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The potential disadvantages of this are the proximity of the camera to the urachal lesion 25 medications to know for nclex generic 500 mg keppra with amex. The laparoscopic approach has been universally found to be a safe and reliable technique to surgically correct urachal remnants. In adults, adenocarcinoma Minimally invasive approach for urachal remnants Persistence of part of or the entire allantois can present in children with a patent urachus. By the fifth month of gestation, the urachus is nearly obliterated to ligamentous structure with an obliterated lumen lined by epithelium and an outer fibromuscular layer. This fibromuscular band then eventually becomes the median Chapter 98 Minimally Invasive Techniques in Lower Urinary Tract Reconstruction 1205 arising in urachal remnants has been successfully treated with laparoscopy. Postoperatively, the children did not have any complications with a median follow-up of 7 months. It has been utilized as a one-stage approach even for infected urachal cysts with excellent results [36]. According to these authors who used a 2­5-mm camera and 2-mm instruments, laparoscopy provided a superior cosmetic outcome and early recovery. Other authors have also concluded, although not from comparative studies, that laparoscopy provides earlier recovery and better cosmetic outcomes [34]. The large bowel serosa is tacked on the abdominal side to the peritoneum anteriorly to close the neovaginal space from the abdominal cavity. The neovaginal space can be created by making a U-shaped perineal flap and bluntly dissecting between the bladder and the rectum. Laparoscopy has been utilized to mobilize the peritoneum and capping the neovagina with bowel serosa. They found an excellent 95% anatomic success rate and 96% functional success rate at 6 months. Although their follow-up is short and this is still early experience, these are very promising results. Minimally invasive genitoplasty Children born with congenital absence or hypoplasia of the vagina in isolation (Mayer­Rokitansky­Kuster­ Hauser syndrome) or in association with other anomalies, like disorders of sexual development or genitourinary development, should be considered for vaginoplasty. A good preoperative work-up is necessary to accurately diagnose this condition and define appropriate treatment. Most experts in this field agree that gradual vaginal dilation should be the first step in the management of these children [37]. The timing of reconstruction is controversial and the recent impetus has been to perform these procedures during adolescent or early adult life due to better psychologic acceptance by these age groups [37]. Several different techniques of open vaginoplasty have been described in the literature, including the Vecchietti procedure, Davydov procedure, and intestinal vaginoplasty. All these techniques have recently been adapted to laparoscopic technique with good results, although the experience is still early. Although a detailed explanation of the various surgical techniques is beyond the scope of this chapter, we will attempt to provide an outline, as well as evidence for the feasibility of the minimally invasive approach. Intestinal vaginoplasty Intestinal vaginoplasty involves harvesting a segment of bowel and using this segment to create a neovagina. Recently, the da Vinci robotic system was used to perform this procedure in a 17-year-old patient [44]. Laparoscopy was utilized for bowel mobilization, segmental resection, and re-establishment of bowel continuity. Two large series from China, one using ileum [42] and the other using colon [43], have both reported excellent safety and feasibility, with excellent postoperative functional outcomes. Laparoscopic Vecchietti procedure the principle of the Vecchietti procedure is traction from inside rather than dilation. The procedure involves placement of an acrylic ball in the superficial surface of the vaginal dimple. This is connected by wires under tension that pass through the vaginal dimple in to the abdominal cavity and out through the anterior abdominal wall to a tightening device. The wires are placed under laparoscopic guidance and passed through the vaginal dimple and attached to the acrylic ball. Traction is applied to the vaginal dimple by gradually tightening these wires and elongating and enlarging the vaginal Conclusions Laparoscopy is an excellent minimally invasive option to surgically correct urachal remnants in children. It is a safe and reliable technique with possible but not proven better recovery and cosmetic appearance compared to open surgical repairs. Laparoscopy is in its infancy with regards to reconstructive bladder and lower urinary tract surgery, particularly in children.

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The Foley catheter should be secured with tape to the lower leg for patients in the flank position silent treatment generic keppra 250 mg visa. Oliguria during prolonged laparoscopy is common and the anesthesiologist must be well versed on this issue and avoid "chasing the urine output" as this can lead to fluid overload [79­82]. The upper arm should be the site for placement of the blood pressure cuff and parenteral lines for which rapid access may be necessary. A pneumatic patient warming device can be adhesed to the upper extremities and torso or on the lower extremities up to the level of the hips to assist in maintaining patient temperature throughout the case. Patient positioning: retroperitoneal procedures Patient positioning for retroperitoneal procedures is similar to that for transperitoneal operations with several noteworthy exceptions. Since the retroperitoneal space presents a smaller overall working environment and a more limited region of port entry, several maneuvers are critical to optimize both. This position displaces the lateral peritoneal reflection along with the colon in an anterior direction [70], doubling the undisturbed anteroposterior length of the retroperitoneal space [71]. The kidney rest is elevated until it is in contact with the flank and more table flexion is utilized than with the transperitoneal approach to enlarge the space between the lower ribs and the iliac wing. This is an important step to enlarge the much more limited surface area for retroperitoneal port insertion. The remainder of the patient padding and positioning is identical to that performed for transperitoneal surgery with the excep- Chapter 81 Renal Surgery for Benign Disease 949 Even though the peritoneal surface and bowel is not exposed through a large incision during laparoscopy, heat exchange can still be significant due to the convection flow of the insufflant. Warming of the patient utilizing these devices or insufflant warmers is important to maintain body temperature throughout the case, especially in older patients. Special laparoscopic drapes with widened apertures, Velcro straps for cords and tubing, and instrument pockets are commercially available, although a standard paper flank drape can be utilized and the aperture enlarged with scissors to give adequate exposure. Channels can also be created for the light and camera cords, as well as the insufflation tubing, by pulling up redundant drape and clamping it to itself while the cords are brought out through the ends. Operative site preparation and draping the ipsilateral abdomen and flank are shaved from the area of the xiphoid to pubis. A solution of providone­ iodine (Betadine) or a similar surface preparation is used to paint the surgical area. During retroperitoneal procedures the set-up is essentially a mirror image of the transperitoneal arrangement with the exception of the patient position which remains unchanged. Placement of generators toward the foot of the bed minimizes cord interference with surgeon movements around the operating table. The patient is positioned on the operating room table in the flank or semi-flank orientation with their affected side up as outlined above. The scrub nurse or technician stands on the opposite side of the table from the primary surgeon, which facilitates passage of equipment directly across the operating table. This arrangement eliminates the need for the operating surgeon to remove their eyes from the primary monitor to reach behind or to their side to receive instruments. The primary tower containing the insufflator, light source, and camera box is positioned across from the operating surgeon so they can visually inspect the settings as well as the pressure readings throughout the case. The secondary tower is placed on the same side as the primary surgeon for use by the scrub nurse or second assistant. Monitor towers are positioned toward the head of the table and angled back toward the operating surgeon. The height of the monitor must be appropriate for the operating surgeon so upward tilting of the head and subsequent neck fatigue can be avoided. Irrigants are hung on one of the intravenous poles near the head of the patient and the suction canisters are also situated near the anesthetic machine. Simple nephrectomy the major advantages of the transperitoneal approach to laparoscopic simple nephrectomy over the retroperitoneal approach are a larger working space and anatomy that is familiar to most surgeons. Disadvantages of this approach include the need to dissect and retract the colon, spleen, and pancreas on the left, and the liver and duodenum on the right. The main advantages of the retroperitoneal approach are the limited dissection required of the bowel, avoidance of areas of intraperitoneal adhesion, and rapid posterior access to the main renal artery when performing nephrectomy. Benzoin Open nephrectomy surgical pan Chapter 81 Renal Surgery for Benign Disease 951 Steps of the procedure: transperitoneal Step 1: Creation of the pneumoperitoneum and initial entry access the patient is positioned on the table in a modified flank position, as described above, with the side of the operative pathology placed upwards. A 1-cm incision is made through the skin in the lower quadrant just lateral to the rectus muscle and midway between the umbilicus and the anterior superior iliac crest in nonobese patients. This location may need to be shifted cephalad and lateral in obese patients due to the large abdominal pannus. A small clamp is utilized to spread the underlying subcutaneous tissues down to the level of the fascia.

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Kidney tumors Kidney tumors may cause flank pain either from renal capsular stretching or by mechanical compression of large tumors treatment 8th feb purchase keppra 250 mg with mastercard. Primary tumor extension in to the renal pelvis can cause urinary obstruction, although this is usually a slow process during which patients are often asymptomatic. The pain is similar to an acute ureteral obstruction and usually follows the intake of large amounts of fluid, which causes diuresis resulting in renal pelvic distention and colic. One aspect of the medical treatment is the management of acute renal colic pain, a condition that demands rapid and effective analgesia. In addition to controlling the pain associated with obstructing calculi, drug therapy that promotes the expulsion of stones is an evolving aspect of medical therapy. Observation with analgesia is most appropriate for patients without infection whose pain can be wellcontrolled with oral medications. However, in cases of persistence, ureteral obstruction, or pain, other minimally invasive interventions are preferred [23]. Such guidelines should help acquire the most suitable imaging modalities, decide which patients should be hospitalized or referred to other departments, and facilitate in the triage and decision-making on conservative versus surgical therapy. Watchful waiting for spontaneous stone passage is certainly the least invasive management option; however, several signs and symptoms may prohibit such a course of action. Fever, chills, or other sign of infection are the most urgent scenarios prohibiting watchful waiting. Evidence of renal insufficiency or frank anuria similarly necessitates urgent intervention. Other than extreme cases necessitating inpatient management, clinical scenarios that may warrant acute intervention include inability to perform routine activities safely and reliably, upcoming travel plans, job restrictions, etc. Patients with obstructing ureteric stones of greater than 6 mm are seldom likely to pass their stone spontaneously, and early admission for procedural therapy may be prudent [2]. Hospitalization for an acute renal colic attack rarely lasts for longer than 24 h, after which the patient can go home. Surgical intervention the presence of urosepsis in a patient with an obstruction from stone disease is a true surgical emergency. This condition requires hospital admission with intravenous fluids, antibiotics, and most importantly, early drainage of the affected kidney using either retrograde placed double-J stents or percutaneous nephrostomy. Retrograde endoscopy should be reserved for relatively mild cases that are medically stable. Double-J stents virtually guarantee drainage of urine from the kidney and bypass the obstruction. This relieves patients of their renal colic pain even if the actual stone remains. In patients with pyonephrosis in association with an obstructing calculus, retrograde endourologic procedures, such as retrograde pyelograms and double-J stent placement, may worsen the infection by pushing infected urinary material in to the obstructed kidney and may exacerbate the systemic sepsis. These situations clearly indicate the need for a percutaneous nephrostomy, especially in patients who are hemodynamically unstable. Later, when the infection is under control and the patient is no longer septic, a more definitive procedure can be performed to remove or fragment the obstructing stone. Approximately 10­20% of all kidney stones may cause the patient enough problems to require surgical removal. If there is no evidence of movement or passage of a ureteral stone that has been treated conservatively for 3­4 weeks or if pain is intractable, surgical intervention Predicting spontaneous stone passage Setting patient expectations with regard to the likelihood of spontaneous stone passage and the time to stone passage is critical to help guide the patient to make an informed decision between conservative management and surgical intervention. Several factors influence the likelihood of spontaneous stone passage, such as location and history of spontaneous expulsion. Indeed, with accurate information, more patients might select early intervention as opposed to expectant observation. In general, smaller calculi are more likely to pass spontaneously, but stone passage also depends on the specific anatomy of the upper urinary tract. Spontaneous passage of urinary calculi of less than 5 mm in diameter may occur in most patients, although the calculus may take 40 days or more to pass [24]. Prospective clinical trials have stratified the spontaneous stone passage rate and time to stone passage. Stones of 4 mm and smaller have a 94% chance of spontaneous passage, whereas stones of 4­6 mm in size will pass spontaneously 50% of the time.

Syndromes

• Nausea
• You cannot control your diarrhea with diet changes and drugs
• Painful urination
• High blood pressure
• Mother taking sulfa drugs during pregnancy
• Persistent symptoms such as memory loss, dizziness, headache, anxiety, and difficulty concentrating
• Kyphotic curves refer to the outward curve of the thoracic spine (at the level of the ribs).
• Feel sleepy or confused.
• You should not have this procedure if you take certain prescription drugs, such as Accutane, Cardarone, Imitrex, or oral prednisone.

Urologists are already familiar with this concept medications kidney stones cheap keppra 500 mg line, albeit to a lesser degree in the setting of bladder resections, stent removals, and ureteroscopic interventions such as basketing of stones. However, in contrast, all but the most basic therapeutic interventions typically require more than one instrument simultaneously. However, in our experience, once instruments are inserted through the working channel, there can be a significant diminution in insufflation pressure, particularly with the smaller single channel scopes such as the pediatric gastroscope. There is also limited ability with current endoscope technology to regulate pressures, although some new platforms have addressed this problem. Important properties to consider in scope selection include scope size, flexibility, maneuverability, number of channels, channel size, ability to insufflate gas through the scope, ability to adequately illuminate the abdominal cavity, and ease of cleaning the lens. For most natural orifices, flexible scopes have proven to be advantageous and for transgastric access this property is essential to even reach the stomach perorally. Most of the described scopes for transgastric or transvaginal access have been standard gastric endoscopes or colonoscopes with two channels, or pediatric gastroscopes with a single smaller channel. The standard gastric endoscopes have a number of advantages over other traditional scopes, including ability to maneuver both up/down and right/left separately, ability to selfclean the lens by depressing a button, and good illumination of the abdominal cavity. There is a tradeoff of between scope size and number and size of channels, as well as the size of the defect. We have found it is generally preferable to have at least two instrument channels that can accommodate standard endoscopic equipment for procedures that involve manipulation of tissues, assuming the scope is the only conduit for instruments. The small size of the urethra, for example, precludes introduction of even the smallest standard dual-channel adult gastric endoscope, although single channel pediatric gastroscopes can be used in our experience [38]. Very small scopes such as ureteroscopes introduced through the bladder may not even require closure of the defect [28]. Urologic scopes have had a more limited role to date, although a flexible cystoscope was described in Gettman et al. Advantages of flexible scopes include maneuverability within the abdominal cavity and potential for retroflexion. Additional challenges of traditional scopes include maintaining position of the scope as there is a tendency for the scope to recoil when pushing an instrument forward, which also affects transmission of forces. Spatial orientation can also be challenging with a tendency for flexible scopes, in particular, to rotate. This problem is most acutely obvious when the scope is retroflexed and the view may be turned completely upside down, which may be difficult or impossible to correct. Endoscopic instruments As with traditional open and laparoscopic surgeries, a variety of instruments are required to permit retraction, incising of tissue, dissection, and approximation of tissue. The challenge is to perform these tasks in a comparable manner to current standards with instruments that are small enough to fit through a small channel and which typically need to be flexible. We have generally had better success with the first two options as the flexible endoscopic scissors have tended to be rather flimsy and difficult to use. It is hoped that industry may provide more robust scissors and other instruments in the future. Several tools in the gastrointestinal endoscopic armamentarium are available for removing tissue. The most basic are a variety of flexible biopsy forceps similar to those used by the urologist cystoscopically, but with two basic differences: longer length to permit them to traverse the gastric endoscope and some have the ability to apply electrocautery directly with the forceps. Similarly, a transcolonic access would need to be reliably closed due to the high bacterial load and risk of severe infections. Intraperitoneal bladder injuries typically require closure, although small vesicotomies can be managed with simple catheter drainage [26]. Reliable methods of closing the bladder defect endoscopically, however, would be ideal. Our group also described the successful use of standard gastrointestinal endoscopic clips for closure in a chronic porcine model [25], although duration of clip attachment and potential for stone formation are potential issues with this technique. For removal of larger tissues, the rat-tooth forceps can be used to directly grasp tissue specimens that have already been excised [25]. Because of the need both for closure of access points and to allow performance of many surgical procedures, tissue approximation has been one of the most intense areas of focus for development. Various other manufacturers have produced devices that are intended to substitute for suturing.

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