Alessandro Tavares

Can video endoscopic inguinal lymphadenectomy achieve a lower morbidity than open lymph node dissection in penile cancer patients

BACKGROUND AND PURPOSE Radical lymphadenectomy improves survival in penile cancer patients, but the morbidity of the classic open procedure exceeds 50%. We report the updated results of Video Endoscopic Inguinal Lymphadenectomy (VEIL), an original minimally invasive procedure recently reported for extended inguinal node dissection in clinical settings. PATIENTS AND METHODS Fifteen consecutive patients who underwent the VEIL technique were prospectively followed and included in this study. The first 10 patients underwent bilateral inguinal dissection for nonpalpable lymph nodes: VEIL at one side and standard open lymph node dissection at the other side. A second cohort consisted of five patients who underwent bilateral VEIL, either for nonpalpable or for palpable (N1) inguinal nodes. Operative data and postoperative outcomes were assessed, and VEIL and the open technique were compared. RESULTS Twenty limbs underwent VEIL and 10 limbs underwent the open procedure. Mean operative time was 120 minutes for VEIL and 92 minutes for the open procedure. There was no difference in the number of nodes removed or in the positivity for metastatic lymph nodes. Complications were observed in 70% of limbs that underwent open surgery and in 20% of limbs that underwent VEIL (P 0.015). Patients who underwent a bilateral VEIL could be discharged from the hospital after an average of 24 hours (range 12-36 hrs), while patients who underwent an open dissection in addition to contralateral VEIL were discharged after an average of 6.4 days (range 5-10 d) There were no recurrences detected during a mean follow-up of 31.9 months (median 33 months). CONCLUSION This preliminary series suggests that VEIL can reduce morbidity, including hospitalization times,compared with standard open surgery. Oncologic results are premature but seem similar to the results from the conventional open operation. VEIL is a promising minimally invasive approach for radical inguinal dissection in penile cancer patients with nonpalpable or low-volume palpable inguinal disease.

Video endoscopic inguinal lymphadenectomy (VEIL): minimally invasive resection of inguinal lymph nodes

OBJECTIVES Describe and illustrate a new minimally invasive approach for the radical resection of inguinal lymph nodes. SURGICAL TECHNIQUE From the experience acquired in 7 operated cases, the video endoscopic inguinal lymphadenectomy (VEIL) technique was standardized in the following surgical steps: 1) Positioning of the inferior member extended in abduction, 2) Introduction of 3 work ports distal to the femoral triangle, 3) Expansion of the working space with gas, 4) Retrograde separation of the skin flap with a harmonic scalpel, 5) Identification and dissection of the long saphenous vein until the oval fossa, 6) Identification of the femoral artery, 7) Distal ligature of the lymph node block at the femoral triangle vertex, 8) Liberation of the lymph node tissue up to the great vessels above the femoral floor, 9) Distal ligature of the long saphenous vein, 10) Control of the saphenofemoral junction, 11) Final liberation of the surgical specimen and endoscopic view showing that all the tissue of the region was resected, 12) Removal of the surgical specimen through the initial orifice, 13) Vacuum drainage and synthesis of the incisions. COMMENTS The VEIL technique is feasible and allows the radical removal of inguinal lymph nodes in the same limits of conventional surgery dissection. The main anatomic repairs of open surgery can be identified by the endoscopic view, confirming the complete removal of the lymphatic tissue within the pre-established limits. Preliminary results suggest that this technique can potentially reduce surgical morbidity. Oncologic follow-up is yet premature to demonstrate equivalence on the oncologic point of view.

Video endoscopic inguinal lymphadenectomy (VEIL): Initial case report and comparison with open radical procedure

OBJECTIVES Inguinal metastases are one of the major determinants of mortality in patients with penile cancer. In high risk patients, while prophylatic inguinal lymphadenectomy may offer survival advantages, it still carries a relatively high morbidity. We describe in this paper the first report of the Video Endoscopic Inguinal Lymphadenectomy (VEIL) in the clinical practice, a technique which aims at reducing the morbidity of the procedure without compromising the cancer control or reducing the template of the dissection. METHODS A 40 year old male with a pT2 penile cancer underwent prophylatic bilateral inguinal lymphadenectomy 6 weeks after partial penectomy. We performed the VEIL technique at the right and a standard radical inguinal lymphadenectomy through an inguinal incision at the left (control). After developing a plane deep to Scarpas fascia, locating 3 ports and infusing gas at 5-10 mmHg, a retrograde dissection with the same limits as the standard open surgery was performed. Intraoperative data, patology, post operatory evolution and oncological follow-up is described for both sides. RESULTS Operative time was 130 min for the VEIL and 90 min for open surgery. Eight and 7 lymphnodes were retrieved at the VEIL side and open side, respectively, and none of then showed positivity at pathology. There were no complications in the limb which underwent the VEIL and there was skin necrosis in the side of the open surgery. After 25 months of follow up, no signs of disease progression were noted. Asked about how he felt about both surgeries, the patient chose the endoscopic approach. CONCLUSION VEIL is feasible in clinical practice. New studies with a greater number of patients and long-term follow-up may confirm the oncological efficacy and possible lower morbidity of these new approach.

Long-Term Outcome of Laparoscopic Pyeloplasty: Multicentric Comparative Study of Techniques and Accesses

PURPOSE The aim of the present study was to analyze long-term follow up (18-108 months) of different techniques and routes for laparoscopic repair of uretero-pelvic junction obstruction comparing efficacy and results. MATERIALS AND METHODS A retrospective analyses of 133 laparoscopic pyeloplasties in 132 patients (mean age 35 years) between August 1995 and November 2008 was performed. Transperitoneal route was performed in 114 patients, and retroperitoneal route was performed in 19 patients. Different repair techniques (dismembered and non-dismembered) were applied at the surgeons discretion. RESULTS Average operative time was 127 minutes (range 45-370). Average blood loss was 127 mL, and mean hospital stay was 24 hours. Complications occurred in 9.6% of surgeries, and conversion rate was 1.7%. Urinary leak occurred after eight (6.1%) surgeries, all managed conservatively. Overall success rate of laparoscopic repair was 96%, higher for dismembered versus non-dismembered procedures (97% versus 89%, P = .04). CONCLUSION Laparoscopic pyeloplasty is a reproducible, highly effective, and minimally invasive treatment for uretero-pelvic junction obstruction. Surgical technique affects operative time and long-term success rates. Dismembered techniques seem to remain more effective after a long-term follow up. Surgical route does not seem to affect success rates.

Hand-assisted laparoscopic nephrectomy as a minimally invasive option in the treatment of large renal specimens

INTRODUCTION We describe our experience with hand-assisted laparoscopy (HAL) as an option for the treatment of large renal specimens. MATERIALS AND METHODS Between March 2000 and August 2004, 13 patients candidate to nephrectomies due to benign renal conditions with kidneys larger than 20 cm were included in a prospective protocol. Unilateral nephrectomy was performed in cases of hydronephrosis (6 patients) or giant pyonephrosis (4 patients). Bilateral nephrectomy was performed in 3 patients with adult polycystic kidney disease (APKD) with low back pain refractory to clinical treatment previous to kidney transplant. The technique included the introduction of 2 to 3 10 mm ports, manual incision to allow enough space for the surgeons wrist without a commercial device to keep the pneumoperitoneum. The kidney was empty, preferably extracorporeally, enough to be removed through manual incision. We have assessed operative times, transfusions, complications, conversions, hospital stay and convalescence. RESULTS The patients mean age (9 women and 4 men) was 58 years. Mean operating time was 120 +/- 10 min (hydronephrosis), 160 +/- 28 min (pyonephrosis) and 190 +/- 13 min (bilateral surgery for APKD). There was a need for a conversion in 1 case and another patient needed a transfusion due to a lesion in the renal vein; 2 patients had minor complications. CONCLUSIONS HAL surgery is a minimally invasive alternative in the treatment of large renal specimens, with or without significant inflammation.

Topical betamethasone and hyaluronidase in the treatment of phimosis in boys: a double-blind, randomized, placebo-controlled trial

PURPOSE To compare the efficacy of three different formulations containing Betamethasone Valerate versus placebo in the topical treatment of phimosis. As a secondary goal, we compared the outcomes after 30 and 60 days of treatment. MATERIALS AND METHODS Two hundred twenty boys aged 3 to 10 years old with clinical diagnosis of phimosis were enrolled. Patients were randomized to one of the following groups: Group 1: Betamethasone Valerate 0.2% plus Hyaluronidase; Group 2: Betamethasone Valerate 0.2%; Group 3: Betamethasone Valerate 0.1% or Group 4: placebo. Parents were instructed to apply the formula twice a day for 60 days and follow-up evaluations were scheduled at 30, 60 and 240 days after the first consultation. Success was defined as complete and easy foreskin retraction. RESULTS One hundred ninety-five patients were included at our final analysis. Group 1 (N = 54), 2 (N = 51) and 3 (N = 52) had similar success and improvement rates, all treatment groups had higher success rates than placebo (N = 38). After 60 days of treatment, total and partial response rates for Groups 1, 2 and 3 were 54.8% and 40.1%, respectively, while placebo had a success rate of 29%. Success and improvement rates were significantly better in 60 days when compared to 30 days. CONCLUSIONS Betamethasone Valerate 0.1%, 0.2% and 0.2% in combination with Hyaluronidase had equally higher results than placebo in the treatment of phimosis in boys from three to ten years-old. Patients initially with partial or no response can reach complete response after 60 days of treatment.

MP66-04 GONADAL FUNCTION AND REPRODUCTIVE SYSTEM ANATOMY IN POST PUBERAL PRUNE BELLY SYNDROME PATIENTS

INTRODUCTION AND OBJECTIVES: Morrison’s survey of SPU members reported no clear consensus in managing peri-operative pain in pediatric patients undergoing common urological procedures. We posit that non-narcotic analgesia allows withholding narcotic use following simple urologic surgery in out-patient surgery in most patients. METHODS: We prospectively tracked analgesic use and pain scales of patients undergoing outpatient penile (non-hypospadias) or groin surgery (hernia, orchidopexy). Parents marked an analgesic usage form and Wong-Baker FACES pain scale on the day of surgery (DOS) and post-operative day 1 (POD1). Patients received a caudal nerve block, unless contraindicated or refused by parents, or a penile block. Postoperative analgesics were either non-narcotic agents or narcotics prescribed at surgeon’s discretion. Descriptive statistics, contingency table analyses, and t-test were performed. RESULTS: 249 male patients, median age 36 mo (2-216mo) underwent penile (64%) or groin (36%) surgery. Caudal (92) or local block (147) was used in 96% of cases. Narcotics prescribed in 152 (61%) was associated with older age (74mo vs 47mo; p 1⁄40.0002). Overall, no difference in analgesic use was noted (p1⁄4NS) on DOS (72%) and POD (62%) and were not affected by surgery or block type. Among patients prescribed narcotics, 76% used any analgesic on DOS and 66% on POD 1 (p1⁄4NS); narcotic use on DOS (91 cases 65 took 1 dose) declined on POD1 (57; p1⁄40.0001) and was unaffected by surgery type or block type. Analgesic type used was similar between surgery types and between DOS and POD1 regardless of block used. Among patients not prescribed narcotics, 72% took 1+ doses of analgesics on DOS which declined to 59% on POD 1 (p1⁄4NS); usage was similar based on surgery type and from DOS to POD1 for both surgery and block types. Pain scale differences were not significant on DOS between non-narcotics and narcotic users (3.2 v 3.6, p1⁄4NS) but were on POD 1 (2.8 v 3.6, p1⁄40.0003). Pain significantly decreased for those using non-narcotics between DOS and POD1 (p1⁄40.004) but not for those using narcotics, perhaps due to pain perception in older children. CONCLUSIONS: Narcotic availability leads to its usage following uncomplicated urologic surgery. Given the efficacy of nonnarcotic analgesics, and the associated costs and potential side effects, prescribing narcotics should be highly selective.