Ernesto Reggio

Laparoscopic Partial Nephrectomy for Hilar Tumors : Evaluation of Short-Term Oncologic Outcome

OBJECTIVES To present our experience performing laparoscopic partial nephrectomy (LPN) for hilar renal tumors and demonstrate the feasibility and short-term oncologic efficacy. METHODS The patients who had undergone LPN for excision of a hilar tumor, defined as a renal tumor that came in direct contact with the renal artery and/or vein, were identified. The clinicopathologic parameters, perioperative course, complications, and oncologic outcomes were analyzed. RESULTS A total of 18 patients with a hilar renal mass (4.4%) underwent elective LPN. The mean tumor size was 3.24 cm (range 1.3 to 8), and the mean preoperative creatinine was 1.04 mg/dL (range 0.6 to 1.8). The mean operating room and warm ischemia time was 173 minutes (range 93 to 337) and 29.4 minutes (range 17 to 50), respectively. The pelvicaliceal system was entered and repaired in 10 patients (55.6%), and the median estimated blood loss was 394.4 mL (range 100 to 1500). The mean hospital stay was 3 days (range 2 to 5). Histopathologic examination confirmed renal cell carcinoma in 13 patients (72.2%). The surgical margins and frozen sections of the tumor base were negative in all cases. The tumor stage was pT1 in 11 patients (85%), pT2 in 1 patient (7.7%), and pT4 in 1 patient (7.7%). The mean postoperative creatinine was 1.2 mg/dL (range 0.6 to 2.3). Postoperative transfusion was required in 4 patients (22.2%), including 1 patient who required intraoperative transfusion (5.5%) and 1 who required angioembolization (5.5%). During a mean follow-up of 12.3 months (range 0.2 to 66), no patient had evidence of local recurrence or metastatic disease. CONCLUSIONS Experienced laparoscopic surgeons can safely perform LPN for hilar renal tumors. The short-term oncologic results have been promising; however, long-term follow-up is necessary.

PATHOLOGIC FINDINGS IN PATIENTS WITH URETEROPELVIC JUNCTION OBSTRUCTION AND CROSSING VESSELS

OBJECTIVES To define the role of crossing vessels in the pathophysiology of ureteropelvic junction (UPJ) obstruction, we analyzed the relationship between the presence of crossing vessels and UPJ pathologic findings in patients undergoing laparoscopic pyeloplasty. The significance of crossing renal vessels in patients with UPJ obstruction is unclear. METHODS We performed a retrospective analysis of 155 consecutive patients undergoing laparoscopic pyeloplasty. Pathologic specimens from the UPJ were evaluated in 95 patients. The presence or absence of crossing vessels was documented intraoperatively. The histopathologic findings allowed for categorization into 5 groups: group 1, normal ureteral tissue; group 2, chronic inflammation; group 3, smooth muscle hypertrophy, group 4, fibrosis; and group 5, smooth muscle atrophy. The pathologic findings between patients with and without crossing vessels were compared. RESULTS Overall, crossing vessels were identified in 98 patients (63.2%). Of the 95 cases with specimens retrieved for histologic analysis, 65 had crossing vessels and 30 did not. The most common UPJ histologic finding in patients with crossing vessels was no intrinsic abnormality (43%). In contrast, this was seen in only 10% of patients without a crossing vessel. In the group without crossing vessels, chronic inflammation (40%) was the predominant histologic findings. Patients with a crossing vessel were less likely to have intrinsic histologic pathologic findings (P < .0003). CONCLUSIONS Patients with crossing vessels and UPJ obstruction had no histologic abnormalities identified in 43% of cases. This finding implicates crossing vessels in the pathogenesis of select cases of UPJ obstruction and direct mechanical compression as the etiology of obstruction in these individuals.

Correlation between lower urinary tract symptoms and erectile dysfunction in men presenting for prostate cancer screening

Lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) are age-related conditions that may have a profound impact on the quality of life. The relationship between LUTS and ED is not completely understood. In this study, we assessed this relationship in men over 45 years of age during a prostate cancer screening program. LUTS and ED were evaluated in 1267 men aged 45–75 years (mean 58.2±8.2 years). Patients completed the International Prostate Symptom Score (IPSS) and the International Index of Erectile Function-5 (IIEF-5). The association between LUTS and ED was analyzed and the influence of age in the results was tested. We also evaluated the influence of the intensity of LUTS in the ED severity. A total of 514 (40.6%) patients were considered symptomatic of LUTS (24.8% with mild, 11.8% with moderate and 4% with severe LUTS). ED was present in 758 (59.9%) men and was considered mild in 25.0%, moderate in 18.3% and severe in 16.7%. The IIEF-5 score had a negative correlation with both the IPSS score (r=−0.33, P<0.001) and age (r=−0.31 and P<0.001). Age was positively associated with the IPSS score (r=0.14 and P<0.001). A significant correlation was observed between LUTS and ED, with 57.6% of the men with LUTS presenting ED as opposed to 29.7% of the asymptomatic population (odds ratio=3.32; 95% CI =2.57–4.29, P<0.001). Age-adjusted univariate analysis revealed a significant and independent influence of LUTS on the incidence of ED (odds ratio=2.72; 95% CI=2.08–3.57, P<0.001). IIEF scores varied significantly according to the severity of the urinary symptoms. Our findings in a prostate cancer screening population confirm that LUTS is an age-independent predictor of ED. Furthermore, they demonstrate that not only the presence of LUTS increases the likelihood of developing ED, but the severity of LUTS is associated with the intensity of ED.

Predictors of Hemorrhage After Laparoscopic Partial Nephrectomy

OBJECTIVES To identify risk factors associated with hemorrhage during laparoscopic partial nephrectomy (LPN), and to determine the impact of hemorrhage on hospital course. METHODS We retrospectively analyzed prospective data from 335 LPNs to identify clinicopathologic factors associated with hemorrhagic complications (blood loss requiring ≥ 1 U transfusion) and extended length of hospitalization (≥ 3 days). We excluded patients with a coagulopathy or perioperative vascular injuries. RESULTS We identified 23 patients (7%) undergoing LPN with hemorrhagic complications (group 1 and 312 patients (93%) without complications (group 2). Mean age was 64.1 ± 14.4 vs 57.6 ± 12.7(P = .006), American Society of Anesthesiologists (ASA) score ≥ 3 seen in 61% vs 37% (P = .02), mean tumor size (cm) was 2.90 ± 2.02 vs 2.59 ± 1.15 (P = .93), mean total operative time (min) was 250.1 ± 116.1 vs 191.8 ± 69.2 (P = 0.006), and mean hospital stay (days) was 4.7 ± 3.4 vs 3.1 ± 3.0 (P = .0002), for groups 1 and 2, respectively. Hypertension, diabetes mellitus, chronic renal insufficiency, obesity, smoking, and coronary artery disease-congestive heart failure were present in group 1 vs group 2: 39.1% vs 31.4% (P = .4), 17.4% vs 8% (P = .12), 8.7% vs 1.9% (P = .09), 4.3% vs 3.5% (P = .57), 17.4% vs 5.4% (P = .04), and 8.7% vs 2.2% (P = .11), respectively. On multivariate analysis, smoking (P < .0437) and ASA score ≥ 3 (P < .0233) were associated with hemorrhagic complications. Hemorrhagic complications were 3.5 times more likely in smokers than nonsmokers (95% confidence interval, 1.0-11.7), and 2.9 times more likely with an ASA class ≥ 3. Only age (P < .0002) and operative time (P < .0001) were associated with longer hospitalization. CONCLUSIONS High ASA scores and smoking are risk factors for hemorrhagic complications during LPN. Hemorrhagic complications did not significantly affect hospitalization length.

Ablation of bull prostate using novel bipolar radiofrequency ablation probe.

PURPOSE We describe the use of a novel bipolar radiofrequency (RF) system for the destruction of prostate tissue in an ex vivo model. MATERIALS AND METHODS A bipolar RF delivery system (Trod Medical, France) was linked to a 500 kHz generator. Eight lesions were created in an ex vivo bull prostate model using 7-mm (n = 4) and 10-mm probes (n = 4). Ablation was performed for 150 seconds. Temperature was recorded at the center of the lesion (Tc) and at the periphery (Tp) of the prostate. Tissue damage, both within and without the intended destruction zones, was assessed. The distance from Tc to Tp was recorded. RESULTS All lesions created with either the 7-mm or 10-mm bipolar RF ablation (RFA) probes demonstrated complete tissue destruction only within the intended zone. Using the 7-mm probe, the mean Tc was 82 degrees C and the mean Tp 34 degrees C. The mean distance from the edge of the lesion to the periphery was 5 mm. Impedance was 62 Ohm, and power was 4 watts during ablation with the 7-mm probe. With the 10-mm probe, the mean Tc and Tp were 70 degrees C and 41 degrees C, respectively. The mean distance from the edge of the lesion to the periphery was 5 mm. Impedance was 78 Ohm, and power was 4.5 watts during ablation with the 10-mm probe. CONCLUSIONS In an ex vivo model, bipolar RFA is capable of producing lesions with precise margins. Spread of heat is limited, evidenced histologically and by significant temperature drop off. This technology holds promise in the management of benign and malignant urologic diseases.

Laparoscopic Ureteroplasty Using On-Lay Appendix Graft

Complex ureteral reconstruction has been performed with ileum, appendix, or other intestinal segments for the treatment of long ureteral strictures. In the past decade, challenging ureteral reconstruction has been approached using laparoscopic urology. We report the case of a 6-cm iatrogenic stricture after treatment of stone disease. The stricture was treated using a laparoscopic on-lay appendix graft. This laparoscopic technique used the on-lay concept, which, in addition to minimizing postoperative pain and the length of hospitalization, allowed a tension-free watertight anastomosis and preserved the ureteral vascular supply. This approach should be considered a viable minimally invasive alternative for ureteral reconstruction when endoscopic treatment has failed.

Diagnostic and Therapeutic Laparoscopic Retroperitoneal Lymph Node Dissection in Low Stages Nonseminomatous GCC: The American View

Laparoscopic retroperitoneal lymph node dissection (RPLND) was initially described only for staging purposes, with no dissection of nodes posterior to the lumbar vessels. Subsequent reports followed demonstrating its safety and feasibility. An initial goal of laparoscopic RPLND was to reduce the incidence of relapse in patients being considered for surveillance protocols while minimizing morbidity with a minimally invasive surgical approach. However, at select centers laparoscopic RPLND has evolved into an identical replication of the open technique and can be performed with therapeutic intent, thus offering control of the retroperitoneum with all the inherent benefits of a laparoscopic approach. This chapter describes our current operative technique when performing laparoscopic RPLND.

Laparoscopic Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Tumors

Laparoscopic retroperitoneal lymph node dissection (LRPLND) is currently being used to treat stage I and II nonseminomatous germ cell tumors (NSGCT). LRPLND can be used as both a staging procedure and therapeutic intervention. The procedure mimics the advantages of open retroperitoneal lymph node dissection with less pain, quicker convalescence, and improved cosmesis. LRPLND is a technically advanced procedure which demands considerable experience in laparoscopic dissection. The most common complication with LRPLND cases has been intraoperative hemorrhage, but this can be minimized with careful and controlled isolation of the great vessels.

DELAYED HEMORRHAGE AFTER LAPAROSCOPIC PARTIAL NEPHRECTOMY: CHARACTERIZATION OF ANGIOGRAPHIC FINDINGS

Doppler Probe Results RNx/NU PNx RALP Patients 16 22 7 Mean Doppler Time (seconds) 111 98 171 Total AV on CT 1 7 N/A Total AV on Doppler 5 11 N/A Patients with AV 5 9 N/A Patients with Crossing Vessel N/A N/A 6 (85.7%) Patients with changed management 4 (25%) 5 (22.7%) 3 (42.9%) Patients with time saved 12 (75%) 17 (77.3%) 5 (71.4%) Use Score “very easy” 16 (100%) 22 (100%) 7 (100%) Complications 0 0 0 Technical Failure 1 (6.3%) 1 (4.5%) 0