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BACKGROUND AND PURPOSE: Whereas ureteroscopic lithotripsy is more efficacious than SWL in treating lower-ureteral stones, the same has not been universally said of its ability to treat proximal ureteral stones. Because failed proximal lithotripsy is often attributable to the complications associated with stone migration into the renal pelvis and calices, an instrument that can prevent this migration is a potentially important tool in the ureteroscopic armamentarium. This study sought to assess the role of just such an instrument, the Stone Cone, in proximal-ureteral lithotripsy. PATIENTS AND METHODS: We treated 19 consecutive patients having proximal-ureteral stones using semirigid ureteroscopy, a Stone Cone Nitinol urologic retrieval coil, and holmium:YAG laser lithotripsy with a 200- or 365-microm fiber. In all patients, both the Stone Cone and the laser fiber were utilized under direct visual guidance through the working channel(s) of the ureteroscope. RESULTS: All 19 patients were rendered stone free after Ho:YAG laser lithotripsy in conjunction with a Stone Cone. No stone fragments were noted to migrate into the renal pelvis, and the Stone Cone did not break or become entrapped in any of the 19 cases. CONCLUSION: The Stone Cone is a powerful new tool for proximal-ureteral lithotripsy and will likely revolutionize the treatment of proximal-ureteral stones. The savings in morbidity, time, and money associated with not having to chase stone fragments using flexible ureteroscopy are considerable.

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This article reports our early experience using laparoscopic instruments and techniques when performing radical retropubic prostatectomy through an entirely extraperitoneal endoscopic approach. Two patients with localized adenocarcinoma of the prostate underwent endoscopic radical retropubic prostatectomy through an entirely extraperitoneal approach (EERRP). The procedure was evaluated for its efficacy in removing prostate and seminal vesicles and in effecting complete vesicourethral anastomosis. Operative time, blood loss, hospital stay, and pathology were also evaluated. Complete endoscopic removal of the prostate and seminal vesicles was achieved in both patients. Endoscopic reconstruction of the bladder neck with watertight anastamosis was successful in both. Operative time and estimated blood loss improved from 5 h and 45 min and 600 cc, respectively, in patient 1 to 4 h and 400 cc in patient 2. Hospital stay was 2.5 days for both. The early experience for EERRP is encouraging. Further evaluation to standardize technique and determine its efficacy and role in treating prostate cancer is in order.

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PURPOSE: We evaluate the efficacy of high dose combination radiotherapy for the treatment of localized prostate cancer. MATERIALS AND METHODS: A total of 212 patients with localized prostate cancer (T1-T3) were treated with transperineal radioactive seed implantation followed by 45 Gy. external beam radiation therapy. Patients with Gleason scores of 2-5 were treated with 125iodine at a minimum peripheral dose of 120 Gy., while 103palladium at a minimum peripheral dose of 90 Gy. was used for those with Gleason scores of 7-10. Patients with Gleason 6 diploid tumors were treated with 125iodine and those with aneuploid tumors were treated with 103palladium. Biochemical failure was defined as inability to achieve a prostate specific antigen nadir value of 0.5 ng./ml. or less. No patient was treated with androgen deprivation therapy. RESULTS: The 212 patients have a minimum of 24 months of followup (mean 33 months). Prostate specific antigen 0.5 ng./ml. or less was reached by 72% of the patients (152 of 212) and positive biopsies were detected in 13.9% (20 of 144). Using life table survivorship analysis the probability of initial biochemical success at 5 years was 91% (95% confidence interval, 83 to 97). The probability of subsequent failure following an initial success was 11% (95% confidence interval, 6 to 20) at 24 months. The complications of combination therapy included proctitis in 21.4% (47 of 212 men), impotence in 38% (38 of 100), urinary retention in 1.5%, incontinence in 2.8%, rectoprostate fistula in 2.4%, rectal wall breakdown in 0.5% and urethral stricture in 0.5%. Six patients (2.8%) required colostomy and urinary diversion. CONCLUSIONS: Short-term responses to high dose combination radiotherapy for localized prostate cancer are promising. The morbidity is acceptable. Further long-term followup is warranted to assess this treatment.

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PURPOSE: We evaluated the efficacy of a totally extraperitoneal approach to endoscopic pelvic lymph node dissection. MATERIALS AND METHODS: Extraperitoneal endoscopic pelvic lymphadenectomy was performed in 125 patients with clinically localized prostate cancer. All patients were candidates for brachytherapy, cryotherapy or radical perineal prostatectomy. The first 65 patients underwent lymphadenectomy regardless of local clinical stage, prostate specific antigen (PSA) or tumor grade. The last 60 patients met 2 of 3 selection criteria, consisting of clinical local stage T2b or greater, prostate specific antigen greater than 20 and Gleason score 7 or higher. Patients were evaluated for morbidity and mortality, nodal yield, operative time, conversion rate to transperitoneal laparoscopic or open lymphadenectomy and hospital stay. RESULTS: Mean operative time was 104 minutes, mean length of stay was 2.1 days and mean nodal yield was 10.2. Of the patients 19.2% had positive nodes, and positive nodal yield increased to 32.9% when selection criteria were used. Of the cases 4% were converted to a transabdominal laparoscopic approach and 2.4% to open lymphadenectomy. Symptomatic lymphoceles required percutaneous drainage in 2.4% of the patients. One patient died of massive pulmonary embolism. CONCLUSIONS: This study demonstrates that the extraperitoneal endoscopic pelvic lymph node dissection is an effective and relatively safe method of surgically staging prostate cancer. It compares favorably to other methods of surgical staging.

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OBJECTIVES: We report our initial experience using laparoscopic instruments and techniques in the performance of radical retropubic prostatectomy (RRP) through an entirely extraperitoneal endoscopic (EE) approach. METHODS: A 62-year-old man with a Gleason score of 7 and clinical stage T1c adenocarcinoma of the prostate underwent EERRP. The procedure was evaluated for achievement of removal of the prostate and seminal vesicles and for complete vesicourethral anastomosis. Operative time, blood loss, hospital stay, and pathologic findings were also evaluated. RESULTS: Complete endoscopic removal of the prostate and seminal vesicles was achieved. Endoscopic reconstruction of the bladder neck with a watertight anastomosis was successful. Operative time was 5 hours and 45 minutes, with an estimated blood loss of 600 cc. Hospital stay was 2.5 days. Final pathologic evaluation was a Gleason score of 7 and Stage T2 disease with negative margins. CONCLUSIONS: The initial experience for EERRP is encouraging. Further evaluation to refine the technique and determine its efficacy and role in treating prostate cancer is in order.

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The insufflated extraperitoneal approach to endoscopic pelvic lymph node dissection has been described as an alternative method of staging carcinoma of the prostate. There are several potential pitfalls in performing this approach, including the use of endoscopic instrumentation, trocars, insufflation equipment, and general anesthesia. In order to overcome potential problems associated with this surgical approach, a totally gasless extraperitoneal approach has been developed. This technique uses standard surgical instruments, does not use carbon dioxide to maintain the operative space, and uses general anesthesia. This procedure is more cost effective, since it uses no special instrumentation except the laprolift and laprofan to maintain the extraperitoneal cavity during lymph node dissection.

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Extraperitoneal endoscopic pelvic lymph node dissection was performed in 60 patients for staging of organ-confined prostatic carcinoma. This procedure has significant advantages over the node dissection performed laparoscopically and should be adopted as the operative approach for staging of prostatic carcinoma.

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A new operative technique of vesicourethral suspension utilizing an entirely extraperitoneal endoscopic approach is described. This method offers a minimally invasive alternative to other operative procedures, including the transperitoneal laparoscopic approach, for the treatment of stress urinary incontinence.

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A case of endometriosis is presented involving the urinary bladder successfully treated by laparoscopic partial cystectomy. The laparoscopic surgical technique is fully discussed. Laparoscopic partial cystectomy represents a viable option in the treatment of vesical endometriosis, obviating the need for a formal laparotomy.

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Eighteen patients undergoing laparoscopic pelvic lymphadenectomy were compared with eighteen patients undergoing lymph node dissection performed via a totally extraperitoneal approach called extraperitoneal endoscopic pelvic lymph node dissection. Operative time, nodal yield, and hospital stays were essentially the same in both groups. However, the laparoscopic approach had a greater incidence of morbidity, leading the authors to adopt a totally extra-peritoneal endoscopic approach to pelvic lymph node dissection. Advantages of using an extraperitoneal approach are presented.

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Laser-assisted vasovasostomy recently has become a popular procedure in the United States. Only the microsurgical carbon dioxide laser is approved by the Food and Drug Administration for vasovasostomies. Using the HGM argon laser, the procedure was performed on 3 laboratory dogs with a patency rate of 100 percent (6/6) and anastomotic leak 17 percent (1/6). This procedure requires little microsurgical expertise, can be performed without the use of a microscope, and does not require a perfectly dry field. The argon laser is a superior technique to previously described laser-assisted vasovasostomies and further clinical correlation is recommended.

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We describe the successful laparoscopic removal of a distal ureteral cystine stone not amenable to ureteroscopic or medical therapy. This approach offers an alternative to open ureterolithotomy in patients when less invasive measures fail.

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Laparoscopic pelvic lymphadenectomy has been found to be efficacious in the staging of genitourinary cancers. Technological advances in endoscopic instrumentation have allowed an extraperitoneal approach to be performed. Presented are two patients who underwent an extraperitoneal endoscopic lymph node dissection as a staging procedure for prostatic carcinoma. Technical aspects of the procedure and advantages relative to the laparoscopic intraperitoneal approach are discussed.

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