Franco Gaboardi

Minimally Invasive Laparoscopic Neobladder

PURPOSE To our knowledge orthotopic reconstruction after laparoscopic radical cystectomy has not been described in the human. After anatomical and surgical studies on cadavers we developed an original technique and performed the first laparoscopic radical cystectomy with pelvic lymphadenectomy and ileal orthotopic neobladder reconstruction in a patient. MATERIALS AND METHODS Our technique has 3 steps, namely laparoscopic pelvic clearance, external reconstruction and laparoscopic reconstruction. After cystoprostatectomy and lymphadenectomy were completed via laparoscopy we removed the surgical specimens through a 5 cm. supraumbilical incision. Through the same incision an ileal loop was extracted from the abdominal cavity, isolated, detubularized and partially reconfigured. Intestinal continuity was restored extracorporeally. All intestinal loops were inserted back into the abdomen and pneumoperitoneum was started again. The ureteroileal (nipple valve) and urethroileal anastomoses were formed via laparoscopy and the neobladder was then completed with an intracorporeal running suture. RESULTS Operative time was 450 minutes and blood loss was 350 ml. Postoperatively pain was minimal. The patient was ambulatory, regained bowel activity on postoperative day 2 and began food intake 2 days later. He was discharged home on postoperative day 7 with an indwelling catheter, which was removed after 7 days. Histopathological examination showed organ confined bladder cancer without margin invasion. CONCLUSIONS To our knowledge we report the first case of laparoscopic radical cystectomy with ileal orthotopic reconstruction. This original technique combines the advantages of minimally invasive laparoscopy with the speed and safety of open surgery.

Laparoscopic radical cystoprostatectomy: a technique illustrated step by step.

OBJECTIVES Laparoscopic surgery is expanding among urologists as a minimally invasive treatment and may now be applied to treat neoplasms of the pelvic organs. Laparoscopic cystoprostatectomy has still not been well codified and illustrated. We describe a technique of laparoscopic radical cystoprostatectomy that we have developed in 10 patients after practicing in laparoscopic radical prostatectomy. METHODS Between June 2001 and July 2002, 10 men with bladder cancer underwent laparoscopic cystoprostatectomy with urinary diversion. This report details step by step our 5-port transperitoneal technique with primary access to the seminal vesicles and Denonvilliers fascia, ureters detection after umbilical arteries incision, endopelvic fascia incision and dorsal vein complex control before division of the vesical and prostatic fibrovascular pedicles with a harmonic scalpel. RESULTS We performed 6 orthotopic ileal neobladders, 2 sigmoid ureterostomies and 2 cutaneous ureterostomies. In all cases no conversion to open surgery was necessary. The mean time to perform the laparoscopic radical cystoprostatectomy, including the lymph node dissection, was 166 minutes (range 150-180). Mean estimated blood loss was 310 ml (range 220-440). Mean hospital stay was 8.1 days (range 7-9) for ileal orthotopic neobladder, 8 days (range 7-9) for sigmoid ureterostomy and 5 days for cutaneous ureterostomy. The mean follow up is 12.3 months (range 5-18). Two patients respectively with stage T2bN0 G2-3 and stage pT1N0 (plus carcinoma in situ) G3 transitional cell carcinoma and surgical margins tumor free had diffusive metastatic disease after 6 months. The other 8 patients are free from disease. CONCLUSIONS Laparoscopic radical cystectomy is still an operation for pioneers but this procedure may be not strictly relegated to a few academic centers. In our opinion laparoscopic cystoprostatectomy is a feasible, fast, safe and easy procedure and urinary diversion may be performed with a laparoscopic, open or combined approach without reducing the advantages of laparoscopy.

Laparoscopic Radical Prostatectomy: Perioperative Complications in an Initial and Consecutive Series of 80 Cases

OBJECTIVES We retrospectively evaluated the intraoperative and early postoperative complications of the initial experience with the first 80 laparoscopic radical prostatectomies performed at our institution. METHODS Between January 17, 2001 and July 24, 2002, 80 patients between 53 and 78 years old (mean age 63.8) with clinically localized prostate cancer underwent laparoscopic radical prostatectomy with the Montsouris technique. A total of 24 (30%) staging pelvic lymphadenectomy were performed. The inpatient and outpatient medical records as well as all complications were reviewed. RESULTS The pathological tumor stage revealed 18 pT2a (22.5%), 29 pT2b (36.25%), 21 pT3a (26.25%), 10 pT3b (12.5%), 1 pT4 (1.25%), 1 pT4 N1 (1.25%). No conversion was necessary in all cases. Mean operative time was 218 minutes (range 150-420) overall, mean blood loss was 376 ml (range 50-1000) and the mean postoperative hospital stay was 4.5 days (range 3-9). The mean and the median duration of bladder catheterization were respectively 11 and 10 days (range 7-23). Injury to the epigastric vessels was detected intraoperatively in 5 cases (6.25%) with immediate hemostasis achieved. There was 1 death (1.25%) 35 days after a cerebrovascular accident occurred on postoperative day 3. We observed 1 (1.25%) postoperative ileus, hemoperitoneum in 5 cases (6.25%), 2 (2.5%) acute urinary retentions, 6 (7.5%) anastomotic leakages, 1 (1.25%) anastomotic stricture, 1 (1.25%) hydrocele and 2 (2.5%) urinary tract infections. CONCLUSIONS In our initial experience laparoscopic radical prostatectomy was performed with no complications in 77.5% of patients. We observed major and minor complications respectively in 16.25% and 6.25% of the patients. Our series provides evidence that the laparoscopic approach is feasible and associated with acceptable perioperative morbidity.

Transrectal Ultrasound–Guided Implantation of Adjustable Continence Therapy (ProACT): Surgical Technique and Clinical Results After a Mean Follow-Up of 2 Years

BACKGROUND Treatment for stress urinary incontinence (SUI) after radical prostatectomy (RP) with the male Adjustable Continence Therapy (ProACT) system, implanted using fluoroscopy for guidance, has been described with promising clinical results. OBJECTIVE This retrospective study aims to describe the surgical technique in detail and to evaluate the continence recovery and complication rate of a cohort of male patients with SUI after RP. All patients were treated with a modified technique that uses transrectal ultrasound (TRUS) for guidance and that may be performed under local anaesthesia. DESIGN, SETTING, AND PARTICIPANTS Between June 2005 and March 2009, we operated on 79 consecutive patients with post-RP urodynamic intrinsic sphincter deficiency. SURGICAL PROCEDURE ProACT system implantation was performed with TRUS guidance under general or local anaesthesia. MEASUREMENTS Perioperative data and adverse events were recorded in all patients. Outcome data (24-h pad test, number of pads per day (PPD) used by patients, a validated incontinence quality of life questionnaire) were analysed in the 62 of 79 patients who completed the postoperative system adjustments. In this group of patients, the mean follow-up is 25 mo. RESULTS AND LIMITATIONS According to the 24-h pad test and the mean number of PPD used, 41 patients were dry (66.1%), 16 patients improved (25.8%), and 5 patients failed treatment (8%). The dry rate in previously irradiated patients was 35.7%. Complications included intraoperative bladder perforations (2 of 79; 2.5%), transient urinary retention (1 of 79; 1.2%), migrations (3 of 79; 3.8%), and erosions (2 of 79; 2.5%). According to the degree of incontinence, the dry rate in patients with mild, moderate, and severe incontinence was, respectively, 85%, 63.6%, and 33.3%. CONCLUSIONS TRUS guidance for ProACT implantation results in success and complication rates that compare favourably with published data using fluoroscopy for guidance. Previous radiotherapy and severe incontinence seem to be a relative contraindication. Larger series and longer follow-up are progressing to establish long-term efficacy.

Long-term analysis of oncological outcomes after laparoscopic radical cystectomy in Europe: results from a multicentre study by the European Association of Urology (EAU) section of Uro-technology.

To report long‐term outcomes of laparoscopic radical cystectomy (LRC) in a multicentre European cohort, and explore feasibility and safety of LRC.

Evaluation of positive surgical margins in patients undergoing robot-assisted and open radical prostatectomy according to preoperative risk groups

OBJECTIVES Recent studies showed that robot-assisted radical prostatectomy (RARP) represents an oncologically safe procedure in patients with prostate cancer (PCa), where the rate of positive surgical margins (PSMs) might be lower in patients treated with RARP as compared with that of those undergoing the open approach (open RP [ORP]). The aim of this study is to analyze the rate of PSMs according to preoperative risk groups in a large cohort of patients treated with RARP and ORP in a single institution with standardized surgical technique and pathological examination. MATERIALS AND METHODS We evaluated 6,194 consecutive patients with PCa undergoing either ORP (71.1%) or RARP (28.9%) between 1992 and 2014. Logistic regression analyses were used to test the association between type of surgery and PSMs in each preoperative risk group (low vs. intermediate vs. high) after adjusting for confounders. RESULTS Overall, 21.6% patients had PSMs. RARP was associated with a lower rate of PSMs in low-risk (11.5 vs. 15.4%, P = 0.01), intermediate-risk (18.9 vs. 23.5%, P = 0.008), and high-risk patients (19.7 vs. 30.1%, P<0.001). In multivariable analyses, after stratification according to risk group categories, no difference in PSMs between RARP and ORP was observed for low-risk (odds ratio [OR] = 0.87, P = 0.46) and intermediate-risk patients (OR = 0.84, P = 0.19). Conversely, RARP was associated with lower odds of PSMs in high-risk patients (OR = 0.69, P = 0.04). Similar results were observed when our analyses were repeated after accounting for pathological characteristics, in patients treated between 2006 and 2014 and in a cohort of men treated by high-volume surgeons (all P≤ 0.03). CONCLUSIONS The introduction of RARP at our institution led to a significant reduction in the risk of PSMs in patients with PCa with high-risk disease.

Current Standard Technique for Modern Flexible Ureteroscopy: Tips and Tricks

BACKGROUND Thanks to advancements in the endoscopic armamentarium, flexible ureteroscopy (fURS) has become a viable and attractive option for the treatment of renal stones because of its high stone-free rates (SFRs) and low morbidity. OBJECTIVE To describe our surgical technique for fURS, step-by-step, for the treatment of renal stones and to assess its effectiveness and safety. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis of 316 consecutive patients who underwent fURS for renal stones at our institution between March 2014 and September 2015 was performed. SURGICAL PROCEDURE Ureteroscopy and laser lithotripsy using a standardized technique with last-generation flexible ureteroscopes. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Clinical data were collected in a dedicated database. Intraoperative and postoperative outcomes were assessed. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS The mean overall stone size was 16.5 ± 7.9mm. Ureteral access sheath placement was possible in 287 patients (90.8%). At 1-mo follow-up, the overall primary SFR was 79.1%; the secondary and tertiary SFRs were 89.5% and 91.5%, respectively. The mean operative time was 72.6 ± 27.5min. The mean number of procedures was 1.27. Complications were reported in 92 patients (29.1%) overall, with Clavien grade 1 in 55 patients (17.4%), grade 2 in 30 patients (9.5%), grade 3 in 6 patients (1.9%), grade 4 in 1 patient (0.3%), and grade 5 in none. The main limitation of the study was the retrospective nature. CONCLUSIONS The fURS procedure is safe and effective for the treatment of renal stones. A staged procedure is necessary to achieve stone-free status with large calculi. PATIENT SUMMARY Flexible ureteroscopy is an effective treatment with low complication rates for the majority of renal stones. Both the modern highly technological armamentarium and surgical know-how should be available.

Adrenal Myelolipoma: Report of Diagnosis by Fine Needle Aspiration

We report 2 cases of adrenal myelolipoma. The diagnosis was suspected preoperatively in the first case on the basis of radiographic findings, ultrasonography and computerized tomography, and was confirmed by an operation. In the second case the diagnosis was established by fine needle biopsy. Computerized tomography and ultrasonography help in the preoperative diagnosis of myelolipoma but only fine needle biopsy can differentiate this lesion from a malignant neoplasm and avoid an operation.

Early Oncologic Failure after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

Purpose: We sought to investigate the prevalence and variables associated with early oncologic failure. Materials and Methods: We retrospectively reviewed the IRCC (International Radical Cystectomy Consortium) database of patients who underwent robot‐assisted radical cystectomy since 2003. The final cohort comprised a total of 1,894 patients from 23 institutions in 11 countries. Early oncologic failure was defined as any disease relapse within 3 months of robot‐assisted radical cystectomy. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncologic surgical principles, and techniques of specimen and lymph node removal. A multivariate model was fit to evaluate predictors of early oncologic failure. The Kaplan‐Meier method was applied to depict disease specific and overall survival, and Cox proportional regression analysis was used to evaluate predictors of disease specific and overall survival. Results: A total of 305 patients (22%) experienced disease relapse, which was distant in 220 (16%), local recurrence in 154 (11%), peritoneal carcinomatosis in 17 (1%) and port site recurrence in 5 (0.4%). Early oncologic failure developed in 71 patients (5%) at a total of 10 institutions. The incidence of early oncologic failure decreased from 10% in 2006 to 6% in 2015. On multivariate analysis the presence of any complication (OR 2.87, 95% CI 1.38–5.96, p = 0.004), pT3 or greater disease (OR 3.73, 95% CI 2.00–6.97, p <0.001) and nodal involvement (OR 2.14, 95% CI 1.21–3.80, p = 0.008) was a significant predictor of early oncologic failure. Patients with early oncologic failure demonstrated worse disease specific and overall survival (23% and 13%, respectively) at 1 and 3 years compared to patients who experienced later or no recurrences (log rank p <0.001). Conclusions: The incidence of early oncologic failure following robot‐assisted radical cystectomy has decreased with time. Disease related rather than technical related factors have a major role in early oncologic failure after robot‐assisted radical cystectomy.

Implantation of an adjustable continence therapy system using local anesthesia in patients with post-radical prostatectomy stress urinary incontinence: a pilot study

PURPOSE We evaluated whether transrectal ultrasound guided ProACT system implantation in patients under local anesthesia and with stress urinary incontinence after radical prostatectomy is feasible in a day hospital setting, and is safe and well tolerated. MATERIALS AND METHODS The procedure was used in 11 consecutive patients (mean age 69.9 years) with stress urinary incontinence after undergoing radical prostatectomy between November 2006 and July 2007. The ProACT system was implanted with a transrectal ultrasound guided procedure after administration of local anesthesia (40 ml ropivacaine 7.5 mg/ml) in perineal skin, subcutaneous tissue, pelvic diaphragm and laterally to the anastomosis. During surgery any reason for discomfort was collected. Pain was evaluated with the visual analogue scale, Numeric Pain Intensity Scale and Simple Descriptive Pain Intensity Scale. Transrectal ultrasound was performed 7 days after surgery to exclude device migrations due to early patient mobilization. RESULTS The ProACT systems were successfully implanted in all patients under local anesthesia without any need for general anesthesia, and without perioperative surgical or anesthesia related complications. Subjective discomfort was minimal. Mean visual analogue scale was 13 mm (range 0 to 28). Mean Numeric Pain Intensity Scale was 1.4 points (range 0 to 4). On the Simple Descriptive Pain Intensity Scale 4 patients (36.3%) reported no pain, 5 (45.5%) reported mild pain and 2 (18.2%) reported moderate pain. Discharge from the hospital was possible for all patients after 6 hours. All transrectal ultrasound performed after 7 days excluded balloon migrations. CONCLUSIONS Transrectal ultrasound guided ProACT system implantation with the patient under local anesthesia only is feasible, safe, well tolerated and may be performed as a day surgery procedure.