Carlos Núñez Mora

Colposacropexia laparoscópica asistida por robot como tratamiento del prolapso urogenital

Laparoscopic colposacropexy has become a substitute for open surgery in the treatment of pelvic organ prolapse. In the same way, robotic assisted surgery is a new step in the evolution of the procedure. In this paper we intend to show our surgical technique and preliminary results. From November 2006 to date, 10 patients have undergone this procedure at the Hospital Clinico San Carlos. The main indication for the operation was existence of symptomatic pelvic prolapse. Both patients with or without hysterectomy have been operated, without making significant differences between them. Preoperative evaluation workout included: cystogram, urinary tract ultrasound and urodynamics in all cases; urinary tract MRI was performed only in selected cases. All patients underwent surgery under general anesthesia, with at least three robotic trocars (8 mm) and one conventional trocar for the assistant; 2 accessory trocars were necessary in some cases, mainly at the beginning of the series. Most procedures in our series were associated with a transobturator suburethral sling for the treatment of stress urinary incontinence or prevention of its appearance after prolapse repair. Our results are comparable to those reported in other larger series in terms of operative time, hospital stay and early or late complications. Pending an evaluation on the long term with larger series, we can include robot assisted colposacropexy among the therapeutic options for symptomatic pelvic floor prolapse repair.Laparoscopic colposacropexy has become a substitute for open surgery in the treatment of pelvic organ prolapse. In the same way, robotic assisted surgery is a new step in the evolution of the procedure. In this paper we intend to show our surgical technique and preliminary results. From November 2006 to date, 10 patients have undergone this procedure at the Hospital Clinico San Carlos. The main indication for the operation was existence of symptomatic pelvic prolapse. Both patients with or without hysterectomy have been operated, without making significant differences between them. Preoperative evaluation workout included: cystogram, urinary tract ultrasound and urodynamics in all cases; urinary tract MRI was performed only in selected cases. All patients underwent surgery under general anesthesia, with at least three robotic trocars (8 mm) and one conventional trocar for the assistant; 2 accessory trocars were necessary in some cases, mainly at the beginning of the series. Most procedures in our series were associated with a transobturator suburethral sling for the treatment of stress urinary incontinence or prevention of its appearance after prolapse repair. Our results are comparable to those reported in other larger series in terms of operative time, hospital stay and early or late complications. Pending an evaluation on the long term with larger series, we can include robot assisted colposacropexy among the therapeutic options for symptomatic pelvic floor prolapse repair.OBJETIVOS La colposacropexia laparoscopica es una tecnica que ha venido a sustituir a la cirugia abierta para el tratamiento de los prolapsos del suelo pelvico. De la misma manera, la cirugia asistida por robot supone un nuevo paso en la evolucion de la tecnica. En este articulo pretendemos mostrar, tanto nuestra tecnica quirurgica como los resultados preliminares obtenidos con la misma. En el Hospital Clinico San Carlos han sido intervenidas con esta tecnica un total de 10 pacientes, desde Noviembre de 2006 hasta la fecha. La principal indicacion en nuestro caso ha sido la presencia de prolapsos pelvicos sintomaticos, habiendose intervenido tanto pacientes histerectomizadas como no histerectomizadas, sin poder establecer diferencias significativas entre ambos casos. Como estudio preoperatorio se ha incluido: Cistografia, Ecografia Reno-vesical, Estudio Urodinamico en todos los casos, y tan solo en aquellos en los que se ha considerado oportuno una Uro-Resonancia. Todas las pacientes han sido intervenidas bajo anestesia general, mediante colocacion de un minimo de tres trocares roboticos (8mm) y uno convencional para el ayudante, aunque en algunos casos, sobretodo al inicio de la serie se precisaron 2 trocares accesorios. Asi mismo, en nuestra serie en la mayoria de los casos se ha asociado una tecnica anti-incontinencia tipo sling suburetral transobturatriz, bien para tratamiento de la incontinencia urinaria de esfuerzo (IUE), bien para prevenir su posible aparicion tras la correcion del prolapso. Los resultados obtenidos son comparables a los descritos en otras series mas numerosas en cuanto a duracion, estancia hospitalaria y complicaciones tanto precoces como tardias. A expensas de realizar una valoracion a largo plazo y con series mas amplias, podemos incluir la colposacropexia laparoscopica asistida por robot entre el arsenal terapeutico disenado para la reparacion de los prolapsos del suelo pelvico sintomaticos.

Prostatectomía radical asistida por robot Da Vinci®: un año de experiencia en el Hospital Clínico San Carlos

El Hospital Clinico San Carlos de Madrid, es el primer centro publico espanol en disfrutar de la ultima tecnologia en cuanto a cirugia se refiere: el robot Da Vinci®. La primera intervencion fue llevada a cabo en nuestro servicio el nueve de octubre de 2006.Desde entonces, se han producido numerosos cambios que nos han permitido ir superando dificultades, hasta superar la curva de aprendizaje. METODOS Durante el periodo comprendido entre el 9 de octubre de 2006 y el 30 de noviembre de 2007 hemos realizado 30 prostatectomias radicales con el robot Da Vinci®. La edad media de los pacientes es de 63 anos (47-70 anos) con riesgo quirurgico segun la Asociacion Americana de Anestesia siempre inferior a III, un grado de Gleason entre 2 y 8 y PSA ?15 (3,5-15). El volumen prostatico medio valorado por ecografia transrectal fue de 36cc (16-90cc). RESULTADOS /CONCLUSIONES: Se utilizaron 6 trocares y un neuoperitoneo de 15mmHg. La duracion media del tiempo de ocupacion de quirofano fue de 5,9 horas (4-14horas). Dos casos fueron reconvertidos a cirugia abierta y uno a laparoscopia. No se han producido complicaciones intraoperatorias severas. En el postoperatorio inmediato 2 pacientes presentaron plexopatia y artralgia, 1 infeccion de uno de los trocares y 2 hematomas por colocacion del trocar. 16 pacientes requirieron transfusion (media 1 concentrado (0-4)). La sonda se retiro entre el 5o y 21o dias (media 11 dias). En lo referente a incontinencia: 10 presentan una continencia completa o incontinencia leve (0-1 absorbentes) y 5 incontinencia moderada (2-5 absorbentes). La potencia sexual se mantiene en 3 pacientes y en el resto existen diferentes grados de disfuncion.

Surgical Approach to a Large Left Adrenocortical Mass with Associated Tumour Thrombosis of the Left Renal Vein: Preservation of the Ipsilateral Kidney

A sixty-years-old male with diagnosis of a left adrenal mass (146 × 99 × 126 mm) with associated tumour thrombosis of the left renal vein with no clear signs of thrombosis of the inferior vena cava was admitted for elective surgery Finally an adrenalectomy and excision of tumour thrombus preserving the ipsilateral kidney was made. Despite of the complex vascular management, this kind of approaches allow to preserve normal renal function in patients with future nephrotoxic treatment like cisplatin.A sixty-years-old male with diagnosis of a left adrenal mass ( 1 4 6 × 9 9 × 1 2 6  mm) with associated tumour thrombosis of the left renal vein with no clear signs of thrombosis of the inferior vena cava was admitted for elective surgery Finally an adrenalectomy and excision of tumour thrombus preserving the ipsilateral kidney was made. Despite of the complex vascular management, this kind of approaches allow to preserve normal renal function in patients with future nephrotoxic treatment like cisplatin.