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INTRODUCTION AND OBJECTIVE:We present a retrospective review of more than 25 years of experience in running volunteer mission trips in Northern India under the aegis of a non- profit philanthropic ...

Purpose: We study the controversies manifested in religious writings, art, sculpture and music as well as the theological disputes surrounding the circumcision of Jesus Christ.Materials and Methods: Data are derived from relevant historical and theological articles.Results: Jesus Christ was circumcised as a Jew on the 8th day after his birth. Until 1960 the Catholic church celebrated the day as Circumcision Day. In medieval times the holy foreskin was worshipped in many European churches.Conclusions: Christianity never condoned the ritual of circumcision and established the sacrament of baptism in its place.

Sir William Osler published his textbook, The Principles and Practice of Medicine, in 1892. It became the definitive treatise on a wide variety of diseases. The section on nephrolithiasis clearly presents the etiology, pathology, symptoms, diagnosis, and treatments. What remains a mystery is the mention, under rare forms of human stones, of a type called "indigo."A search of Index Medicus starting from 1909 backward to its inception in 1879 was performed for key words "indigo," "calculus," "renal" or "bladder stones" and "indicanuria." Twelve textbooks of urology published before 1940 were scrutinized for references to indigo calculi.Only two references to indigo were found, both related to its use for treating constipation (1887 and 1891). Of the 12 textbooks, only 4 make passing reference to "indigo stones." They all mention that such calculi are very rare, but direct references to cases are lacking. One textbook references a study of blue stones from Egyptian mummies.It is unlikely that Osler's reference to an indigo calculus was taken lightly during his writing of The Principles and Practice of Medicine. The case of the indigo calculus is fascinating and perhaps enlightening if only for the source of Osler's intrigue.

Image transmission is an integral part of telemedicine, allowing evaluation of patients at remote sites. We developed a simple method of wireless transmission of digital images to a hand-held computer (PDA) and evaluated its feasibility and diagnostic accuracy in patients with acute renal colic or renal trauma.The CT images from 11 patients with suspected renal colic and one patient with renal trauma were transmitted using a cellular telephone with a wireless modem link to a PDA (Sony Clie 615C). A diagnostic interpretation was recorded for the presence/absence of an upper-tract stone, stone location, estimated stone size, and signs of upper-tract obstruction. Radiologic staging of trauma was provided in the patient with a renal injury. Comparison was made with the final dictated report of a staff radiologist.Ten CT sets of patients with renal colic were used for comparison, the remaining one being excluded because of ambiguity in the final radiology report. An average of 5.9+/-1.6 images, average size 32.2+/-5.2 kb (range 21-42 kb) for each patient were sent at an average speed of 1 kb/sec. Interpretation correctly identified stone presence in 80%, hydronephrosis in 100%, and perinephric stranding in 80% and stone size within 1+/-1 mm. A stage-3 renal trauma was correctly identified and staged.Wireless teleradiology to PDA units provides image quality sufficient for diagnostic interpretation. Anticipated improvements in wireless transmission and PDA screen image resolution will enhance the speed, quality, and quantity of images transmitted. Wireless teleradiology may facilitate convenient rapid evaluation of patients at remote sites.

Technology and refinements in urology have prospered with the bonding of engineers and surgeons. The introduction of fiberoptics and the development of the ureteroscope opened the doors to the field of ureteroscopy. Advances in rigid and flexible ureteroscopy with irrigating and working channels have expanded the capability of the urologist to diagnose and treat most abnormalities of the upper tracts in adult and pediatric populations. Instrument development has easily paralleled the growth and development of the ureteroscope and has improved success, patient safety, and comfort with the incorporation of access sheaths, nitinol materials, and Ho:YAG laser technology. Owing to their minimal morbidity and high success rate, ureteroscopic evaluation and therapeutic interventions in the upper tract represent the gold standard of management. Albert Einstein said, "There are only two ways to live your life. One is as though nothing is a miracle. The other is as though everything is a miracle." Contemporary ureteroscopy is a historical miracle that has opened a vista of endless limits in upper tract endoscopy (Fig. 4, Box 1).

Vaginal adenosis, without a history of diethylstilbestrol (DES) exposure, is a rare condition with an unclear etiology. A 40- year-old female presented with complaints of persistent excessive watery vaginal discharge. On examination, there was red, patchy, diffuse lesion all over the vaginal wall and cervix. Histopathological examination of the lesion revealed vaginal adenosis. This case is presented here for its rarity. How to cite this article Hena SNB, Akhter N, Das S, Kutubi A. Vaginal Adenosis in a 40-year-old Lady: A Case Report and Review of Literature. J South Asian Feder Obst Gynae 2013;5(2):80-82.

The antegrade continence enema (ACE Malone) procedure has improved the lives of many patients who struggle with intractable forms of constipation. We describe a laparoscopic approach to this technique and review the literature.

Objectives. To review the pediatric renal trauma cases during the past 10 years to determine the appropriate indications for imaging and operative intervention. Methods. We searched the medical records from 1989 to 1999 and identified 61 patients aged up to 18 years old with objective data on renal trauma grade by either computed tomography or operative exploration and analyzed the data. Results. Of the 61 cases, 46 were blunt and 15 were penetrating injuries. Thirty-two (70%) of 46 patients with blunt injuries and all 15 patients (100%) with penetrating injuries sustained significant grade 2-5 injuries. The 14 grade 1 blunt injuries included 4 (29%) with gross hematuria, 7 (50%) with microscopic hematuria, and 3 (21%) with normal urinalyses. The 32 grade 2-5 blunt injuries included 20 (63%) with gross hematuria, 8 (25%) with microscopic hematuria, and 4 (13%) with normal urinalyses. The 15 grade 2-5 penetrating injuries included 9 (60%) with gross hematuria, 2 (13%) with microscopic hematuria, and 4 (27%) with normal urinalyses. Five of the blunt (11%) and 13 of the penetrating (87%) injuries were managed with renal operative intervention, including 12 repairs of lacerations or vessel injuries and 6 nephrectomies. Conclusions. Renal injuries of significant grade were encountered that presented with microscopic hematuria, as well as with normal urinalysis findings. Therefore, the decision for renal imaging for the diagnosis and grading of renal injuries should not be based on urinalysis alone in isolation from clinical status, history, and mechanism of injury. Although the vast majority of renal injuries do not require surgical intervention, their accurate grading prompts treatment with surveillance, bed rest, and close in-hospital monitoring.

Purpose: Susruta, a pioneer surgeon of antiquity, practiced around 1000 BC in India. We review his many contributions with special reference to the management of urological ailments.Materials and Methods: Information gleaned from the available English translation of 3 volumes of Susruta’s treatise in surgery is analyzed with commentaries and historical perspectives chronicled by Oriental and Occidental historians.Results: Susruta belonged to the period between 600 and 1000 BC. His conceptions of anatomy, physiopathology and therapeutic strategies were of unparalleled brilliance, considering the early age in the history of mankind with no supportive knowledge base preceding his era. His discussions of many aspects of urological diseases are often reaffirmed in the principles of urology today.Conclusions: Through his rational understanding, elaborate teachings and practice of the art of surgery, and many urological ailments in particular Susruta has earned the glory of being the pioneer urologist of antiquity.

Various reparative, reconstructive, extirpative, and miscellaneous surgeries of the bladder with laparoscopic techniques are in the process of evolution. Our increasing expertise enhanced by improved instrumentation make these procedures feasible and encourage us to venture into this relatively less explored arena of laparoscopic urology. Copytight © 2000 by W. B. Saunders Company

Objectives. Laparoscopy may be complicated by neuromuscular injuries, both to the patient and to the surgeon. We used a survey to estimate the incidence of these injuries during urologic laparoscopic surgery, to assess risk factors for these injuries, and to determine preventive measures. Methods. A survey of neuromuscular injuries associated with laparoscopy submitted to 18 institutions in the United States was completed by 18 attending urologists from 15 institutions. Results. From among a total of 1651 procedures, there were 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2). Neuromuscular injuries were twice as common with upper retroperitoneal as with pelvic laparoscopy (3.1% versus 1.5%). Among patients with neuromuscular injuries, those with rhabdomyolysis were heavier (means 91 versus 80 kg) and underwent longer procedures (means 379 versus 300 minutes), and those with motor deficits were older (means 51 versus 42 years of age). Of the surgeons, 28% and 17% reported frequent neck and shoulder pain, respectively. Conclusions. Although not common, neuromuscular injuries during laparoscopy do contribute to morbidity. Abdominal wall neuralgias, injuries to peripheral nerves, and joint or back injuries likely occur no more frequently than during open surgery, but risk of rhabdomyolysis may be increased. Positioning in a partial rather than full flank position may reduce the incidence of some injuries. Measures to reduce neuromuscular strain on the surgeon during laparoscopy should be considered.

Despite excellent postoperative continence with pubovaginal sling procedures, the resultant morbidities of de novo urgency and urinary obstruction due to sling tension remain valid concerns. The feasibility and outcome of dynamic suburethral suspension using bilateral strips of external oblique aponeurosis left attached medially to the anterior rectus sheath and joined beneath the urethra under no tension were determined.Between May 1995 and April 1998, 25 women with stress urinary incontinence were evaluated and underwent a dynamic suburethral suspension procedure. All patients were followed annually with a 10-point questionnaire by an independent registered nurse who analyzed the results, complications and satisfaction outcome.At a mean followup of 26 months all patients (100%) were cured of stress incontinence. Associated urge incontinence due to detrusor overactivity persisted in 3 patients postoperatively and, thus, the overall postoperative cure/dry rate was 88% for the study group. Of the 18 patients with preoperative urgency 12 (66%) were cured postoperatively. De novo urgency developed in 1 patient after surgery. No patient had prolonged urinary retention. Overall 92% of the patients were satisfied with the outcome of surgery.This dynamic suburethral suspension procedure cured stress incontinence in the majority of patients with no resultant urinary obstruction. The mechanism of action is believed to work by providing a viable suburethral "backboard" of support and by dynamic lifting of the proximal urethra cradled by the fascial loop precisely at the time of abdominal strain. Pronounced urge incontinence due to detrusor overactivity is unlikely to benefit from suspension procedures.

The long-term surgical outcome of abdominal colposuspension, laparoscopic colposuspension and vaginal needle suspension for managing anatomical stress urinary incontinence in women was evaluated.Three nonrandomized contemporaneous groups of 10 women each with anatomical stress urinary incontinence were treated with abdominal colposuspension, laparoscopic colposuspension or vaginal needle suspension. Immediate postoperative and subsequent outcomes were evaluated using a 10-point questionnaire annually up to 36 months.Immediately after surgery the laparoscopic colposuspension group required less analgesia as well as briefer catheterization and hospital stay. Continence rates 10 months postoperatively were 100% for the abdominal colposuspension group, 90% for the laparoscopic colposuspension group and 100% for the vaginal needle suspension group. At 36 months postoperatively these results had declined to 50, 40 and 20%, and satisfaction with surgical outcome was 60, 90 and 60%, respectively.Despite initially high success rates of these 3 surgical procedures based on the principle of retropubic suspension of the proximal portion of the urethra, responses to questionnaires given at longer postoperative intervals showed a sharp decline in success. We probably should redirect our treatment strategy for women with anatomical stress incontinence to include urethral coaptation and direct suburethral suspension.

Chronic filarial disease with lymphedema is affecting about 15 million individuals worldwide, India alone accounts for 38% of the total disease. The disease causes physical disability, psychological despair, social isolation, and loss of economic productivity to the tune of about 1.5 billion dollars annually in India alone. The global elimination of lymphatic filariasis (LF) programme has been launched in many countries. It was felt that LF, though not usually deadly, is a prime disabler both of people and of progress. Yet it is a disease that is curable with the right resources and political will. Thus under the leadership of the World Health Organization (WHO) emerged the global alliance in the year 2000 for the elimination of lymphatic filariasis (GAELF). The goal of the alliance was set to eliminate LF as a public health menace by 2020. Their strategy is, the entire population at risk in the endemic areas is to be treated with annual single dose of filaricidal drug combination of albendazole and DEC for 4-5 years to cover the life span of the adult filarial worms.

Objectives . Significant obesity is considered to be a relative contraindication to laparoscopic surgery. This study reviews the complications encountered in massively obese patients undergoing urologic laparoscopic surgery. Methods . Body mass index (BMI) was used as an objective index to indicate massive obesity. Eleven institutions compiled retrospective data on 125 patients having a BMI greater than 30. Procedures performed included 76 pelvic lymph node dissections, 14 nephrectomies, 7 bladder neck suspensions, and 28 miscellaneous procedures. Results . For the group as a whole, the mean BMI was 35.1 (range 30.1 to 57.2). Mean operative time was 202 minutes (range 60 to 480). Conversion to open surgery occurred in 15 of the 125 patients (12%). Complication rates (minor and major) were 22% (27 occurrences in 125 patients) intraoperatively and 26% (33 occurrences in 125 patients) postoperatively. The major complications included 2 trocar injuries to abdominal wall vessels, 1 bladder injury, 3 peripheral nerve injuries, 1 dysrhythmia, 1 deep vein thrombosis, 1 wound seroma, 1 nephrocutaneous fistula, 1 incisional hernia, and 1 death. Conclusions . In this review, complication rates for urologic laparoscopic surgery on massively obese patientswere higher than in the general population undergoing laparoscopic surgery (0.3% to 21%).

Recent interest in urologic laparoscopy is a welcome renaissance of minimally invasive procedures that provide superior benefit to patients. It behooves the urologist to avoid complacency and embrace the resurgence of laparoscopy. Dedicated pursuit and perseverance will facilitate the evolution and future of urologic laparoscopy.

Twenty-four male patients with known or suspected urethral stricture disease were evaluated using ultrasonic urethrography and standard retrograde x-ray urethrography for comparative analysis of the two techniques. Each patient also had cystoscopy for direct visual verification of the extent of the stricture. Ultrasonic urethrography proved a simple, yet sensitive and reliable, diagnostic study that can provide more accurate information regarding stricture length, lumen caliber, and extent of spongiofibrosis than radiologic urethrography. It allows examination of the urethra in different planes. The ultrasonic equipment is portable, and ultrasonic study provides the distinct advantage of avoiding ionizing radiation.

Laparoscopic urology carries special significance in children because the reduced trauma of access and the earlier recovery translate into less psychological trauma and easier acceptance of surgery...

Purpose: The Raman spectroscopic technology can be utilized for the detection of changes occurring at the molecular level during the pathological transformation of the tissue. The potential of its use in urology is still in its infancy and increasing utility of this technology will transform noninvasive tissue diagnosis. The Nobel laureate, Sir C.V. Raman is credited for the discovery of the principles of Raman spectroscopy. Materials and Methods: Applications of Raman spectroscopy in the bladder, renal, prostate, and other urological disorders were gathered from Medline and abstracts from recent international urological meetings. Current status and future directions of Raman spectroscopy in urology were also reviewed. Results: Raman spectroscopic technology is used to interrogate biological tissues. The potential use of this technology in urology has shown encouraging results in the in vitro diagnosis and grading of cancers of the bladder and the prostate. Raman microprobes have been used for the characterization and identification of renal lithiasis. Technology may be available for the urologists to determine the margin status intraoperatively during partial nephrectomy and radical prostatectomy. The future would see the development of optical fiber probes to incorporate them into catheters, endoscopes, and laparoscopes that will enable the urologist to obtain information during the operation. Conclusion: Raman spectroscopy is an exciting tool for real-time diagnosis and in vivo evaluation of living tissue. The potential applications of Raman spectroscopy may herald a new future in the management of various malignant, premalignant, and other benign conditions in urology.

The appropriate management of patients with cystine calculi necessitates a fundamental understanding of the pathophysiology of cystinuria and a working knowledge of the available therapeutic modalities. The following case reports and review of the literature serve to illustrate that successful treatment involves a multidimensional approach to eradication of calculi with long-term follow-up aimed at prevention.

It is estimated that 1% of patients with endometriosis have involvement of the urinary tract, with the bladder being the most common location. Ureteral endometriosis is a rare entity, and the majority of cases are found at exploratory laparotomy for extensive involvement of the pelvic organs. Obstruction of the ureter may be caused by extrinsic or intrinsic disease, with the extrinsic form occurring four times as often. Progressive ureteral obstruction can be insidious in onset and ultimately lead to renal failure. Hormone therapy has had variable success, and open surgery has been the mainstay of treatment. Only one case of ureteral endometriosis, both intrinsic and extrinsic, diagnosed at ureteroscopy has been reported previously. We present a case of ureteral obstruction secondary to isolated intrinsic endometriosis diagnosed at ureteroscopy and treated endoscopically with holmium laser ablation and leuprolide therapy.

Laparoscopic pyeloplasty offers similar success rates compared to open surgery. However, the advanced laparoscopic skills required may limit its widespread application. In select patients the dorsal lumbotomy approach can provide similar postoperative advantages to minimally invasive surgery. We analyze the perioperative management of laparoscopy vs dorsal lumbotomy for the repair of ureteropelvic junction obstruction.In a retrospective review 13 patients who underwent dorsal lumbotomy pyeloplasty were compared to 19 patients who underwent laparoscopic pyeloplasty between 1998 and 2003. Preoperative confirmation of obstruction was obtained through excretory urogram or renal Lasix scan. All 13 patients undergoing dorsal lumbotomy had a dismembered pyeloplasty. Of the 19 laparoscopic cases 16 had a dismembered pyeloplasty and 3 had a Fenger procedure. Average followup was 12 months for the open group and 13.3 months for the laparoscopic group. Postoperative results were evaluated with excretory urogram or renal Lasix scan as well as subjective outcomes by the patients.Operative time was slightly longer for the laparoscopy group at 231 minutes vs 200 minutes. Estimated blood loss and postoperative morphine requirements were also similar. Hospital stay was 3.3 days for the dorsal lumbotomy group compared to 2.4 for the laparoscopy group. The overall success rate for the laparoscopic group was 94.7% compared to 100% for the dorsal lumbotomy group. Each group had 1 complication, paresthesia of anterior/medial thigh that resolved by 6 months.Our preliminary results show that a dismembered dorsal lumbotomy pyeloplasty is comparable to laparoscopic dismembered pyeloplasty with regard to intraoperative and postoperative hospital course.

The incorporation of robotics into surgical technology is a relatively recent development. Robotic surgical systems can be classified as master-slave systems, precise-path systems, or intern-replacement systems. Master-slave systems, the most familiar type, were developed from initial experiments in "telepresence" surgery funded by the US Department of Defense. Urology has embraced the use of commercial robotic surgical systems in a growing number of clinical applications. Although drawbacks and limitations exist for the use of surgical robotics, the systems are developing rapidly and an expanded role for this technology in the future of urology is inevitable. This article reviews the history of the use of robotics in surgery, focusing on its specific application to urology.

Simultaneous removal of multiple organs is a situation seldom encountered by the urologist but may be needed in patients with adult polycystic kidney disease or malignancies or infectious processes involving more than one organ. Historically, open surgery has been considered necessary to gain adequate exposure. However, hand-assisted laparoscopic surgery is suitable for many of these patients. The hand-port and trocar positions are chosen according to the laparoscopic experience of the surgeon and depend on whether an ambidextrous or nondominant-hand procedure is planned. Several techniques are described, with a focus on bilateral nephrectomy.

Purpose: The feasibility of using minimally invasive laparoscopic techniques adhering to the surgical principles of management of anatomical stress incontinence was evaluated in 10 women.Materials and Methods: Postoperative performances and early surgical results were compared with those of contemporaneous groups of women undergoing open colpo-suspension or vaginal needle suspension.Results: Laparoscopic colpo-suspension proved to be technically feasible with less postoperative pain and shorter hospitalization.Conclusions: All 3 groups of patients had similar relief from stress incontinence in the early postoperative followup.

In laparoscopy, the term "mirror imaging" is used to describe a visual illusion resulting in paradoxical movements when a surgeon is positioned opposite the laparoscope. Mirror imaging is a common problem, creating difficulty in ergonomics and task performance. We introduce the use of a video image converter box (IC box) to overcome mirror imaging. The IC box converts the analog signal to a digital one, performs image rotation or inversion or both, and then reproduces an analog signal for monitor viewing. A laboratory study evaluated whether the IC box could improve performance during laparoscopic tasks.Fourteen laparoscopic surgeons (10 novice and 4 experienced) completed three laparoscopic tasks while positioned opposite the camera and experiencing mirror imaging: (1). suture cutting; (2). multiple transfers of a piece of foam; and (3). multiple transfers of a pinto bean. Participants were timed during each test both with and without the use of the IC box.All surgeons completed each task faster using the IC box (P0.015). On average, use of the IC box allowed subjects to complete assignments in less than one-third the time needed without the IC box. In Task 3, requiring multiple transfers of a small bean, all participants using the IC box completed the task. However, without the box, only 1 of 14 participants accomplished the goal in the allotted time.Use of the IC box eliminates mirror imaging and improves performance and efficiency during laparoscopic tasks. The box would significantly benefit surgeons positioned opposite the camera during laparoscopic surgery.

Penile calciphylaxis is a rare condition resulting in infection and gangrene. Most cases are associated with systemic calciphylaxis. The pathophysiology, diagnosis and management of penile calciphylaxis as a distinct entity have received little attention. We reviewed the literature to increase understanding of this disease.A retrospective review of the literature was performed after treating a case of penile calciphylaxis. Patient characteristics, presentation, serum chemistry studies, management and outcomes are reported.A total of 34 cases of penile calciphylaxis were identified in the literature including our patient. Average patient age was 58 years. All patients had end stage renal disease, and diabetes mellitus was a co-morbidity in 76%. Additional areas of gangrene beyond the genitalia were found in two-thirds of patients. Average calcium phosphate product was 78.5 mg.2/dl.2 (range 20.6 to 52.5) and mean parathormone level was 553 pg./ml. (10 to 65). Parathyroidectomy was performed in 8 patients. All patients were treated with either local débridement/wound care or partial/total penectomy. Survival was better in patients who underwent parathyroidectomy (75%) than in those treated with local débridement or penectomy alone (28%). The overall mortality associated with this disease was 64% with a mean time to death of 2.5 months.Penile calciphylaxis is a result of medial calcification and fibrosis of blood vessels. The co-morbidity and mortality associated with this disease are extremely high. Secondary hyperparathyroidism and an increased calcium phosphate are characteristic and require aggressive medical management. Surgical management of penile lesions and parathormone is controversial. Our review suggests that parathyroidectomy may improve survival and that survival is independent of the type of local treatment for the penile lesions.

OBJECTIVE To compare the outcome in contemporaneous groups of patients undergoing hand-assisted laparoscopic radical nephrectomy (HALRN) or open (flank) radical nephrectomy (ORN), as many series worldwide have confirmed the feasibility and advantages of LRN in managing renal cell carcinoma (RCC). PATIENTS AND METHODS We retrospectively evaluated 44 patients who underwent radical nephrectomy for RCC from 1999 to 2001, 22 by HALRN and 22 by ORN, through an extraperitoneal 11th or 12th rib flank incision. Standard perioperative variables were assessed; a validated questionnaire was also sent to each patient after surgery, allowing them to report their overall satisfaction and the period needed for them to return to both routine and full activities. The outcomes of HALRN and ORN were compared using Wilcoxon rank-sum analysis. RESULTS There was a statistically significant difference between HALRN and ORN in operative duration, length of hospital stay, total narcotic requirement, pain scores at 1 week and 1 month after surgery, and the time to resume routine and full activity, with all variables (except operative duration) lower in the HALRN group. There were no significant differences between the groups in pain at 1–3 days, estimated blood loss or overall satisfaction. CONCLUSION Compared with ORN, HALRN is associated with lower narcotic requirement, pain scores, a shorter hospital stay and earlier resumption of routine and full activities. However, several obstacles remain, including increased operative duration and the increased equipment costs.

As laparoscopic techniques develop, endoscopic lymph node dissection is becoming preferred as the minimally invasive technique for lymph node staging of pelvic malignancies. We developed an extraperitoneal laparoscopic approach to staging pelvic lymphadenectomy, and describe our technique, results and experience in our initial 9 patients.

Treatment of urolithiasis within a pelvic kidney presents a technical challenge. We report an extraperitoneal laparoscopy-assisted percutaneous approach to access the lower-pole calix of a pelvic kidney for percutaneous nephrolithotomy.

Over the past decade, laparoscopy has matured to a common, and in some cases, standard surgical approach. Over this time period, many technological advances have contributed to this progression, one of which is hand assistance. Hand-assisted laparoscopy allows a shortened technical learning curve, security and ease in dissection, the ability to remove organs en bloc, and shorter operative times while maintaining the postoperative advantages of laparoscopy.We present our experience with a hand-assisted laparoscopic approach for two patients requiring bilateral nephrectomy in preparation for renal transplantation and a third patient having concurrent right simple nephrectomy and simple cystectomy for chronic pyocystis.The hand-assisted approach allowed for utilization of one anesthetic, repositioning of the patient without violating the sterile field, and a short convalescent time. The average hospital stay was 5 days, including two patients who required postoperative revascularization of their clotted arteriovenous fistulas.The established indications for hand-assisted laparoscopy include removal of large surgical specimens en bloc, anticipated difficult dissection, and failure of standard laparoscopic procedure progression. We propose that removal of multiple organs should be added to this list.

Arteriocavernosal fistula resulting from blunt perineal trauma caused high-flow priapism in the patient described. The fistula was delineated by pudendal angiography and treated by percutaneous emb...

A large symptomatic bladder diverticulum in a 72-year-old man was removed through laparoscopic dissection. The surgical technique of laparoscopic diverticulectomy is described. Laparoscopic diverticulectomy can be done with minimal morbidity and has distinct advantages over other forms of treatment of bladder diverticula.

Laparoscopy was utilized in the evaluation of 27 nonpalpable testes in 21 patientsprior to exploration and necessary definitive surgery. Laparoscopic prediction of the location of the nonpalpable testes was accurate in all cases. Laparoscopic findings can help in determining the appropriate technique of orchiopexy expected to yield better testicular salvage. It can also prevent unnecessary exploration of children with anorchia as evidenced by blind-ending vas deferens and spermatic vessels.

A 19-year-old man presented with a palpable abdominal mass, left supraclavicular adenopathy and intratesticular swelling of the left testis on ultrasound. Fine needle aspiration of the supraclavicular nodes revealed embryonal carcinoma. Serum a-fetoprotein and b human chorionic gonadotropin levels were elevated at 20 and 168 m./dl., respectively. The patient received 4 courses of combination chemotherapy with bleomycin, etoposide and cisplatin. Serum markers became normal (a-fetoprotein 3.6 and b human chorionic gonadotropin less than 2 m./dl.) and all metastatic lesions disappeared. The 4 3 4 3 4.5 cm. area of retroperitoneal swelling that remained was excised at left orchiectomy. Only necrotic tissue with no viable tumor was identified in both specimens. The patient complained of abdominal ache with fullness, anorexia and weight loss 2 years later. Computerized tomography (CT) of the abdomen revealed a large retroperitoneal lymphocele extending into the pelvis (fig. 1, A). Laparoscopic marsupialization was performed through a 10 mm. umbilical camera port and 2, 5 mm. ports on the right side of the abdomen. After opening the anterior wall of the lymphocele 5 l. fluid were drained. A large posterior peritoneal window was established by widely opening the anterior cyst wall (fig. 2). Abdominal CT 4 months postoperatively showed a small residual lymphocele in the upper retroperitoneum with no recurrence of the marsupialized lymphocele (fig. 1, B). DISCUSSION