Guy Vallancien

PERIOPERATIVE COMPLICATIONS OF LAPAROSCOPIC RADICAL PROSTATECTOMY: THE MONTSOURIS 3-YEAR EXPERIENCE

PURPOSEnWe prospectively evaluated the morbidity, and minor and major complications of laparoscopic radical prostatectomy performed by a single surgical team.nnnMATERIALS AND METHODSnBetween January 28, 1998 and February 28, 2001, 567 patients 42 to 77 years old (mean age plus or minus standard deviation 63.5 +/- 6) with clinically localized prostate cancer underwent laparoscopic radical prostatectomy, including 458 (80.6%), without lymphadenectomy. Mean body mass index was 25.3 +/- 2.9 (range 17.3 to 37.5). American Society of Anesthesiologists score was 1 to 3 in 65%, 27% and 8% of cases, respectively. A total of 12 patients (2.1%) had undergone intra-abdominal surgery below the mesocolon and 40 had undergone urological surgery. Intraoperative and postoperative data were recorded as well as all complications and their severity score within the initial 30 days postoperatively.nnnRESULTSnA total of 105 complications were observed in 97 patients (17.1%), including 21 major (3.7%) and 83 minor (14.6%) complications. Of the patients 21 (3.7%) underwent reoperation for a postoperative complication, including 10 (1.76%) who required an intensive care unit stay. Seven cases (1.2%) were converted to conventional retropubic radical prostatectomy. Mean blood loss was 380 +/- 195 ml. and the overall transfusion rate was 4.9%. In 2 patients (0.3%) deep vein thrombosis was associated with another surgical complication but not with pulmonary embolism. Urological, bowel and hemorrhagic complications represented 66.6%, 16.2% and 7.6% (total 89.4%) of all complications, and 20%, 33.3% and 33.3% of all repeat interventions, respectively.nnnCONCLUSIONSnLaparoscopic radical prostatectomy was performed according to the defined protocol with no complications in 82.9% of patients. The morbidity of this approach compares favorably with that of retropubic surgery. Growing experience and knowledge sharing concerning the prevention and early management of these complications would make possible a further decrease in the morbidity of laparoscopic radical prostatectomy.

Complications of Transperitoneal Laparoscopic Surgery in Urology: Review of 1,311 Procedures at a Single Center

PURPOSEnThe development of laparoscopic surgery in urology is increasing rapidly. We describe our experience with complications during and after transperitoneal laparoscopic surgery after 9 years of practice.nnnMATERIALS AND METHODSnA total of 1,311 laparoscopic procedures were performed by 5 senior urologists in the same department since 1992, of which 72% were classified as difficult or very difficult (prostatectomy, nephrectomy for cancer, nephroureterectomy, partial nephrectomy, cystectomy, para-aortic lymph node dissection), 27.5% as moderately difficult (nephrectomy for benign disease, adrenalectomy, genitourinary prolapse, ureteropelvic junction, pelvic and ureteral stones, ureterovesical reimplantation, pelvic lymph node dissection) and 0.5% as easy (lymphocele, renal cyst and so forth).nnnRESULTSnThere was no mortality or anesthetic complications. The overall transfusion rate was 2.4%. Complications were serious in 0.7% of cases, all of which required reoperation, intermediate in 1.8% of which 1% required reoperation and minor in 1.1%. The main complications were bowel (1.2%), vascular (0.5%) and ureteral injuries (0.8%). The conversion rate was 1.2% and the reoperation rate was 2.4%. Of the patients 1.2% had to be admitted to the intensive care unit. Postoperative complications were observed in 19% of cases. Laparoscopic surgery is associated with essentially the same complications as open surgery, and they, particularly bowel injuries and bleeding, can be diagnosed and often treated with repeat laparoscopy.nnnCONCLUSIONSnComplications during and after transperitoneal laparoscopy remain low and are not superior to those observed during and after open surgery. As laparoscopy becomes more widely used, urologists wishing to learn this technique must realize that the learning process is long but essential.

Laparoscopic Partial Nephrectomy for Reanl Tumor: Single Center Experience Comparing Clamping and No Clamping Techniques of the Renal Vasculature

PURPOSEnWe performed a nonrandomized retrospective comparison of 2 techniques for laparoscopic partial nephrectomy, that is without and with clamping the renal vessels.nnnMATERIALS AND METHODSnBetween December 1997 and February 2002, 28 consecutive patients underwent transperitoneal laparoscopic partial nephrectomy for renal tumor. In group 1 (12 patients) partial nephrectomy was performed with ultrasonic shears and bipolar cautery without clamping the renal vessels, while in group 2 (16 patients) the renal pedicle was clamped before tumor excision. In group 2 patients intracorporeal kidney cooling was achieved by a ureteral catheter connected to 4C solution. Intracorporeal freehand suturing techniques were used to close the collecting system when opened and approximate the renal parenchyma.nnnRESULTSnAll procedures were successfully completed laparoscopically. Mean renal ischemia time +/- SD was 27.3 +/- 7 minutes (range 15 to 47) in group 2 patients. Mean laparoscopic operating time was 179.1 +/- 86 minutes (range 90 to 390) in group 1 compared with 121.5 +/- 37 minutes (range 60 to 210) in group 2 (p = 0.004). Mean intraoperative blood loss was significantly higher in group 1 than in group 2 (708.3 +/- 569 versus 270.3 +/- 281 ml., p = 0.014). Three patients in group 1 and 2 in group 2 required blood transfusions. Immediately postoperatively mean creatinine was 1.26 +/- 0.36 and 1.45 +/- 0.61 mg./dl. in groups 1 and 2, respectively (p = 0.075). Surgical margins were negative in all specimens. Pathological examination revealed renal cell cancer in 18 cases (stages pT1 in 17 and pT3a in 1), oncocytoma in 4, angiomyolipoma in 5 and renal adenoma in 1.nnnCONCLUSIONSnLaparoscopic partial nephrectomy represents a feasible option for patients with small renal masses. Clamping the renal vessels during tumor resection and suturing the kidney mimics the open technique and seems to be associated with less blood loss and shorter laparoscopic operative time.

Cystectomy with Prostate Sparing for Bladder Cancer in 100 Patients: 10-year Experience

PURPOSEnTo minimize the risk of incontinence and impotence without compromising oncological outcome, we performed prostate sparing surgery during radical cystectomy for bladder cancer.nnnMATERIALS AND METHODSnSince 1992, 100 patients with a mean age of 64 years (range 48 to 82) underwent cystectomy for bladder transitional cell carcinoma with prostate sparing based on normal digital rectal examination of the prostate, normal prostate specific antigen (PSA), percent free PSA greater than 15 and normal transrectal ultrasound of the prostate. Prostate biopsies to exclude prostate cancer were performed on patients with an abnormal digital rectal examination, high PSA, percent free PSA less than 15 or hypoechoic lesions on ultrasound. Surgery consisted of transurethral resection of the prostate with analysis of frozen section of the prostatic urethra and transitional prostate and cystectomy with reconstruction by a Z ileal bladder anastomosed to the prostatic capsule after confirmation of the absence of prostate or bladder cancer on frozen sections of the surgical capsule specimens. Patients were followed closely with imaging and laboratory studies every 6 months and annually for 3 years thereafter.nnnRESULTSnPerioperative death occurred in 1 patient due to septicemia, 20 patients (20%) died of cancer and 6 (6%) died of nonrelated cancer causes. Mean followup 38 months (range 2 to 111). Postoperative pathological stage was PT0 in 2 cases, PtaT1 in 22, PT2 in 48, PT 3 in 28 and N+ in 13. The 5-year actuarial global survival according to pathological stage was pTaT1N0 in 96% of cases, pT2N0 in 83%, pT3N0 in 71% and N+ in 54% (p = 0.0001). The 5-year actuarial cancer specific survival was PT0, Ta T1 in 90% of cases, PT2 in 73%, PT3 in 63% and N- in 8%. The cancer specific survival according to pathological grade was 100% for well differentiated tumors (grade I), 76% for moderately differentiated tumors (grade II) and 47% for poorly differentiated tumors (grade III) (p = 0.003). Local recurrence was pTaT1N0 in 1 of 22 cases (4.5%), pT2N0 in 2 of 40 (5%), pT3N0 in 2 of 23 (8.5%) and N+ in 0 of 13 (0%). Prostate cancer was diagnosed in 3 patients (2 errors in the diagnosis and 1 cancer de novo within 5 years of followup). At 1-year followup 86 of 88 patients (97%) are fully continent (no pad) during the day, and 84 (95%) void 1 to 2 times a night to stay dry. Of 61 patients with previously adequate sexual function 50 (82%) maintained potency with retrograde ejaculation secondary to transurethral resection, 6 (10%) have partial potency and 5 (8.1%) are impotent.nnnCONCLUSIONSnCystectomy with prostate sparing for bladder cancer is feasible and offers promising functional results with no additional oncological risk. Careful selection of patients is mandatory.

A 10-Year Clinical Experience with Intermittent Hormonal Therapy for Prostate Cancer

OBJECTIVESnTo evaluate, over a 10-year period, the feasibility, efficacy, duration of action and adverse effects of intermittent hormonal therapy (IHT) in patients with advanced prostate cancer or biochemical recurrence after radical treatment.nnnMATERIALS AND METHODSnTwo hundred and thirty-three patients with prostate cancer have been included in an IHT protocol since 1992. Fifty-five patients had already been treated by radical prostatectomy (group A), 35 patients had received radiotherapy or a treatment with high-intensity focused ultrasound (HIFU) (group B) and 143 patients had not received any previous treatment (group C). Three-monthly injection of LHRH analogue combined with a non-steroidal antiandrogen was administered during the treatment phase (on phase). Treatment was stopped (off phase) when the PSA level fell below 4 ng/ml, regardless of the duration of the on phase. Criteria for resumption of hormonal therapy were PSA >20 ng/ml, PSA progression slope over the previous three months >5 ng/ml per month or recurrence of pain or urinary symptoms.nnnRESULTSnThe median follow-up was 34.9 months (range: 13-151) and the median initial PSA was 28 ng/ml (range: 1-433). Five cycles were performed in the patients with the longest follow-up. The mean duration of cycles was gradually decreased from 19.6 months to 11.8 months. The on/off ratio was close to 30% regardless of the cycle or patient group. Ten patients (4%) died from their cancer during the study, with a median survival of 42.2 months. Six patients (2.5%) developed painful symptoms during IHT.nnnCONCLUSIONSnIHT ensures medium-term (three years) control of the disease, using a treatment resumption criteria of PSA >20 ng/ml and was not associated with major complications.

Laparoscopic Ureterolithotomy for Ureteral Calculi

Background and Purpose: Most patients with ureteral calculi that do not pass spontaneously can be treated by either extracorporeal shockwave lithotripsy (SWL) or ureteroscopy. In rare cases of large, hard and chronically impacted stones, or after failure of first–line treatments, surgical ureterolithotomy is still indicated. Laparoscopy allows performing this procedure in a minimally invasive manner. Patients and Methods: Twenty–four patients (22 men and 2 women) underwent laparoscopic ureterolithotomy between 1994 and 1999. The procedure was indicated in 10 cases as a salvage treatment after failure of SWL (5 patients), ureteroscopy (2 patients), both (1 patient), laparoscopic ureterolithotomy (1 patient), or even open ureterolithotomy (1 patient), and in 14 patients as a primary treatment for large stones (median size 11.5, range 8–33 mm). The first 3 procedures were carried out via the retroperitoneal route and the following 21 via the transperitoneal approach. Results: All but 1 stone were successfully removed in a mean operating time of 111 (range 45– 180) min. Postoperative pain was managed with first–line analgesics. Hospital stay ranged from 2 to 10 (mean 3.8) days. The 2 postoperative complications encountered were prolonged ileus (1 patient) and venous thrombosis (1 patient). Conclusions: Laparoscopic ureterolithotomy is a safe and effective procedure that enables the urologist to maintain a minimally invasive strategy when first–line treatment have failed or are unlikely to be effective.

Thick Loop Transurethral Resection of the Prostate

Objectives: To evaluate the safety and efficacy of the new resection loops for transurethral resection of the prostate (TURP). These loops, which are both thicker and have a modified shape, allow simultaneous resection, increased tissue vaporization, and improved hemostasis. Methods: Two open studies have been performed with the thick resection loop. In one series, 91 patients underwent TURP with the Vapor Cut (G. Vallancien, Paris), and in another series, 65 patients underwent Wedge (Microvasive, Natick, Mass., USA) resection (A. Perlmutter, New York). Results: At 1 year follow-up, patients who underwent thick loop resection enjoyed the same clinical benefit of thin loop TURP without additional morbidity. Peak urinary flow rate improved to 18.4 and 16.3 cm3/s at 1 year with the Vapor Cut and Wedge, respectively. IPSS fell to 7.2 (Vapor Cut) and 6.2 (Wedge). Postoperative bleeding, meatal stenosis, and urethral stricture were noted, but no impotence or incontinence was observed. Conclusions: Thick loop resection offers the advantage of improved surgical vision during resection, thus allowing a more accurate and safer resection. This can be performed with only minor modifications of the standard TURP technique.

Germ-cell tumours containing non germ-cell neoplasms: teratoma with malignant transformation

Abstract Objective: To evaluate the outcome of patients with non germ-cell neoplasms arising in germ-cell tumours [also designated teratoma with malignant transformation (TMT)]. Methods: The records of patients with TMT from three institutions were reviewed retrospectively. Results: 12 males were diagnosed as having TMT. All but 2 patients had a teratoma component in the primary tumour. Sarcoma was the most frequent histologic type of TMT, identified in 9 patients, with rhabdomyosarcoma ranking first among the subtypes (3/9). Other histological types included nephroblastoma and ependymoblastoma (1), adenocarcinoma (1) and bronchoalveolar carcinoma (1). All patients with advanced disease were treated with cisplatin-containing chemotherapy, followed by resection of residual masses in 5. Eight of the 10 patients who attained a complete remission subsequently relapsed. Histologically-adapted chemotherapy was administered to 7, of whom 3 obtained a partial response and 3 disease stabilisation. With a median follow-up of 5 years, 3 of 12 patients (25%) are alive and free of disease. Conclusions: TMT is a rare phenomenon occurring in a wide spectrum of histologic subtypes, the most common being sarcoma. Its poor prognosis compared with germ-cell tumours may be improved by histologically-adapted chemotherapy combined with optimal surgery.

The Need for an International Classification of Benign Prostatic Hyperplasia

An international classification of patients suffering from benign prostatic hyperplasia is essential, as we are currently unable to categorize patients thereby allowing application of the most appropriate treatment as a function of selected items. We have adopted 4 items: weight of the prostate (P); quality of life index (Q); international prostatic symptom score (S), and maximum flow rate (F). 112 patients were analyzed according to this classification and the results are presented. We have tried to develop a simple, easy to remember classification in order to easily allocate a given patient to a particular category. This proposed classification corresponds to a real ‘Prostate Who’s Who’, which should be evaluated and improved to act as a working basis for an international classification of benign prostatic hyperplasia.

Laparoscopic Simple Prostatectomy

Open prostatectomy is a long accepted method of treating patients with large hyperplasic glands. New therapeutic options have demonstrated efficiency and safety for high volume benign prostatic hyperplasia (BPH). Minimally invasive laparoscopic and endourological treatments have reproduced similar results to open simple prostatectomy with some clinical advantages. Results indicate that laparoscopic simple prostatectomy is a viable option for the surgical treatment of BPH. Available clinical series evidence that in patients with BPH and formal surgical indication, surgery could be safely and properly performed by a laparoscopic technique. Publications concerning laparoscopic simple prostatectomy (LSP) or laparoscopic adenomectomy are mostly based on non experimental studies, such as comparative studies, correlation studies and case reports. The studies underpinning this current chapter were identified through a systematic research using PubMed. There are no randomized or high levels of evidence studies available for LSP. Our objective is to present the available experience in laparoscopic simple prostatectomy which, in our view, is a reproducible, effective procedure for removal of large prostatic adenomas with overall low perioperative morbidity.