure helps reduce disincentives to live kidney donation and has increased the live kidney donor pool. The left kidney of the donor is the preferred allograft because the right renal vein is shorter. Similarly, the right renal artery might be foreshortened because it hides behind the inferior vena cava during laparoscopic transperitoneal dissection. There are instances, however, in which it is not practical to take the left kidney due to vascular anomalies or asymmetric function. We describe a novel technique for obtaining greater renal arterial length utilizing laparoscopic interaortocaval dissection.

Journal of Endourology, Aug 1, 2010

To evaluate our single institution experience with percutaneous cryoablation of renal masses !3 c... more To evaluate our single institution experience with percutaneous cryoablation of renal masses !3 cm in diameter for complications and short-term outcomes. Patients and Methods: Between March 2003 and February 2009, 108 patients with 110 renal masses !3 cm in diameter were treated with percutaneous cryoablation therapy. Technical success of the ablation procedure, complications, and evidence for local tumor recurrence were evaluated for each patient. Results: Average maximal renal tumor diameter was 4.1 cm (range 3.0-8.3 cm; standard deviation 1.1 cm). A single cryoablation procedure was performed for treatment of each patient. A technically successful ablation was achieved for 107 of 110 (97%) tumors. The three technical failures all resulted from incomplete cryoablation of the deepest margin of a centrally located renal tumor. A total of 9 severe adverse events occurred in six patients, resulting in an 8% major complication rate. Two patients in whom major complications developed were part of the group of only four patients for whom ablation was performed for tumors >7 cm in diameter. There were no procedural-related deaths. No evidence for local tumor recurrence was identified in any patients with follow-up contrast-enhanced CT or MRI obtained 3 months or longer from the time of the ablation. Follow-up in these patients averaged 15 months (range 3-42 mos). Conclusion: Percutaneous cryoablation of renal masses !3 cm in diameter can be performed with high technical success and low complication rates. Extra scrutiny is needed during cryoablation of central renal masses to make sure the ablation zone extends to include the deepest margin of the tumor. Although our experience is limited, percutaneous cryoablation of renal tumors >7 cm in diameter may be associated with increased complications. The lack of local renal tumor recurrences seen in this study on short-term follow-up is encouraging, but longterm follow-up remains necessary to ensure treatment durability.

The Journal of Urology, Aug 1, 2006

Transabdominal sacrocolpopexy is a definitive treatment option for vaginal vault prolapse with du... more Transabdominal sacrocolpopexy is a definitive treatment option for vaginal vault prolapse with durable success rates. However, it is associated with increased morbidity compared with vaginal repairs. We describe a minimally invasive technique of vaginal vault prolapse repair and present our experience with a minimum of 1 year followup. The surgical technique involves 5 laparoscopic ports: 3 for the da Vinci robot and 2 for the assistant. A polypropylene mesh is attached to the sacral promontory and vaginal apex using polytetrafluoroethylene sutures. The mesh material is then covered by peritoneum. Patient analysis focused on complications, urinary continence, patient satisfaction and morbidity with a minimum of 12 months followup. A total of 30 patients with post-hysterectomy vaginal vault prolapse underwent robotic assisted laparoscopic sacrocolpopexy at our institution and 21 have a minimum of 12 months followup. Mean followup was 24 months (range 12 to 36) and mean age was 67 years (range 47 to 83). Mean operative time was 3.1 hours (range 2.15 to 4.75). All but 1 patient were discharged home on postoperative day 1 and the 1 patient left on postoperative day 2. Recurrent grade 3 rectocele developed in 1 patient, 1 had recurrent vault prolapse and 2 had vaginal extrusion of mesh. All patients were satisfied with outcome. The robotic assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy. We found a decreased hospital stay, low complication rates and high patient satisfaction with a minimum of 1 year followup.

Journal of Robotic Surgery, Jan 19, 2011

The objective of this study was to describe anatomic and symptomatic outcomes at 5 years or longe... more The objective of this study was to describe anatomic and symptomatic outcomes at 5 years or longer after robotic-assisted laparoscopic sacrocolpopexy using very lightweight polypropylene Y-mesh. Methods: A prospective analysis of consecutive patients who underwent surgery at a single center between 2007 and 2011 was performed. Patients consented to objective and subjective assessment at 5 years or longer postoperatively. Surgical success was defined as meeting all of the following: (1) no retreatment for pelvic organ prolapse (POP) since surgery, (2) no prolapse beyond the introitus, (3) no apical descent below −5, and (4) no prolapse symptoms reported. Secondary outcome measures included Sandvik Incontinence Severity Index, the PFDI-20, the PFIQ-7, the PISQ-12, and the SSQ-8), rates of dyspareunia, mesh complications, and subjects' need for any surgical or nonsurgical prolapse treatment since their index surgery. Results: Eighty percent of the potential study group (253/316) presented for examination and subjective assessment at 5 years or longer after their index surgeries. The surgical success rate was 226 (89.3%) of 253 with no apical failures. Only 4.4% (11/253) of the group met both objective and subjective failure criteria. Sixteen patients were classified as surgical failure owing to subjective criteria alone despite having no significant objective prolapse on examination. Ten patients (4%) elected to undergo subsequent POP repair. These operations consisted of 5 native tissue anterior repairs and 5 native tissue posterior repairs. In addition, 1 patient elected to use a pessary for recurrent anterior POP. The remaining 16 patients who experienced surgical failure elected no further prolapse treatment. Conclusions: Robotic-assisted laparoscopic sacrocolpopexy using very lightweight mesh provided excellent long-term results with no meshrelated complications.

Transplantation Proceedings, Mar 1, 2002

Background: The exact relation between Body Mass Index (BMI) and outcome of laparoscopic donor ne... more Background: The exact relation between Body Mass Index (BMI) and outcome of laparoscopic donor nephrectomy (LDN) is unknown. A recent meta-analysis showed that a high BMI does not correlate with perioperative complications. Perirenal and intra-abdominal fat burden may have a stronger correlation with perioperative complications and long-term results of LDN. Therefore, we measured the amounts of perirenal and intra-abdominal fat of live kidney donors and correlated these with outcome of LDN. Methods: We analysed 62 CT-scans of live kidney donors that underwent LDN in our center between 2004 and 2010, and measured: Perirenal fat volume (cm3) (PFV), distances in mm of perirenal (PRF, from Gerota to the kidney), abdominal (IAF, from the aorta to the linea alba) and subcutaneous fat (SCF, from skin to abdominal wall. The PFV was calculated selecting the perirenal fat (in Gerota) from the most cranial to the most caudal slice of the CT-scan. All these measurements were correlated with each other, with donor BMI, and with the following outcome parameters of LDN: Warm ischemia time, operation duration, estimated blood loss, complications, length of stay, decrease in glomerular filtration rate (1 year) and increase in 1 year-serum creatinine using bivariate correlations. Because of the limited number of available CT-scans, we repeated the analyses on a larger group of donors (n = 480) with pre-operative MRI-scans. Results: The PFV did not correlate with any of the outcome measures, neither did the PRF, IAF and SCF. Remarkably, MRI-scan analyses demonstrated that IAF correlates significantly with operation duration, estimated blood loss, conversion, BMI and differences in GFR and 1 year serum creatinine. Conclusion: In a large cohort of live kidney donors, we have demonstrated that IAF is strongly correlated with outcome of LDN whereas perirenal fat is not. We conclude that the measurement of IAF may be a valuable tool to predict peri-and postoperative outcome of LDN.

Journal of Endourology, Sep 1, 2005

Technological advances have increased the applicability of endoscopic treatment for upper-tract t... more Technological advances have increased the applicability of endoscopic treatment for upper-tract transitional-cell carcinoma (TCC). Percutaneous and ureteroscopic tumor resection have become reasonable treatment options for patients with anatomically or functionally solitary kidneys, bilateral upper-tract tumors, significant renal insufficiency, or comorbid disease that would preclude standard open surgery. This approach also is being used increasingly on those with a normal contralateral kidney in whom nephroureterectomy and en bloc removal of the ipsilateral ureteral orifice and surrounding bladder cuff is considered the standard therapy. This paper reviews the current role of ureteroscopic management of upper-tract TCC.

The Journal of Urology, Mar 1, 2010

Purpose: Transureteroureterostomy is a treatment alternative for ureteral obstruction when more c... more Purpose: Transureteroureterostomy is a treatment alternative for ureteral obstruction when more conventionally reconstructive techniques are not feasible. We report on long-term outcomes of patients treated with transureteroureterostomy. Materials and Methods: A retrospective chart review of all patients treated with transureteroureterostomy from January of 1985 to February of 2007 was performed. Results: We identified 63 patients who underwent transureteroureterostomy at our institution. Average treatment age was 31.5 years (range 1 to 83). Transureteroureterostomy was performed for 21 (33%) malignant and 42 (67%) benign indications. Reconstructions were 30 right-to-left (47.6%) and 33 left-to-right (52.4%) with 21 concurrent urinary diversions. There were 16 patients (25.4%) who received radiation before transureteroureterostomy. Postoperative complications occurred in 15 (23.8%) patients and were more common in those undergoing diversion for malignancy. Mean followup was 5.8 years (range 0.1 to 22.2) and 5 patients were lost to followup. Of the 56 patients with followup imaging the transureteroureterostomy was patent in 54 (96.4%) and obstructed in 2 (3.6%). Mean preoperative and recent calculated glomerular filtration rate for this cohort were 62.8 (range 13 to 154) and 71.8 (range 22 to 141) ml per minute, respectively (p ϭ 0.04). Stone disease developed in 8 patients, and was treated with percutaneous nephrolithotomy (2), spontaneous passage (2), ureteroscopy (1) and surveillance (3). Subsequent urological intervention was required for obstruction or revision in 6 (10.3%) patients. Conclusions: We demonstrated the long-term safety and effectiveness of transureteroureterostomy with sustained improvement of renal function compared to preoperative status. Recurrent stricture, distal obstruction and stone disease occur in a small percentage of patients, and can be treated in most with minimal intervention.

The Journal of Urology, Jul 1, 2003

Technical advances in ureteroscopy allow for more aggressive management of upper tract pathology.... more Technical advances in ureteroscopy allow for more aggressive management of upper tract pathology. We evaluate to what extent clinical practice and treatment efficacy have been impacted by improvements in technology and technique. In 1998, 176 consecutive patients underwent 182 ureteroscopic procedures at our institution. Retrospective chart review was performed. Factors such as clinical indication, pathology location, type of ureteroscope, procedure duration, procedure success, complication rate and length of stay were evaluated. Data from the 1998 cohort were compared to those obtained from a cohort of patients from 1992. Statistical analysis was performed using chi-square test. Overall stone extraction rate was 94.4% (1992) vs 88.5% (1998) (p = 0.05). Proximal stones were treated in 13.5% (1998) vs 28.3% (1998) of cases. Distal stone extraction rate was 97.2% (1992) vs 95.1% (1998) (p = 0.43) and proximal stone extraction rate was 76.5% (1992) vs 71.9% (1998) (p = 0.73). Diagnostic inspection success rate was 98.3% (1992) vs 98.3% (1998). Use of flexible ureteroscopy was 11.5% (1992) vs 29.4% (1998). Complication rate was 12% (1992) vs 10.2% (1998) (p = 0.76). Of the cases 76.1% were outpatient in 1998 vs only 50% in 1992. Recent advances in ureteroscopic technology permit more aggressive instrumentation of the upper tract as reflected in higher use of flexible ureteroscopy and more frequent attempts to manage proximal ureteral calculi. These advances have not translated into better efficacy of calculus treatment. Furthermore, our data reflect a nationwide trend toward outpatient treatment.

The Journal of Urology, Oct 1, 1999

The Journal of Urology, Dec 1, 2002

Purpose: Abdominal surgery causes adhesions that may render subsequent laparoscopic access and di... more Purpose: Abdominal surgery causes adhesions that may render subsequent laparoscopic access and dissection problematic. We determined the effect of previous surgery on the operative outcome in a large series of patients undergoing urological laparoscopy. Materials and Methods: The records of 700 consecutive laparoscopic procedures performed at a single institution from 1995 to 2001 were reviewed. Patient gender, American Society of Anesthesiologists (ASA) patient classification, surgical history, operative time, estimated blood loss, transfusion rate, rate of conversion to an open procedure, complication rate and hospital stay were assessed in each patient. Patients were categorized by anatomical site of previous surgeries and the type of laparoscopic procedure performed. Statistical analysis was performed with 1-way ANOVA, and the chi-square, Fisher exact and Kruskal-Wallis tests. Results: Of the 700 patients 366 (52%) had never undergone surgery, 105 (15%) had a history of abdominal surgery at the same anatomical region and 229 (33%) had a history of abdominal surgery at a different region. Overall previous abdominal surgery of any type was associated with female gender, higher ASA classification, increased age and an increased rate of perioperative transfusion (p ϭ 0.0001). A history of surgery at the same site was associated with increased operative time (p ϭ 0.03) and increased hospital stay (p ϭ 0.02). Differences in operative blood loss (p ϭ 0.3), and the complication (p ϭ 0.11) and conversion (p ϭ 0.08) rates in patients with and without a history of surgery did not attain significance. Outcomes analysis of individual types of surgery showed similar results except for renal biopsy. In these cases previous surgery was not associated with increased age, ASA score or transfusion rate. Conclusions: Of all patients presenting to a single center for urological laparoscopy 48% had a history of abdominal surgery. Overall compared with patients with no history of surgery those with such a history tended to be older, predominantly female and at significantly higher operative risk. Patients with a history of surgery who underwent nephrectomy or pyeloplasty were also more likely to have received blood transfusion perioperatively, which was probably related to their increased age and higher degree of medical co-morbidity. There were no significant differences in operative blood loss, rate of conversion to open procedure or rate of operative complications. Therefore, previous abdominal surgery does not appear to affect adversely the performance of subsequent urological laparoscopy.

The Journal of Urology, Jul 1, 2004

Purpose: Major vascular injuries are uncommon but serious complications of laparoscopic surgery. ... more Purpose: Major vascular injuries are uncommon but serious complications of laparoscopic surgery. Early recognition and conversion to an open procedure may be required to avoid further complications. We report 2 cases in which the vena cava was transected during retroperitoneoscopic nephrectomy, and review the literature. Materials and Methods: All urological laparoscopic cases from 1993 to 2002 at 2 institutions were reviewed to identify major vessel transection. Two cases of inadvertent transection of the vena cava were identified. Medical records were reviewed for clinical and pathological information to identify factors leading to this complication. A MEDLINE search was performed to identify similar reports in the literature. Results: Two patients at 2 institutions were identified with vena caval transection during retroperitoneoscopic nephrectomy. In both cases the vena cava was misidentified as a renal vein. The injury was recognized immediately in both cases and an open repair was performed by vascular surgery. Both patients recovered with no sequelae. In both cases a rotated camera on an angled laparoscope in addition to the relative lack of retroperitoneal landmarks may have contributed to a loss of orientation within the operative field. A similar report of an aortic transection was also found in the literature. Conclusions: Disorientation of the operating surgeon within the surgical field secondary to rotation of the camera lens and lack of retroperitoneal landmarks may contribute to vena caval transection during retroperitoneoscopic nephrectomy. This injury has not been found in transperitoneal nephrectomy, likely because more intra-abdominal landmarks exist, aiding in maintenance of orientation. Prompt intraoperative recognition and repair of the transection results in a favorable outcome.