Laparoscopic ureterocalicostomy: development of a technique simplified by application of Nitinol clips and a wet monopolar electrosurgery device.
OBJECTIVE
We developed a technique for laparoscopic ureterocalicostomy with the use of intracorporeal suturing and subsequently simplified the technique by application of experimental Nitinol clips.


METHODS
We performed laparoscopic ureterocalicostomy on 16 domestic swine divided into four groups of four animals each. The kidney was exposed laparoscopically, and the renal artery was atraumatically clamped. The lower pole of the kidney was amputated to expose a lower-pole calix, and hemostasis of the cut renal surface was obtained with a wet monopolar electrosurgical device (Floating Ball device [FB]; TissueLink, Dover, NH). Anastomosis of the ureter to the lower-pole calix was performed over a guidewire using 3-0 Vicryl suture in group 1 and Nitinol clips in group 3. A double-J ureteral stent was then deployed retrograde under fluoroscopic guidance. In addition, we evaluated the use of fibrin glue as a sealant over the sutured or clipped anastomotic site (groups 2 and 4, respectively). Ureteral stents were removed after 3 weeks, and the animals were evaluated and sacrificed after an additional 3 weeks.


RESULTS
Laparoscopic ureterocalicostomy was completed in all 16 animals. In each case, excellent renal parenchymal hemostasis was obtained with the FB device, with a mean hemostasis time of 4.1 minutes. The mean anastomotic time with standard suture reconstruction was 37.1 +/- 5.4 minutes, while the anastomotic time with the Nitinol clips was 29.0 +/- 8.0 minutes (P = 0.0339). Retrograde pyelograms in groups 1 and 3 (no fibrin glue) showed a patent anastomosis with no hydronephrosis in three of the four animals in each group. One animal in group 1 and one animal in group 3 developed large urinomas secondary to anastomotic failure. The animals that received fibrin glue over the anastomotic site (groups 2 and 4) all showed narrowed anastomoses with severe hydronephrosis.


CONCLUSIONS
With available instrumentation, laparoscopic ureterocalicostomy is technically feasible. Nitinol clip technology significantly reduces collecting-system reconstruction time. Application of fibrin glue as a urinary tract sealant resulted in an unexpected adverse outcome.
Vanlangendonck
Richard
R
Division of Urologic Surgery, Washington University St. Louis, St. Louis, Missouri 63110, USA.
Venkatesh
Ramakrishna
R
Vulin
Christopher
C
Quayle
Sejal
S
Morrissey
Kevin
K
Landman
Jaime
J
D000497:Alloys; D000714:Anastomosis, Surgical; D000818:Animals; D003251:Constriction, Pathologic / Q000209:etiology; D004598:Electrosurgery / Q000295:instrumentation*; D015718:Fibrin Tissue Adhesive / Q000008:administration & dosage / Q000009:adverse effects; D006490:Hemostatics / Q000008:administration & dosage / Q000009:adverse effects; D006869:Hydronephrosis / Q000209:etiology; D007670:Kidney Calices / Q000000981:diagnostic imaging / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D023421:Models, Animal; D011859:Radiography; D015607:Stents; D013537:Sutures; D013552:Swine; D014513:Ureter / Q000601:surgery; D014517:Ureteral Obstruction / Q000601:surgery*; D014519:Ureterostomy / Q000295:instrumentation* / Q000379:methods
D000497:Alloys; D015718:Fibrin Tissue Adhesive; D006490:Hemostatics; C013616:nitinol