Leslie A. Deane, MD

Seal strength tests on two laparoscopic instruments indicate that each offers separate advantages when sealing ureters and blood vessels, researchers reported at the World Congress of Endourology & SWL.  

Clinically, the study findings serve as a guideline for surgeons who routinely use the two devices-the Harmonic ACE (Ethicon Endo-Surgery, Cincinnati) and the Ligasure V (Valleylab, Boulder, CO)-as adjuncts to standard monopolar electrosurgical instruments during the course of a laparoscopic procedure. 

For the study, researchers from the University of California, Irvine, used a porcine model to seal multiple blood vessels and both ureters using each device. The burst pressure of the seals was tested, as were the seal time, seal quality, and the animals' serum albumin. The tissue was also submitted for histopathologic evaluation. 

The Harmonic ACE appeared to cause a lower amount of subjective tissue damage than both one or two seals with the Ligasure V. 

"In blood vessels, though some surgeons may seal the vessel twice when using the Ligasure V, this work suggests that one seal is better than a double seal.," said study co-author Michael Louie, MD, a clinical instructor in urology at the UC-Irvine, working with Ralph V. Clayman, MD, and colleagues. 

As there appears to be more tissue effect when two seals are employed with the Ligasure V, one seal is the safer method, the researchers conclude. When considering the ureteral transection, both devices appear to be equally efficacious. 

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Seal strength tests on two laparoscopic instruments indicate that each offers separate advantages when sealing ureters and blood vessels, researchers reported at the World Congress of Endourology & SWL.

Sealing devices show distinct advantages in study

An innovative technique for tubeless percutaneous nephrolithotomy appears to be a viable alternative to the traditional practice of mandating stenting the ureter and placing a nephrostomy tube following minimally invasive removal of large renal calculi, according to researchers from Duke University, Durham, NC. Which patients benefit most from the procedure remains undetermined, the researchers noted.

  Between July 2007 and July 2008, 35 patients with a mean stone burden of 531.8 mm

) underwent a tubeless-stentless PNL. Only a ureteric catheter remained in situ following these procedures and this was routinely removed on postoperative day 1 in all cases. Twenty-four patients (68.6%) received treatment as outpatients; among those admitted for treatment, mean length of hospital stay was 1.9 days. Seven patients (20%) had multiple accesses performed and seven had a supracostal puncture. Patient body mass index ranged from 14.2 to 61.4, which attested to the safety of this approach even in the morbidly obese. However, in this population, the complication rate is 20% if multiple access tracts are used, reported Michael Ferrandino, MD, clinical associate in laparoscopy and endourology, working with Glenn Preminger, MD, and colleagues. Complications reported among these patients included one pleural effusion, one pulmonary embolus, and one hemothorax/pneumothorax. 

"Our group needs to characterize who would benefit most greatly from this procedure and therefore reduce morbidity and potential mortality," Dr. Ferrandino said. He noted that in cases presenting a high risk for perforation or significant bleeding, "we would not advocate the tubeless procedure." 

A third abstract on this topic originated at the Naval Medical Center in San Diego. Researchers under the direction of Brian K. Auge, MD, analyzed the outcomes of 107 patients undergoing a tubeless procedure for renal nephrolithiasis. 

Among these patients, the immediate targeted stone-free rate was 72%, as defined by postoperative computed tomography scan. The low complication rate consisted of seven asymptomatic subcapsular hematomas (.06%), one pseudoaneurysm that required selective embolization (.009%), one urine leak and five emergency room visits for pain (.046%). Because fibrin sealant was applied to the tract in these patients, Dr. Auge's team speculated that doing so decreased postoperative drainage from the wound. 

Overall, tubeless PNL may be a feasible option in selected cases, and is safe as long as the collecting system remains intact and hemostasis is perfect at the conclusion of the procedure. 

An innovative technique for tubeless percutaneous nephrolithotomy is a viable alternative to stenting the ureter and placing a nephrostomy tube.

Leslie A. Deane, MD

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Sealing devices show distinct advantages in study

Tubeless percutaneous nephrolithotomy: Safe, effective in select patients