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Purpose: To present the safety and efficacy of totally ultrasonography-guided percutaneous nephrolithotomy (PCNL) for managing urinary stones in pediatric patients. Patients and Methods: Ten children with a mean age of 5.4 (3-11) years underwent totally ultrasonography-guided PCNL from March 2013 to November 2013. The pyelocaliceal system was punctured with the patient in the prone position by using ultrasonographic guidance, and the tract was dilated using a single-shot dilation technique. All steps of renal access were performed by using ultrasonography; no fluoroscopy was used. PCNL in all cases was performed by using adult instruments. Results: The mean stone size was 28.9±6.7 mm (range 17-35 mm). The mean access time to stone was 4.45±2.25 minutes (range 3-10 min). The mean nephroscopic time was 45.9±17 minutes (range 20-80 min). The stone-free rate was 83%. Mean hospital stay of patients was 3 days (range 2-5 days). No major complications were happened. Only one patient needed ureteral stent insertion because of urinary leakage from the nephrostomy tract. Conclusion: Our experience with totally ultrasonography-guided PCNL using adult size instruments in children revealed proper results and acceptable complications compared with the standard technique of PCNL. Likewise, this alternative method has the advantage of preventing radiation hazard.

Objective: This study evaluated the outcomes of laparoscopic donor nephrectomy (LDN) and proposed modifications for kidney donation surgery. From February 1997 to February 2011, 1510 LDNs were performed., Patients and Methods: Surgical modifications included a modified open access technique for entry into the abdominal cavity, using vascular clips for safe and cost-effective control of the renal pedicle, control of the lumbar veins, and adrenal vein using bipolar cautery instead of clips, and leaving the gonadal vein intact with the ureter. Kidneys were extracted by hand through a Pfannenstiel incision. Heparin was not used after the first 300 cases to prevent potential hemorrhagic complications., Results: Although three major vascular injuries occurred using the closed access method that were managed successfully, no access-related complications occurred using the modified open access technique. Clip failure did not happen in any cases. Patient and graft survival at 1 year post-transplantation were 96.5% and 95.5%, respectively, and at 5 years post-transplantation were 95.3% and 89.5%, respectively., Conclusion: The proposed surgical modifications are based on 14 years of experience and 1510 cases, and make LDN simple, safe, and cost-effective. The excellent recipient and graft outcomes with minimal morbidity obtained further confirm that LDN can be considered as the gold standard for kidney donation surgery.

Purpose: To evaluate the safety and efficacy of spinal anesthesia compared with general anesthesia in patients who underwent percutaneous nephrolithotomy (PCNL)., Patients and Methods: One hundred patients with American Society of Anesthesiologists (ASA) score <3 were randomly divided into two groups according to the type of anesthesia. Spinal anesthesia was performed using an injection of 0.25 mg/kg bupivacaine 0.5% in the intrathecal space; no opium (fentanyl) agent was used. All procedures were performed with the patient in the prone position. Stone access was made by using fluoroscopic guidance, and the tract was dilated using a single-stage technique. All patients received a solution including 1 mg/kg morphine in every 100 mL physiologic saline through the volumetric pump during the 3-hour post-PCNL period in the recovery room. Afterward, morphine (0.05 mg/kg) was injected only according to the verbal rating scale greater than 3 after discharge from the recovery room until 24 hours after surgery., Results: The two groups were matched by mean age, distribution of stone location, and stone burden. Mean operative time, hospital stay, stone-free rate and mean hemoglobin drop were comparable between the two groups. The rate of complications according to the Clavien grading system was nearly similar in both groups. Mean analgesic requirement during 24 hours after PCNL was 6.8 mg in the spinal group and 13.2 mg in the general group (P<0.001)., Conclusion: It seems that using spinal anesthesia by intrathecal injection of local anesthetic solutions vs general anesthesia has comparable surgical outcomes and reduces the requirement for analgesia after PCNL in the early postoperative period.

Purpose: To evaluate the safety and cost-effectiveness of Hem-o-lok and metallic titanium clips for both renal arterial and venous control in laparoscopic nephrectomies., Patients and Methods: All patients who underwent laparoscopic nephrectomy from June 2000 to March 2011 in our center were included. Before July 2005, we used three medium-large titanium clips for safe control of renal vessels. After July 2005, we used two clips for renal artery control (one 10 mm Hem-o-lok clip and one medium-large titanium clip) and two clips for renal vein control (12 mm and 10 mm Hem-o-lok clips) in all cases. To prevent possible complications, we placed vascular clips 2 to 3 mm away from the aortic root of the renal artery underneath lumbar vessels. Episodes of clip failure were defined as intraoperative or postoperative hemorrhage or exploration because of clip failure., Results: This study included 1834 laparoscopic nephrectomies (1423 donor nephrectomies, 214 simple nephrectomies, and 197 radical nephrectomies). All arteries and renal veins were controlled by titanium and Hem-o-lok clips. One complication that was probably related to vascular clips (titanium and Hem-o-lok), however, involved a delayed hemorrhage from a pseudoaneurysm at the aortic root of the renal artery, which was repaired at exploration. No complication was clearly related to vascular clips. Using Hem-o-lok and titanium clips instead of vascular staplers resulted in $670 savings per operation., Conclusions: Hem-o-lok and metallic vascular clips applied properly by trained surgeons according to published safety measures provide a safe and considerable cost-saving option for vascular control in laparoscopic nephrectomy.

Objective: It was intended to demonstrate the update report of our experience with laparoscopic management of ureteropelvic junction obstruction by division of the aberrant vein and cephalad relocation of the crossing artery in a large group of patients with long-term follow-up., Patients and Methods: Three hundred and twenty-nine patients were candidate to undergo laparoscopic transperitoneal ureteropelvic junction obstruction management from June 2001 to March 2009. Intraoperatively, lower pole crossing vessels were identified in 117 patients (35.5%). After division of the aberrant vein, the crossing artery was relocated cephalad and fixed to peripelvic tissue. Renal pelvic emptying with proper pyeloureteral peristalsis was considered in 71 patients, so neither pyeloplasty nor Double-J stent was fixed for them. Postoperative outcomes were assessed with intravenous urography and/or diethylene triamine pentaacetic acid-diuretic renal scan., Results: Of the 71 patients who underwent this laparoscopic approach, 42 were completely followed over a long-term period. The mean age of patients was 27 (7-69) years. The mean operative duration was 133 (55-185) minutes and blood loss was negligible. The mean hospital stay was 2.8 (1-7) days and mean follow-up was 29 (3-84) months. Overall success rate was 90% and recurrence of obstruction was noted in two patients. No significant complications were observed., Conclusion: Cephalad relocation of the lower pole crossing artery after division of the crossing vein in selected cases could be an ideal alternative for dismembered pyeloplasty with noticeable outcomes in long-term follow-up.

Background and Purpose: Laparoscopic partial nephrectomy is a demanding procedure. To popularize the procedure, simplifying the technique is of great concern for most laparoscopic urologists. Our objective was to evaluate the results of laparoscopic partial nephrectomy (LPN) when eliminating bolster in repair of the tumor bed., Patients and Methods: Thirty-three patients with single sporadic renal masses who underwent LPN are included in this study. After tumor excision, both parenchymal tissue and collecting system (if violated) were closed with a single row of polyglactin 2/0 stitches in running fashion. No bolster was applied in the renal defect, even in broad tumor beds. To avoid time-consuming knot tying, the sutures were buttressed by the use of Hem-o-Lok clips. No ureteral stenting was performed after repair. Data on perioperative and early postoperative outcomes were collected prospectively., Results: Mean tumor size was 4.06 +/- 1.13 cm (range 1.80-6 cm), with 15 tumors larger than 4 cm in greatest diameter. Blood loss was minimal. Mean ischemia time was 25.8 +/- 6.9 minutes (range 14-39 min). Urine leakage occurred in one (3.0%) patient and was managed conservatively. Three (9.0%) patients received blood transfusion. All of the procedures were completed laparoscopically without the need for open conversion or postoperative surgical intervention., Conclusion: LPN could be accomplished safely without the use of bolster. Such an approach could help simplify the procedure and consequently popularize it among urologists.

Purpose: To assess the safety and efficacy of acute dilatation of THE intramural ureter for ureteroscopy by the railway technique., Patients and Methods: Between January 2000 and December 2004, 400 consecutive ureteroscopic procedures were performed, among which 15 male and 5 female patients (5%) with an average age of 40 years (range 25-65 years) underwent acute dilatation of the intramural ureter by the railway technique A guidewire is placed into the ureter, and a 3F ureteral catheter is passed through the working channel of the ureteroscope (8.5F-10F) for 3 to 5 cm into the ureter. The ureteroscope is rotated so that it lies between the guidewire (outside) and the ureteral catheter (inside) and advanced between the guidewire and the ureteral catheter like riding over a railway. Postoperatively, no double-J stent was used. The mean follow-up was 25 months (range 6-60 months). An intravenous urogram and voiding cyctourethrography were obtained at 3 months, and ultrasonography was performed every 6 months in the first year and every 2 years after ureteroscopy in all 20 patients., Results: Ureteral access was achieved with the railway technique in all 20 patients. Perforation or intramural false passage of the ureter did not appear. Follow-up imaging showed no distal-ureteral stricture or vesicoureteral reflux., Conclusions: Acute dilatation of the intramural ureter by the railway technique is cost effective, safe, easy, rapid, and predictable. This time-saving technique often removes the need for balloon dilatation of the distal ureter.