L. Gausa

Laparoscopic Live Donor Nephrectomy With the Use of 3-mm Instruments and Laparoscope: Initial Experience at a Tertiary Center

Laparoscopy has become the standard of care for kidney recovery during live donor nephrectomy (LDN) because of the well-documented better outcomes of minimally invasive surgery compared with the open approach. Especially in the donor population, the cosmetic results are of great importance; therefore, an effort to reduce the incision size should be attempted while maintaining the safe general principles of surgery. We present our initial experience with the use of 3-mm instruments for laparoscopic LDN.

Simplified Technique for Parastomal Hernia Repair After Radical Cystectomy and Ileal Conduit Creation

OBJECTIVE To review the results of parastomal hernia repair with a simplified technique of translocation of the stoma with no need for a midline incision. METHODS A total of 405 radical cystectomies with creation of an ileal conduit were reviewed at our institution. The primary goal of the review was to determine the incidence of parastomal hernias in a large series of cystectomies and their management at our institution. Surgical correction of parastomal hernia was indicated in case of pain, discomfort, risk of bowel obstruction, and/or distortion of the abdominal wall. The simplified technique includes an elliptical incision around the stoma and dissection of the hernias sac down to the level of the fascia. The sac is incised and the peritoneum is entered. The ileal conduit is thereafter mobilized to guarantee sufficient length. This is crucial to be able to transpose the conduit 5-10 cm superiorly and to obtain a tension-free ileostomy. RESULTS Sixty-three patients (16%) presented during the follow-up after ileal conduit a palpable defect or bulge adjacent to the stoma. The review highlighted 19 patients (4.69%) who developed a parastomal hernia and underwent surgical repair. Four cases (21%) recurred at a median follow-up of 55 months. Recurrence was not found to be related to gender, age, body mass index, protein level, radiotherapy, adjuvant chemotherapy, or previous abdominal surgery on univariate analysis. Postoperative complications included one wound infection (5.2%) and one stomal necrosis (5.2%). CONCLUSIONS The technique herein proposed simplifies the management of parastomal hernia repair by avoiding a midline incision, which implies a reduction in surgical trauma with acceptable recurrence and postoperative complication rate.

Bladder Preservation Strategy Based on Combined Therapy in Patients with Muscle-Invasive Bladder Cancer: Management and Results at Long-Term Follow-Up

Objective: To evaluate a bladder preservation strategy in patients with either muscle-invasive bladder cancer (MIBC) or development of MIBC cancer due to progression of non-muscle-invasive bladder cancer (NMIBC). Methods: Between October 1982 and March 1998, 48 patients (mean age 61 years, range 45–75) with MIBC (T2a–b and T3a) were treated using transurethral resection followed by three cycles of systemic chemotherapy. 42 patients (87.5%) had primary MIBC and 6 (12.5%) had MIBC subsequent to NMIBC. After chemotherapy, 39 patients (81.25%) achieved complete remission and 4 (8.3%) partial remission. Results: With a median follow-up of 98.5 months (13–246), the overall survival of the 48 patients was 62.6%. The cancer-specific survival (CSS) of the 39 patients with complete remission was 80.8%. Among the 39 patients with complete remission, 19 had invasive recurrence during follow-up with a CSS of 53.2%; by comparison, among patients with preserved bladders, CSS was 72.1% (p = 0.046). Predictive factors analysed were age, sex, tumour size >3 cm, grade, associated carcinoma in situ (CIS), number of tumours and number of previous recurrences. In multivariate analysis only tumour size and CIS were significant predictive factors for progression after preservation. Of the 6 patients with MIBC after NMIBC, 3 (50%) had no remission and underwent cystectomy and 15 patients (38.6%) had NMIBC recurrences during follow-up. CIS and high-grade tumours were treated with bacillus Calmette-Guérin. A bladder preservation rate of 81% and a CSS rate of 89% were obtained in the group with NMIBC recurrences. Conclusions: Conservative management of MIBC cancer is a feasible alternative to cystectomy in selected cases. Patients with MIBC after progression of primary NMIBC are not good candidates for a bladder preservation approach. NMIBC recurrences after bladder preservation in patients with MIBC respond to transurethral resection and bacillus Calmette-Guérin instillations.

Hemangioma of the Prostatic Urethra: Holmium Laser Treatment

Urethral hemangiomas are benign vascular tumors that are found in perimontanal prostatic localization and less frequently in the urethra. Although different urethral procedures have been postulated for its treatment, the best results are achieved using lasers. A patient who underwent endoscopic holmium laser treatment for such hemangiomas is presented. Total disappearance of the lesions without any complications was achieved.

Invasive Bladder Cancer in the Eighties: Transurethral Resection or Cystectomy?

PURPOSE Describe morbidity and survival in patients older than 80 years with muscle invasive bladder cancer (MIBC) treated with radical cystectomy (RC) or transurethral resection (TUR) in our institution. MATERIALS AND METHODS We reviewed our database of all patients older than 80 years treated with RC and TUR for MIBC between 1993 and 2005 in our institution. Twenty-seven patients were submitted to RC, with mean age of 82 years and mean follow-up of 16.4 months. RC was carried out following diagnosis of previous MIBC in 14 cases (51.9%). The American Society of Anesthesiology (ASA) score was III or IV in 23 patients (85.1%). Seventy-two patients with a mean age of 84 years and mean follow-up of 33 months, diagnosed with MIBC, were managed by means of TUR. The ASA score was III-IV in 64 (88.8%) patients. RESULTS Pathological stage of the RC specimen was pT3 in 18 cases (66.7%). Mean hospital stay was 16 days. Early complications were assessed in 8 patients (29.6%), with an overall survival (OS) of 42.94%, and cancer-specific survival (CSS) of 60.54%. In patients submitted to TUR, clinical stage was T2 in 36 cases (50%). The mean hospital stay was 7 days, with a readmission rate (RR) of 87.5%. OS and CSS was less than 20%. CONCLUSIONS RC in octogenarian patients is a safe procedure, with complication and survival rates comparable to RC series in general population. Transurethral resection (TUR) for patients with MIBC within this age range is a much less morbid procedure, but disease specific survival is lower.

Cistoprostatectomía radical robótica: análisis oncológico, funcional y de las complicaciones

OBJECTIVES To review our experience in robot-assisted radical cystectomy, assessing the complications and oncological and functional results. MATERIALS AND METHODS From 2007 to 2014, we performed 67 robot-assisted radical cystectomies combined with lymphadenectomy in 61 cases. The operations were performed on 37 patients due to muscle-invasive tumours and on 30 due to high-risk nonmuscle-invasive tumours. Urinary diversion was conducted extracorporeally, using a Studer neobladder in 47 cases. RESULTS The mean blood loss was 300mL. No case required conversion to open surgery. The median number of lymph nodes extracted was 16 (range 3-33). Pathology revealed 16 pT0, 15 pTis,-pT1-pTa and 44 muscle-invasive tumours, 8 pN+ and 1 with positive margins. The mean hospital stay was 9 days. With a median follow-up of 16 months, 9 (13%) patients were readmitted after the discharge, most for infections associated with the vesical catheter and other catheters. Forty patients (59.7%) presented complications (most were Clavien grade 1-2). There was recurrence during the follow-up in 4 cases (6%), and 4 (5.9%) patients died from cancer. Nineteen (28.3%) patients had complications after 30 days, most of which were urinary tract infections. Of the 47 patients with a neobladder, 45 (96%) had proper daytime continence and 42 (89%) had proper nighttime continence. Ninety percent and 64% of the patients with previously normal sexual function and reduced sexual function, respectively, were able to preserve sexual function with or without drug treatment. CONCLUSIONS Robot-assisted radical cystectomy plus lymphadenectomy, with extracorporeal reconstruction of the urinary diversion, offers good oncological and functional results without increasing the number of complications.