O. Castillo

Laparoscopic adrenalectomy for adrenal masses: does size matter?

OBJECTIVES To examine the impact of adrenal tumor size on perioperative morbidity and postoperative outcomes in patients undergoing laparoscopic adrenalectomy. METHODS A total of 227 laparoscopic adrenalectomies were divided in three groups according to size as estimated by pathologic specimen maximum diameter: less than 6 cm (group 1, n = 140), between 6 and 7.9 cm (group 2, n = 47), and equal to or larger than 8 cm (group 3, n = 40). We prospectively recorded and analyzed clinical and pathologic data. RESULTS Average operative time was 60 minutes (range, 50 to 90 minutes) for group 1, 75 minutes (range, 65 to 105 minutes) for group 2, and 80 minutes (range, 65 to 120 minutes) for group 3. Estimated blood loss, median (interquartile range) was 50 mL (range, 20 to 100 mL), 100 mL (range, 48 to 225 mL), and 100 mL (range, 50 to 475 mL) for groups 1, 2, and 3, respectively. We observed a total of 10, 4, and 4 complications in groups 1, 2, and 3, respectively. Average hospital stay was 2 days (range, 2 to 3 days), 2 days (range, 2 to 3 days), and 3 days (range, 2 to 4 days), respectively, for groups 1, 2, and 3. Operative time, average blood loss, and mean hospital stay were significantly higher (P <or=0.05) for group 3 compared with group 1. CONCLUSIONS Laparoscopic adrenalectomy in large adrenal masses (8 cm or greater) is associated with significantly longer operative time, increased blood loss, and longer hospital stay, without affecting perioperative morbidity.

Port Site Metastasis and Tumor Seeding in Oncologic Laparoscopic Urology

Tumor seeding and port site metastasis remain a valid concern during laparoscopic procedures for urologic malignancies. A systematic review of all cases reported in published studies was performed. A MEDLINE search identified 17 English studies reporting a total of 29 cases of port site metastasis or tumor seeding secondary to urologic laparoscopic procedures in the past 20 years. Many factors contribute to port site metastases and tumor seeding. Nevertheless, we believe that only proper preoperative criteria, along with cautious intraoperative judgment, will keep port site metastasis to a minimum in the future.

Complications in laparoscopic radical cystectomy. The South American experience with 59 cases.

OBJECTIVE In this study, we have gathered the second largest series yet published on laparoscopic radical cystectomy in order to evaluate the incidence and cause of intra and postoperative complication, conversion to open surgery, and patient mortality. MATERIALS AND METHODS From 1997 to 2005, 59 laparoscopic radical cystectomies were performed for the management of bladder cancer at 3 institutions in South America. Twenty nine patients received continent urinary diversion, including 25 orthotopic ileal neobladders and 4 Indiana pouches. Only one case of continent urinary diversion was performed completely intracorporeally. RESULTS Mean operative time was 337 minutes (150-600). Estimated intraoperative blood loss was 488 mL (50-1500) and 12 patients (20%) required blood transfusion. All 7 (12%) intraoperative complications were vascular in nature, that is, 1 epigastric vessel injury, 2 injuries to the iliac vessels (1 artery and 1 vein), and 4 bleedings that occurred during the bladder pedicles control. Eighteen (30%) postoperative complications (not counting mortalities) occurred, including 3 urinary tract infections, 1 pneumonia, 1 wound infection, 5 ileus, 2 persistent chylous drainage, 3 urinary fistulas, and 3 (5%) postoperative complications that required surgical intervention (2 hernias - one in the port site and one in the extraction incision, and 1 bowel obstruction). One case (1.7%) was electively converted to open surgery due to a larger tumor that precluded proper posterior dissection. Two mortalities (3.3%) occurred in this series, one early mortality due to uncontrolled upper gastrointestinal bleeding and one late mortality following massive pulmonary embolism. CONCLUSIONS Laparoscopic radical cystectomy is a safe operation with morbidity and mortality rates comparable to the open surgery.

Management of rectal injury during laparoscopic radical prostatectomy

PURPOSE Because laparoscopic radical prostatectomy remains a challenging procedure, rectal injury is always a potential complication. We review the incidence of rectal injuries at our institution in the first 110 consecutive laparoscopic extraperitoneal radical prostatectomies. MATERIALS AND METHODS Nine (8%) out of the first 110 laparoscopic extraperitoneal radical prostatectomies performed between December 2001 and February 2004, were complicated by rectal injury. Mean patient age was 64.9 years (range 52 to 74) and mean prostate specific antigen was 11.45 ng/mL (range 4.8 to 37.4). Median preoperative Gleason score was 6 (range 4 to 8) and clinical stage was T1c, T2a, T2b in 6, 2 and 1 patient, respectively. Mean operative time was 228 minutes (range 150 to 300). RESULTS From 9 injuries, 6 were diagnosed and repaired intraoperatively and 3 were diagnosed postoperatively. From the 6 cases of intraoperative diagnosis and repair, 3 patients healed primarily without colostomy and a recto-urinary fistula was evidenced by pneumaturia in the remaining three. These 3 patients were managed conservatively with urethral catheterization during 30 days. One of the patients required secondary fistula repair by anterior transphincteric, transanal surgical approach (ASTRA). Urinary fistula was diagnosed postoperatively on 3 patients. A diverting colostomy was performed on one patient with secondary fistula repair by ASTRA. Another patient required laparotomy due to peritonitis and urinary fistula was later managed with ASTRA. On the third patient conservative management with urethral catheter was successful. All fistulas repaired with ASTRA evolved uneventfully. There was no perioperative mortality. CONCLUSIONS Rectal injury during laparoscopic radical prostatectomy can be managed intraoperatively or by a minimally invasive procedure without the need of colostomy. Laparoscopic radical prostatectomy is a challenging procedure and is associated with a very flat learning curve; the incidence of rectal injuries is prone to diminish with experience.

Nefrectomía laparoscópica simple con asistencia de notes transvaginal y uso de instrumentos laparoscópicos estándar

Resumen Introduccion La cirugia endoscopica transluminal a traves de orificios naturales (NOTES™) es una tecnologia emergente, que permite realizar procedimientos quirurgicos sin el uso de incisiones abdominales. Sin embargo existen limitaciones respecto al equipamiento disponible para simular la cirugia tradicional. Nuestro objetivo es presentar nuestra experiencia con la tecnica de nefrectomia transvaginal NOTES con el uso de instrumentos laparoscopicos estandar. Materiales y Metodos Presentamos dos pacientes de sexo femenino de 23 y 26 anos, ambas con diagnostico de infecciones urinarias recurrentes y atrofia renal secundaria. Se les realizo una nefrectomia simple con asistencia de NOTES, utilizando un puerto de trabajo transvaginal para la camara y dos puertos adicionales de 10 (umbilical) y 3 mm en el abdomen. Resultados El procedimiento total duro 120 min en el primer caso y 40 minutos en el segundo, con una perdida sanguinea promedio de 200 cc. (0-200). No se reportan complicaciones, siendo ambas pacientes dadas de alta 36 horas despues de su cirugia. Conclusion La nefrectomia laparoscopica con asistencia de NOTES transvaginal es tecnicamente posible con el uso de instrumentos laparoscopicos estandar. El desarrollo y acceso a trocares y pinzas especiales para la tecnica NOTES™, permitira realizar una tecnica pura sin el uso de incisiones abdominales.

Complete excision of urachal cyst by laparoscopic means: A new approach to an uncommon disorder

OBJECTIVE Anomalies of the urachal remnant are rare. Urachal cysts are usually asymptomatic, however, when they become infected, they can mimic a wide variety of intra-abdominal pathologies. We present two patients in which an urachal cyst was found. METHODS Two male patients 25 and 38 years old respectively underwent laparoscopic resection of an urachal remnant. In one of the cases the urachal remnant was complicated by infection. Opportune clinical and radiologic diagnose was made in both cases and complete excision of the urachal remnant was carried out by laparoscopic means. RESULTS The procedures were performed without complications and follow up showed excellent results. Both patients presented very short convalescence with rapid recovery. CONCLUSIONS The treatment of choice for urachal pathology is the complete excision of the complicated lesion. For this matter laparoscopic surgery assures surgical results comparable to conventional surgery adding the advantages of a minimally invasive approach.

Prostatectomía simple (adenomectomía) por vía laparoscópica: experiencia en 59 pacientes consecutivos

OBJECTIVE Laparoscopic adenomectomy 150 is a minimally invasive alternative to open surgery in large prostates. Our aim is to discuss our series of 59 patients treated by means of laparoscopic adenomectomy with precise vascular control. MATERIALS AND METHODS Between June 2003 and June 2006, a total of 59 patients with a mean age of 65.5 years (51 to 82), underwent laparoscopic extraperitoneal adenomectomy. All the patients had a history of lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH). The mean International Prostate Symptom Score (IPSS) was 20 points (16-22). The information was collected prospectively in a database. The analysis was performed subsequently. RESULTS All 59 adenomas were completely removed laparoscopically without conversion to open surgery. The mean preoperative prostate volume by ultrasound was 108.5 cc (75-150). The average operating time was 123 minutes (90-180). The mean loss of blood was 415 ml (50-1500) and 4 patients (14.8%) required a blood transfusion. Two (7.4%) of the patients presented perioperative complications. The mean hospital stay and the bladder catheterization time were 3.5 (2-7) and 4.2 (3-7) days respectively. CONCLUSIONS Laparoscopic extraperitoneal simple prostatectomy is an effective procedure for the treatment of large prostatic adenomas. There seems to be less perioperative morbidity and, in our experience, this technique seems to be feasible and reproducible; however, its learning curve is a complicated matter to deal with.

Linfadenectomía retroperitoneal laparoscópica en cáncer de testículo no seminoma estadio I

OBJETIVOS Se presenta una serie de pacientes con cancer de testiculo no seminoma estadio I sometidos a linfadenectomia retroperitoneal por via laparoscopica. METODOS Entre marzo de 1993 y enero de 2004, 111 pacientes con diagnostico de cancer de testiculo no seminomatoso estadio I fueron intervenidos quirurgicamente por linfadenectomia retroperitoneal laparoscopica (LRP-L). Todos los procedimientos fueron realizados por el mismo cirujano (O.A.C). Los datos clinicos fueron recolectados de forma prospectiva en una base de datos creada para tal fin. Se analizaron la caracteristicas del grupo de pacientes, tiempo operatorio, sangrado, tiempo de hospitalizacion, complicaciones operatorias y perioperatorias, tasa de conversion a cirugia abierta y seguimiento. RESULTADOS Se realizaron 111 LRP-L en 111 pacientes con edad promedio de 29.3 anos (rango 15-44 anos). 61 procedimientos correspondieron a LRP-L derecha y 50 a LRP-L izquierda. El tiempo operatorio promedio fue de 138 minutos (rango 60-300 minutos). Se presentaron complicaciones intraoperatorias en 10 pacientes (9%), de las cuales, 9 correspondieron a lesiones vasculares (8.1%) y 1 a lesion duodenal (0.9%). Se realizo conversion a cirugia abierta en 3 pacientes (2.7%). El tiempo promedio de hospitalizacion fue de 43.3 horas (rango 24-120). 5 pacientes (4.5%) presentaron recurrencia del tumor, con un seguimiento promedio de 30 meses (rango 24-94 meses). Las recurrencias se ubicaron a nivel retroperitoneal, en mediastino y a nivel pulmonar. El tiempo de recurrencia oscilo entre 4 y 64 meses. CONCLUSIONES La LRP-L ofrece resultados oncologicos equivalentes a los obtenidos con cirugia abierta, con la ventaja de ser minimamente invasiva y consecuentemente disminuir la morbilidad. La linfadenectomia retroperitoneal laparoscopica es una buena alternativa para el manejo de los pacientes con cancer de testiculo en estadio I.

Bilateral simultaneous laparoscopic adrenalectomy for congenital adrenal hyperplasia: Initial experience

OBJECTIVE Congenital adrenal hyperplasia (CAH) is an uncommon syndrome which represents a therapeutic challenge. We analyzed the role of bilateral simultaneous laparoscopic adrenalectomy in the management of CAH. MATERIAL AND METHODS : Between October 2004 and September 2006, three female patients underwent bilateral simultaneous laparoscopic adrenalectomy for CAH. Data were retrospectively collected. Variables analyzed were persistence of CAH clinical signs, variations in 17 OH progesterone level and corticoid medication, operative time, median blood loss, postoperative pain, hospital stay, and body image perception after surgery. RESULTS Median age was 16.3 years. Complete regression of virilization signs, acne and hyperpigmentation was achieved in one case. The other two cases showed partial regression of signs. Levels of 17 OH progesterone reached normal parameters in all cases. Steroids doses were lowered and given only for replacement purposes. Mean operative time was 125, 65 and 60min for whole, right and left procedure, respectively. Median blood loss remained under 50ml in all cases and there were no complications. Median postoperative pain level was 5 according to visual analog pain scale. Median hospital stay was 4 days. CONCLUSION Bilateral simultaneous laparoscopic adrenalectomy shows all the advantages of minimally invasive surgery, and appears a viable alternative to medical management, which is not exempt from complications.

Primary laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ-cell testis tumor

Abstract Introduction This report is intended to retrospectively assess cancer control and morbidity of primary laparoscopic reproperitoneal lymphadenectomy (L-RPLND) in patients with clinical Stage I non seminomatous germ cell tumour (NSGCT). Material and methods One hundred and sixty-four patients with clinical Stage I NSGCT underwent primary diagnostic LRPLND between 1993 and 2006. Patients were operated unilaterally limiting the dissection to templates. Kaplan Meier curves were generated estimating time to recurrence. Results Of the 164 patients, 82 (48%) had embryonal components and 35 (20%) lymphovascular invasion in the orchiectomy specimen. The median (IQR) age, operative time, length of hospital stay, blood loss and number of lymph nodes retrieved was 28 years (24–33), 135 minutes. (120–180), 48 hours (24–48), 50 cc (20–100) and 14 (10–18) nodes, respectively. All patients had negative serum markers preoperatively. Presence of lymph node metastasis was identified in 32 (19.5%) patients. Follow-up was available in 15 of these. Fourteen received adjuvant chemotherapy and 2 of them had recurrence at 3 and 64 months. Absence of lymph node metastasis was diagnosed in 132 (80.5%) patients. Follow-up was available in 80 of these. Among them 7 recurred (5 retroperitoneum, 2 lung), one of them 33 months after L-RPLND. Median follow-up for patients without recurrence was 14 months (IQR:4–35). The cumulative 3-year recurrence free rate was 82% (95%CI: 64–91). Seventeen (10%) of 164 patients had intra or perioperative complications.