A. Haertig

Résultats carcinologiques et fonctionnels de la prostatectomie totale laparoscopique robot-assistée

The current gold standard treatment for localized prostate cancer remains open radical prostatectomy. From 1992, several teams have tried to explore less invasive surgical access. The first robotically assisted laparoscopic prostatectomy (RALP) case was reported in 2000. Enhancement of the ergonomics and optimization of the surgical vision provided by the robotic interface, are some reasons that explain the worldwide widespread of RALP. Although this procedure accounted for the vast majority of radical prostatectomies performed in United States, its diffusion is still limited in Europe. The cost for robot purchase and maintenance are obvious limiting factors for its expansion. According to the literature, the operating time and the blood loss are, once the learning curve is completed, similar to those of open or laparoscopic procedures. Hospital stay and time before bladder catheter removal are shorter compared to other approaches. Intermediate oncological and functional outcomes do not show difference with the open or laparoscopic results. Given that these data are encouraging, the limited follow-up with RALP do not allow to draw any definitive statement in comparison with conventional techniques.

Article de revueRésultats carcinologiques et fonctionnels de la prostatectomie totale laparoscopique robot-assistéeOncologic and functional outcomes after robot-assisted laparoscopic radical prostatectomy

The current gold standard treatment for localized prostate cancer remains open radical prostatectomy. From 1992, several teams have tried to explore less invasive surgical access. The first robotically assisted laparoscopic prostatectomy (RALP) case was reported in 2000. Enhancement of the ergonomics and optimization of the surgical vision provided by the robotic interface, are some reasons that explain the worldwide widespread of RALP. Although this procedure accounted for the vast majority of radical prostatectomies performed in United States, its diffusion is still limited in Europe. The cost for robot purchase and maintenance are obvious limiting factors for its expansion. According to the literature, the operating time and the blood loss are, once the learning curve is completed, similar to those of open or laparoscopic procedures. Hospital stay and time before bladder catheter removal are shorter compared to other approaches. Intermediate oncological and functional outcomes do not show difference with the open or laparoscopic results. Given that these data are encouraging, the limited follow-up with RALP do not allow to draw any definitive statement in comparison with conventional techniques.

Résultats à long terme de la promontofixation laparoscopique dans les cystocèles de haut grade

PURPOSEnTo evaluate long-term functional and anatomical results of laparoscopic-sacral colpopexy (LSC) for the treatment of high-grade cystoceles.nnnMATERIALnBetween 1997 and 2005, 43 women with symptomatic cystoceles of high grade (grade 3 or 4), isolated or not, were treated by LSC. All patients were seen at three months, six months and then yearly during follow-up. Each visit included an interrogatory searching for functional urinary symptoms or sexual and digestive symptoms. A clinical examination, always performed by the same operator, searched for an anatomical recurrence, which was defined by an anterior prolapse of stage greater or equals to 2. In addition, a uroflowmetry was performed systematically. Prognostic factors for cystocele recurrence were established by univariate analysis.nnnRESULTSnWith a mean follow-up of 4.1 years (2-10.1), the rate of correction of cystocele was 84%. Seven women had an anterior recurrence and were as follows: stage 2 (n=5), stage 3 (n=1) and stage 4 (n=1) associated with urinary-functional symptoms in three cases, with sexual problems in three cases or with rectal symptoms in two cases. In case of isolated cure of cystocele, we found no recurrence during follow-up. Mean uroflowmetry was 24+/-9ml/s. Nine women (21%) had dysuria associated with cystocele recurrence in four cases. Four patients had a pollakiuria (n=1), an urgenturia (n=1) or a stress-urinary incontinence (n=2) without anatomical recurrence. In a case, chronic-pelvic pain was revealing erosion of the tape into the bladder wall. No significant factor was associated with cystocele recurrence.nnnCONCLUSIONnLSC offered a viable and long-lasting correction of high-grade cystoceles, mostly when they are isolated. Anatomical recurrence was mainly revealed by the occurrence of functional symptoms. In case of atypical urinary symptoms, a cystoscopy has to be done to look for an erosion into the bladder wall.

Résultats de la néphrectomie partielle pour les carcinomes à cellules rénales de plus de 4 cm

To date, radical nephrectomy (RN) remains the gold standard treatment for renal cell carcinoma (RCC) larger than 4 cm. However, from the early 1990s, improvements in surgical techniques have lead to the development of nephron-sparing surgery (NSS) for small renal tumours of less than 4 cm in diameter. This surgical procedure avoids nephronic waste with an acceptable morbidity and similar oncological outcomes compared to radical surgery. Recent large published series did not show any difference between NSS and RN in terms of oncological safety. Specific and disease-free five-year survival rates (82% to 97.3% and 81% to 97.3%, respectively) have confirmed the safety of NSS. Regarding laparoscopic NSS, the technique is still under evaluation and only mid-term outcomes are available so far. However, these studies are still limited and longer follow-up is needed before any definitive statement can be made. Current guidelines recommend NSS only in case of RCC of less than 4 cm in diameter in elective indications. In daily practice however, surgical teams are pushing back the limit above the threshold of 4 cm. More and more surgeons are either considering anatomical location or technical expected difficulties rather than just the tumour size. NSS leads to higher risk of bleeding, especially in case of tumours larger than 4 cm. Therefore, it is absolutely necessary to investigate thoroughly the vascularization of the tumour to avoid such complications with exhaustive and accurate preoperative imaging.

Article de revueRésultats de la néphrectomie partielle pour les carcinomes à cellules rénales de plus de 4 cmResults of nephron-sparing surgery for renal cell carcinoma of more than 4 cm in diameter

To date, radical nephrectomy (RN) remains the gold standard treatment for renal cell carcinoma (RCC) larger than 4 cm. However, from the early 1990s, improvements in surgical techniques have lead to the development of nephron-sparing surgery (NSS) for small renal tumours of less than 4 cm in diameter. This surgical procedure avoids nephronic waste with an acceptable morbidity and similar oncological outcomes compared to radical surgery. Recent large published series did not show any difference between NSS and RN in terms of oncological safety. Specific and disease-free five-year survival rates (82% to 97.3% and 81% to 97.3%, respectively) have confirmed the safety of NSS. Regarding laparoscopic NSS, the technique is still under evaluation and only mid-term outcomes are available so far. However, these studies are still limited and longer follow-up is needed before any definitive statement can be made. Current guidelines recommend NSS only in case of RCC of less than 4 cm in diameter in elective indications. In daily practice however, surgical teams are pushing back the limit above the threshold of 4 cm. More and more surgeons are either considering anatomical location or technical expected difficulties rather than just the tumour size. NSS leads to higher risk of bleeding, especially in case of tumours larger than 4 cm. Therefore, it is absolutely necessary to investigate thoroughly the vascularization of the tumour to avoid such complications with exhaustive and accurate preoperative imaging.