J.M. García-Mediero

Estado actual de la cirugia transumbilical por puerto unico en urologia: retos y aplicaciones

CONTEXT Laparoscopic surgery in urology is considered to be an important advance, although it is not exempt from some morbidity associated to the use of multiple trocars and specifically to the extraction of the specimen. In order to decrease this morbidity and improve esthetics, other techniques are being developed, such as natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). It is aimed to review the current status of laparoendoscopic single site surgery in urology. ACQUISITION OF EVIDENCE A nonsystematic review has been carried out by means of the bibliographic search using the terms LESS and Urology from 2007 to 2012. The current LESS experience in urology is described, and its principal indications and the different single site devices and instruments available on the market are described. SYNTHESIS OF EVIDENCE LESS surgery arose as one more step in the constant evolution of minimally invasive surgery in an attempt to improve esthetics, reduce surgical trauma and decrease pain and the post-operative complications associated to the conventional laparoscopy with multiple trocars. Since it was first described in 2007, the experience has been increasing exponentially and the LESS technique, whether assisted or not by robot, is becoming consolidated for a large spectrum of urological indications (both in oncological and reconstructive surgery) on a much greater scale than the NOTES technique. Even though most of the existing data are not randomized and very rarely comparative, with the selection bias that this represents, it seems clear that the esthetic benefit and analgesic control associated to the LESS surgery is real and reproducible. The complications associated to it are greater in cases of major oncology surgery and are due more to the technique itself then to the approach. CONCLUSIONS Although the real benefit of the LESS surgery in urology cannot be appropriately quantified, the cosmetic improvement, less pain and greater patient satisfaction with their wound are clear. Appropriate training in this type of procedures in centers having large volumes and the continuous technical improvements in the instrumental development by the biomedical industry has resulted in the fact that the transumbilical LESS technique in urology has been born to stay.

Pielolitectomía por puerto único umbilical sobre riñón en herradura: una nueva indicación

INTRODUCTION Laparoscopic surgery through a single port is an evolution of laparoscopic surgery, possible after recent technological development of new access systems. It is an established minimally invasive technique, although its indications in the field of Urology are currently under development. MATERIAL AND METHODS We present the first case of incision-less pyelolithectomy, performed through a single-port placed in the umbilicus, performed in a 47 years-old male patient (38.2 BMI) with solitary 4 cm diameter lithiasis in a horseshoe kidney. An umbilical 2.5 cm incision was used for the introduction of a prototype of the reusable Richard Wolf single-port system, without any ancillary elements. RESULTS After placement of left double-J stent proximal left ureter and renal pelvis, pyelolithectomy and pyelorraphy were performed with DuoRotate-Instruments© (Richard Wolf). Water-tightness was demostrated with methylene blue intravesical instillation and no drain was placed. The procedure lasted for 280 min and bleeding was 30 cc. The patient was discharged 24 hours later without pain. CONCLUSION Incision-less pyelolithectomy is a feasible and resolutive option to treat pelvic lithiasis. It can be considered the most beneficial option in aesthetical terms in experienced centers, especially in peculiar cases like horseshoe kidney.

Radical laparoscopic salvage prostatectomy: medium-term functional and oncological results.

AIM To analyze the surgical, functional, and oncological results of radical laparoscopic salvage prostatectomy in local postradiotherapy recurrence. PATIENTS AND METHODS Between May 2005 and April 2007, we treated nine patients with radical laparoscopic salvage prostatectomy. Five patients had received prior treatment with brachytherapy and the other four with external radiotherapy. The average age of the patients was 59.3 years (range 51-68). The average preoperative prostate-specific antigen was 9.1 ng/mL (range 2.6-30). The average follow-up period was 26.8 months (range 15-39). RESULTS The average duration of surgery was 170 minutes (from 120 to 240). There was no need to resort to open surgery or transfusions. There were no cases of rectal injuries. Four cases were pT2c, 1 pT3a, 3 pT3b, and 1 pT4a. The Gleason score was 7 in three cases, 8 in two cases, and 9 in another four. Two patients had nodal metastasis. Postoperative prostate-specific antigen was undetectable in seven of the nine patients. Two patients experienced biochemical recurrence 16 and 13 months after the surgery. After a minimum follow-up period of 15 months, they were free from recurrence. There were no cases of urethrovesical anastomotic stenosis. Three patients manifested severe incontinence (more than two diapers per day), which was corrected in two cases by implanting an artificial sphincter. The other six patients required 0 to 1 pads/day. Before the surgery, only one of the five potential patients maintained his erectile function. CONCLUSIONS Radical laparoscopic salvage prostatectomy is a complex technique that seems to allow attaining high and long-lasting rates of biochemical remission in patients with local postradiotherapy recurrence. Although there is less morbidity in our series in comparison with the anastomotic stenosis and rectal injuries rate published in radical retropubic salvage prostatectomy, more extensive comparative studies are required to confirm this fact.

Nefrectomía parcial laparoscópica

OBJECTIVES To analyze the surgical and oncologic outcome of prospective experience with laparoscopic partial nephrectomy. We describe the surgical technique and mid term oncological results achieved. MATERIAL AND METHODS 60 patients were operated with this technique between June 2005 and June 2009. The mean age of patients was 58.9 [38-77] years, being 40 (66.7%) males and 20 (33.3%) women. The average BMI was 26.8 [18-40]. Laterality was 28 (46.7%) tumors rights and 32 (53.3%) left, being located in the upper pole in 14 (23.3%) patients, in the middle third in 13 (21.7%) in the lower pole in 22 (36.7%) and hiliar region in 11 (18.3%). In 23 cases (38.3%) tumors were located in the anterior valve, in 24 (40%) in posterior valve, in 10 (16.7%) at the outer edge and 3 (5%) at the inner edge. The average size tumor on CT was 3.3 [1-6.4] cm and in the surgical specimen 3.1 [1.2-7] cm. RESULTS The mean operative time was 107.17 [50-185] min, with a warm ischemia time of 33 [0-70] min. In 56 cases (93.3%) had a single artery and 4 (6.7%) cases had 2 arteries. The artery was clamped alone in 15 patients (25%), artery and vein in 44 (73.3%) and no clamping was performed in 1 (1.7%). We repaired the urinary tract in 32 patients (53.3%), leaving ureteral catheter in all patients. 20% of patients (12) required transfusion. Intraoperative complications occurred in 5 patients (8.7%). These were: 1 splenic injury requiring splenectomy (1.7%), 1 tear in the vena cava, sutured laparoscopically (1.7%) and 3 cases of bleeding due to bulldog malfunction (5%). Postoperative complications occurred in 11 patients (18.7%) and these were: 1 wall hematoma that required reoperation (1.7%), 1 urinary fistula ending in renal atrophy and subsequent nephrectomy (1.7%), 3 intracavitary hematomas hich resolved conservatively (5%), 1 arteriovenous fistula that needed embolization (1.7%), 1 urinoma that was resolved with percutaneous drainage (1.7%) and 3 cases of postoperative fever (5%). Margins were positive in 1 patient (1.7%). In 49 cases (81.7%) histology was renal cell carcinoma, in 8 (13.3%) oncocytoma, in 2 (3.3%) angiomyolipoma and 1 (1.7%) metastasis. The average stay was 5 [3-29] days. Median follow up was 31 [12-61] months. There was a local recurrence at 16 months (hiliar primary tumor 2.5 cm) and an ipsilateral adrenal metastasis at 34 months (primary tumor 5.6 cm in left lower pole). CONCLUSIONS In this series of laparoscopic partial nephrectomy low rate of complications, good oncologic results and low recurrence rate in the short term are shown. More patients and further monitoring is required to strengthen the functional and oncological outcomes of this surgical technique.

Reimplantación ureteral laparoendoscópica por puerto único transumbilical

OBJECTIVE To analyze the outcomes of umbilical laparoendoscopic single-site (LESS) ureteral reimplantation using a reusable single-port platform. MATERIAL AND METHOD The casuistic of LESS ureteral reimplantation in 5 patients is presented. The surgical technique using KeyPort system (reusable umbilical single-site platform) is described. Dissection, suctioning and suturing by minilaparoscopy through 3.5mm accessory port in the iliac fossa are performed. Operative and postoperative outcomes are presented. The median follow-up at time of analysis was 11 ± 14 months. RESULTS The median age of patients was a 49 ± 34 year; male-female ratio was 1:1.15. Left surgery was carried out in all cases. In 4 patients, the etiology was secondary to stenosis (3 iatrogenic and 1 pelvic endometriosis). In the remaining case, the procedure was performed after excision of a symptomatic adult ureterocele. In all cases, bladder catheter and double-J ureteral catheter were inserted for 7 ± 3 and 30 ± 15 days and then removed. No conversion to convectional laparoscopic or open surgery occurred. The surgery time was 145 ± 60 min, and intraoperative bleeding was 100 ± 75 cc. Neither transfusion nor high analgesia was necessary. No postoperative complications, minor or major, have been reported. Hospital stay was 2 ± 0.5 days. In any patient, restenosis or worsening of renal function occurred. CONCLUSIONS In experimented centers, transumbilical laparoendoscopic single-site ureteroneocystostomy is a safe alternative with comparable results to conventional laparoscopy and an excellent cosmetic result at low cost thanks to device reuse.

Tratamiento de la estenosis de uréter distal mediante reimplantación urétero-vesical laparoscópica

INTRODUCTION to analyse the results achieved to treat iliac or pelvic ureteric stricture using laparoscopic reimplantation of the ureter in a psoic bladder. MATERIAL AND METHOD in a four-year period, we performed laparoscopic ureteral reimplantation in a psoic bladder in 6 patients (right/left 1:1; male/female 1:2; mean age 59.2 years, range 47-87). In 4 cases the lesion was iatrogenic and in 2 cases idiopathic. Ureteral resection with bladder cuff and cystorraphy followed by ipsilateral lymph node dissection was performed in idiopathic cases or those with history of previous urothelial tumour (4 cases in total) before ureteral reimplantation. Bladder was extensively mobilized and fixed to minor psoas tendon before performing ureteroneocystostomy. Mixed intra and extravesical technique with submucosal tunnel (Politano) was used in a case and in the remaining 5 cases extravesical technique with submucosal tunnel (Goodwin) was used. Mean follow-up was 26 months (range 18-34). RESULTS there was no need to convert to open surgery. Time of surgery was 230 minutes in the case treated with Politano ureteroneocystostomy and 120 (range 75-150) in those treated purely extravesically. The mean hospital stay was 3.2 days (range 2-5). There were no intra or postoperative complications. Histologic assessment always revealed ureteral fibrosis and in 2 cases accompanying granulomatous inflammation and dysplasia. No patient suffered re-stricture or impairment in renal function during follow-up. CONCLUSIONS laparoscopic ureteral reimplantation is an effective and safe minimally invasive technique to treat benign distal stricture of the ureter. Simplicity of extravesical reimplantation has an advantage over its intravesical counterpart.

Linfadenectomía retroperitoneal laparoendoscópica por puerto único en tumor germinal no seminomatoso

INTRODUCTION Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. LESS is possible in virtually any urologic surgery. PATIENT AND METHOD We present a 38-year-old male with BMI 31.2 and with history of stage I nonseminomatous mixed germ cell tumor showing interaortocaval lymph node recurrence without elevation of tumor markers. Patient was undergone to right laparoendoscopic single-site retroperitoneal lymph node dissection (LDRP-LESS) by umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany). RESULTS After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum. Complete retroperitoneal lymph node dissection on the right side from iliac vessels to renal vessels, including the paracaval and interaortocaval space, was performed. The specimen was inserted into a laparoscopic bag and was removed together with multichannel system. Abdominal drainage was not employed. Surgical time was 85 min and estimated bleeding 50 cc. The patient was very satisfied with the cosmetic results and was discharged the following day without needing analgesia. The pathology report revealed metastatic seminoma in 5 of 11 lymph nodes receiving systemic chemotherapy (VP16-CDDPs) for 4 cycles with good tolerance. A year later, the patient was disease-free and had no complications. CONCLUSIONS Umbilical primary LDRP-LESS, with excellent oncologic and cosmetic results, is feasible in selected cases. This approach could be considered the least invasive surgical option economically advantageous due to the reusable nature of the instruments used.

La opción óptima: nefrectomía radical LESS umbilical con extracción vaginal

INTRODUCTION Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. The reusable nature of its instruments also has significant economic advantages. PATIENT AND METHOD We present a 34-year-old patient with a solid mesorenal lesion measuring 8 cm in the left kidney treated with pure LESS radical nephrectomy assisted by vaginal extraction of the specimen. The umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany) with DuoRotate curved instruments allows for minimum crushing and fewer spatial conflicts. Its perfect umbilical adaptation provides a hermetic system. The instruments double rotation provides considerable movement precision. Vaginal extraction avoids damage to the abdominal wall and the need for widening the umbilical incision. RESULTS After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum and dissect the renal hilum. Hem-o-lok clips were placed on the artery and vein, which were subsequently sectioned. The specimen was inserted into a laparoscopic bag. Under direct vision, we placed a 15-mm trocar through the bottom of the vaginal posterior fornix to facilitate the extraction of the bags thread. The incision was widened with the fingers, and the specimen was extracted, closing the vagina from the perineum with visualization from the navel. Abdominal drainage was not employed. The surgical time was 180 min. The patient was discharged the following day without needing analgesia. A year later, the patient was disease-free and had no complications. CONCLUSIONS Umbilical LESS radical nephrectomy with vaginal extraction is feasible in selected cases. The procedure is oncologically safe, avoids scars and facilitates early recovery. From a practical point of view, this approach greatly simplifies natural orifice transluminal endoscopic surgery (NOTES) and enables a minimally invasive equivalent result.

Results of Simplified Urethropexy in the Recovery of Continence After Radical Laparoscopic Prostatectomy

PURPOSE To analyze the effectiveness of simplified urethropexy in the evolution of urinary incontinence after radical laparoscopic prostatectomy. PATIENTS AND METHODS Between January 2007 and December 2008, 104 patients were included in a randomized trial to assess the effectiveness of simplified urethropexy. The simplified urethropexy technique was performed on conclusion of a urethrovesical anastomosis with running suture and, before cutting the suture material, a suture was applied using the same material with a needle through the pubic tubercle, tightening it and securing it with a Hem-o-lok. Fifty-one patients qualified for the trial in the simplified urethropexy group (group 1) and another 51 in the control group without urethropexy (group 2). Incontinence was defined as the lack of the need for protection for normal life, and the degree of continence was compared at 3, 6, and 12 months after surgery. RESULTS Surgery lasted 141 minutes in group 1 and 139 in group 2 (NS). There were no secondary complications such as urine retention, osteitis pubis, or bladder perforation. After 3 months, 47.1% of patients in each group declared continence (NS). After 6 months, 72.6% of patients in group 1 and 66.7% in group 2 (P<0.05) declared continence. After 12 months, 92.2% of patients in group 1 and 84.3% in group 2 declared continence. CONCLUSIONS In our experience, simplified urethropexy is a simple, nontime-consuming technique that shows a slight clinical improvement in continence within 6 and 12 months, without reaching significant differences with the Fisher Test. It would be necessary to perform a trial with a greater number of patients to confirm these data.