Panagiotis Kallidonis

Technique of Laparoscopic-Endoscopic Single-Site Surgery Radical Nephrectomy

BACKGROUND Laparoscopic-endoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. OBJECTIVE To assess the feasibility of LESS radical nephrectomy (LESS-RN). DESIGN, SETTING, AND PARTICIPANTS Ten patients with body mass index (BMI) < or = 30 underwent LESS-RN for renal tumour by two experienced laparoscopists. SURGICAL PROCEDURE TriPort (Olympus Winter & Ibe, Hamburg, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and flexible grasper and scissors was used. A 5-mm 30 degrees camera was also used. The standard laparoscopic transperitoneal nephrectomy technique was performed. MEASUREMENTS Patient demographics, operative details, and final pathology were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. RESULTS AND LIMITATIONS Ten cases were successfully accomplished (two right-sided tumours and eight left-sided tumours; tumour diameter ranges: 4-8 cm). The mean patient age was 63.5 yr (22-77 yr), and median BMI was 23.56 (18.2-26.6). The mean operative time was 146.4 min (120-180 min), and the mean blood loss was 202 ml (50-900 ml). Pathological examination observed organ-confined T1 renal cell carcinoma in nine cases and pT3b tumour in one case. One bleeding complication occurred. Limitations regarding the intraoperative instrument ergonomics and the requirement for ambidexterity of the surgeon were noted. CONCLUSIONS LESS-RN proved to be safe and feasible. Further clinical investigation in comparison to the established techniques should take place to evaluate the outcome of LESS-RN.

Ureteral Obstruction: Is the Full Metallic Double-Pigtail Stent the Way to Go?

BACKGROUND The Resonance metallic ureteral stent (Cook Medical, Bloomington, Indiana, USA) has been introduced for the management of extrinsic-etiology ureteral obstruction for time periods up to 12 mo. OBJECTIVE The current study aims to determine short- and medium-term effectiveness of the Resonance stent in malignant and benign ureteral obstruction. DESIGN, SETTING, AND PARTICIPANTS In total, 50 patients with extrinsic malignant obstruction (n=25), benign ureteral obstruction (n=18), and previously obstructed mesh metal stents (n=7) were prospectively evaluated. INTERVENTION All patients were treated by Resonance stent insertion. Twenty stents were inserted in antegrade fashion, and the remaining stents were inserted in a retrograde approach. No patient dropped out of the study. The follow-up evaluation included biochemical and imaging modalities. MEASUREMENTS We evaluated the technical success rate, stricture patency rate, complications, and the presence and type of encrustation. RESULTS AND LIMITATIONS The technical success rate of transversal and stenting of the strictures was 100%. In 19 patients, balloon dilatation was performed prior to stenting. The mean follow-up period was 8.5 mo. The stricture patency rate in patients with extrinsic malignant ureteral obstruction was 100% and in patients with benign ureteral obstruction 44%. Failure of Resonance stents in all cases of obstructed metal stents was observed shortly after the procedure (2-12 d). In nine cases, stent exchange was demanding. Encrustation was present in 12 out of 54 stents. CONCLUSIONS The Resonance stent provides safe and sufficient management of malignant extrinsic ureteral obstruction. Resonance stent use in benign disease needs further evaluation, considering the untoward results of the present study.

Endoscopic Extraperitoneal Radical Prostatectomy: Evolution of the Technique and Experience with 2400 Cases

OBJECTIVES We report the outcome of 2400 endoscopic extraperitoneal radical prostatectomy (EERPE) cases performed in three institutions, with emphasis on the evolution of the EERPE technique. METHODS In total, 2400 EERPE procedures were performed in three institutions. Several surgeons performed the operations. The presented cases also include the learning curve of the surgeons. EERPE was performed in all cases of localized prostate cancer with the same indications to open and transperitoneal laparoscopic radical prostatectomy. RESULTS Average patient age was 63.3 years (range 41-81 years), and mean preoperative prostate specific antigen (PSA) level was 9.8 ng/mL (range 0.08-93 ng/mL); 857 (38%) patients had previously undergone abdominal or pelvic surgery, while 143 (5.8%) patients had prior prostatic treatment. Pelvic lymph node dissection took place in 1219 (50.8%) patients. Bilateral nerve sparing was performed in 672 patients and unilateral in 284 patients; 100 patients underwent intraoperative hernia repair with mesh placement (82 unilateral and 18 bilateral). Mean operative time was 150.7 minutes (range 50-340 minutes). Conversion to open surgery was never deemed necessary. Fifteen patients received transfusion (0.7%). The mean catheterization time was 6.19 days (range 3-40 days). Overall, 71.7% and 94.7% of the patients were continent at 3 and 12 months, respectively. Totally, 956 patients were treated with nerve-sparing procedure either interfascial or intrafascial; 672 patients underwent bilateral neurovascular bundle preservation, and 284, unilateral. Younger patients tend to have better postoperative potency. Bilateral nerve-sparing EERPE in patients younger than 55 years results in potency rate of 32.4%, 75.3%, and 84.9% at 3, 6, and 12 months postoperatively. CONCLUSIONS The functional and oncological outcome of EERPE is comparable to other approaches for radical prostatectomy. Continuous refinements contribute to the improving outcome of the procedure. Long-term results especially in terms of oncological efficacy are expected.

Ureteral Metal Stents: 10-Year Experience With Malignant Ureteral Obstruction Treatment

PURPOSE Ureteral patency in malignant ureteral obstruction cases is a therapeutic challenge. We report our long-term experience with palliative treatment for extrinsic malignant ureteral obstruction with percutaneous placement of metal mesh stents. MATERIALS AND METHODS From January 1996 to December 2005, 90 patients with a mean age of 59 years (range 35 to 80) with ureteral obstruction due to extrinsic ureteral compression and/or encasement by primary or metastatic tumors, or retroperitoneal lymphadenopathy underwent implantation of self-expandable metal mesh stents. A total of 119 ureters were managed. Followup included urinalysis, blood biochemistry tests and transabdominal ultrasound or intravenous urography. RESULTS The technical success rate of percutaneous antegrade insertion of ureteral self-expandable metal mesh stents was 100%. Renal biochemistry normalized and hydronephrosis gradually resolved 1 to 2 weeks after stent insertion. Median followup was 15 months (range 8 to 38). Hyperplastic reaction and/or encrustation, or tumor ingrowth developed in 45 stents. Secondary intervention, such as repeat balloon dilation and coaxial stenting, was done to improve patency. Migration was observed in 13 metal stents. The primary and secondary patency rates during followup were 51.2% and 62.1%, respectively. A double pigtail or external-internal stent was inserted in 45 cases in which secondary interventions did not ensure patency. CONCLUSIONS Internal drainage of extrinsic malignant ureteral obstruction with metal mesh stents provides long-term decompression of the upper urinary tract in select cases. Certain problems limit the application of metal mesh stents in the ureter. Further studies are warranted to identify independent predictors of ureteral patency after the application of metal stents for malignant obstruction.

Endoscopic extraperitoneal radical prostatectomy: the University of Leipzig experience of 2000 cases.

INTRODUCTION Review of experience with endoscopic extraperitoneal radical prostatectomy (EERPE) for localized prostate cancer. PATIENTS AND METHODS 2000 patients underwent EERPE. Mean age of the patients was 63.2 (41-77) years. Mean preoperative PSA was 10.2 ng/ml (0.64-82 ng/ml). 601 patients had undergone previous surgery. The functional and oncological outcomes were reviewed. RESULTS Mean operation time was 156 (50-320) min. Complication rate according to Clavien system was: 0.45% intraoperatively, 8.6% in the early and 0.3% in the late postoperative period. Positive surgical margins were found in 127 patients with pT2 stage (9.7%) and in 237 patients with pT3 stage (34.4%). 44/937 lymphadenectomies (4.7%) had positive lymph nodes. Mean catheterization time was 6.3 days. After 12 months, 92% of the patients were completely continent, 7% needed 1-2 pads/day and 1% used more than 2 pads daily.730 patients underwent nerve sparing procedure. The 12 month potency rates with or without administration of PDE 5 inhibitors were 34.1% in the unilateral nerve sparing group and 67.7% in the bilateral group. In the intrafascial nsEERPE group, after 12 months, 93.2% of the patients were completely continent, 7.1% required 1-2 pads per day and 0.6% more than 2 pads per day. Twelve months potency rate for unilateral and bilateral nerve sparing intrafascial procedure was 33.3% and 78.5 % respectively. The rate of positive surgical margins was 6.3% in pT2 and 21.2% in pT3 specimens. DISCUSSION Functional and oncological results of this large series are promising. The recently introduced intrafascial nsEERPE further improves the outcome of the procedure.

Urological laparoendoscopic single site surgery: Multi-institutional analysis of risk factors for conversion and postoperative complications

PURPOSE We analyzed the incidence of and risk factors for complications and conversions in a large contemporary series of patients treated with urological laparoendoscopic single site surgery. MATERIALS AND METHODS The study cohort consisted of consecutive patients treated with laparoendoscopic single site surgery between August 2007 and December 2010 at a total of 21 institutions. A logistic regression model was used to analyze the risks of conversion, and of any grade and only high grade postoperative complications. RESULTS Included in analysis were 1,163 cases. Intraoperatively complications occurred in 3.3% of cases. The overall conversion rate was 19.6% with 14.6%, 4% and 1.1% of procedures converted to reduced port laparoscopy, conventional laparoscopic/robotic surgery and open surgery, respectively. On multivariable analysis the factors significantly associated with the risk of conversion were oncological surgical indication (p=0.02), pelvic surgery (p<0.001), robotic approach (p<0.001), high difficulty score (p=0.004), extended operative time (p=0.03) and an intraoperative complication (p=0.001). A total of 120 postoperative complications occurred in 109 patients (9.4%) with major complications in only 2.4% of the entire cohort. Reconstructive procedure (p=0.03), high difficulty score (p=0.002) and extended operative time (p=0.02) predicted high grade complications. CONCLUSIONS Urological laparoendoscopic single site surgery can be done with a low complication rate, resembling that in laparoscopic series. The conversion rate suggests that early adopters of the technique have adhered to the principles of careful patient selection and safety. Besides facilitating future comparisons across institutions, this analysis can be useful to counsel patients on the current risks of urological laparoendoscopic single site surgery.

Comparative assessment of laparoscopic single-site surgery instruments to conventional laparoscopic in laboratory setting.

INTRODUCTION Laparoendoscopic single-site surgery (LESS) represents the latest innovation in laparoscopic surgery. We compare in dry and animal laboratory the efficacy of recently introduced pre-bent instruments with conventional laparoscopic and flexible instruments in terms of time requirement, maneuverability, and ease of handling. MATERIALS AND METHODS Participants of varying laparoscopic experience were included in the study and divided in groups according to their experience. The participants performed predetermined tasks in dry laboratory using all sets of instruments. An experienced laparoscopic surgeon performed 24 nephrectomies in 12 pigs using all sets of instruments. Single port was used for all instrument sets except for the conventional instruments, which were inserted through three ports. The time required for the performance of dry laboratory tasks and the porcine nephrectomies was recorded. Errors in the performance of dry laboratory tasks of each instrument type were also recorded. RESULTS Pre-bent instruments had a significant advantage over flexible instruments in terms of time requirement to accomplish tasks and procedures as well as maneuverability. Flexible instruments were more time consuming in comparison to the conventional laparoscopic instruments during the performance of the tasks. There were no significant differences in the time required for the accomplishment of dry laboratory tasks or steps of nephrectomy using conventional instruments through appropriate number of ports in comparison to pre-bent instruments through single port. DISCUSSION Pre-bent instruments were less time consuming and with better maneuverability in comparison to flexible instruments in experimental single-port access surgery. Further clinical investigations would elucidate the efficacy of pre-bent instruments.

A Comparison of Outcomes for Interfascial and Intrafascial Nerve-sparing Radical Prostatectomy

OBJECTIVE To compare the outcome of intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE) with interfascial (standard) nsEERPE. METHODS Four-hundred patients underwent nsEERPE; 200 patients underwent bilateral intrafascial nsEERPE (group A) and 200 bilateral standard nsEERPE (group B). Tumor stages of T1 and T2a, prostate-specific antigen level <10 ng/mL, maximal Gleason score 3+4 (not 4+3) and preoperative potency were considered as candidates for nsEERPE. Patients were randomized to the aforementioned groups. Perioperative data, and functional and oncological outcome were reviewed. Patients not requiring any pads or requiring 1 pad for safety were defined as continent. Patients responding positively to sexual encounter profile diary question numbers 2, 3, and 5 were considered as potent. RESULTS Perioperative data were similar between groups. At 3 months, 74% of group A and and 63% of group B were continent. At 6 months, the respective figures were 87.9% and 76.2%, respectively (A, B). At 12 months, 93.2% of group A and 90.7% of group B were continent. Potency rates of group A were 93.5% (<55 years), 83.3% (55-65 years), and 60% (>65 years) at 12 months. The respective figures for Group B were 77.1%, 50%, and 40%. Positive surgical margins were detected in 9% and 9.5% of groups A and B, respectively. CONCLUSIONS Intrafascial nsEERPE provides significantly better potency in patients <55 years of age at 12 months and in patients 55-65 years of age at 6 and 12 months, with probably limited effect on the oncological outcome. Significantly improved continence was observed at 3 and 6 months in favor of intrafascial nsEEPRE.

Fournier’s Gangrene, a Urologic and Surgical Emergency: Presentation of a Multi-Institutional Experience with 45 Cases

Objective: To review multi-institutional, multidisciplinary experience in the management of Fournier’s gangrene (FG) in an attempt to identify etiologic parameters as well as to propose methods of efficient management. Patients and Methods: Retrospective chart review of 45 patients diagnosed with FG and treated in three departments (general surgery and urology departments) was performed. Results: Average patient age was 50 ± 15.8 (range 33–81) years. Five female and 40 male patients. Seven patients deceased due to the disease. In 26 and 6 cases, perianal or ischiorectal abscess was present, respectively. These abscesses were extending up to the level of rectovesical/Douglas pouch in 12 cases. Abscesses in the scrotum and perineum were revealed in 10 and 6 cases, respectively. A fistula to the rectum and 8 sinuses to the skin were observed. Colostomy was performed in 25 cases, diverting cystostomy in 17, and orchidectomy in 12 cases. In 18 patients (40%) repeat debridement was deemed necessary. Three patients required more than 3 debridement procedures. Average hospitalization time was 15.7 ± 11.6 (range 4–40) days. Conclusion: FG is a life-threatening form of necrotizing soft tissue infection. The disease is unpredictable and the currently proposed methods for prognosis are promising but still questionable.

Laparoendoscopic Single-site Partial Nephrectomy: A Multi- institutional Outcome Analysis

BACKGROUND Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the surgical trauma associated with conventional laparoscopy. Partial nephrectomy (PN) represents a challenging indication for LESS. OBJECTIVE To report a large multi-institutional series of LESS-PN and to analyze the predictors of outcomes after LESS-PN. DESIGN, SETTING, AND PARTICIPANTS Consecutive cases of LESS-PN done between November 2007 and March 2012 at 11 participating institutions were included in this retrospective analysis. INTERVENTION Each group performed LESS-PN according to its own protocols, entry criteria, and techniques. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Demographic data, main perioperative outcome parameters, and perioperative complications were gathered and analyzed. A multivariable analysis was used to assess the factors predicting a short (≤ 20 min) warm ischemia time (WIT), the occurrence of postoperative complication of any grade, and a favorable outcome, arbitrarily defined as a combination of the following events: short WIT plus no perioperative complications plus negative surgical margins plus no conversion to open surgery or standard laparoscopy. RESULTS AND LIMITATIONS A total of 190 cases were included in this analysis. Mean renal tumor size was 2.6, and PADUA score 7.2. Median operative time was 170 min, with median estimated blood loss (EBL) of 150 ml. A clampless technique was adopted in 70 cases (36.8%), and the median WIT was 16.5 min. PADUA score independently predicted length of WIT (low vs high score: odds ratio [OR]: 5.11 [95% confidence interval (CI), 1.50-17.41]; p=0.009; intermediate vs high score: OR: 5.13 [95% CI, 1.56-16.88]; p=0.007). The overall postoperative complication rate was 14.7%. The adoption of a robotic LESS technique versus conventional LESS (OR: 20.92 [95% CI, 2.66-164.64]; p=0.003) and the occurrence of lower (≤ 250 ml) EBL (OR: 3.60 [95% CI, 1.35-9.56]; p=0.010) were found to be independent predictors of no postoperative complications of any grade. A favorable outcome was obtained in 83 cases (43.68%). On multivariate analysis, the only predictive factor of a favorable outcome was the PADUA score (low vs high score: OR: 4.99 [95% CI, 1.98-12.59]; p<0.001). Limitations of the study were the retrospective design and different selection criteria for the participating centers. CONCLUSIONS LESS-PN can be safely and effectively performed by experienced hands, given a high likelihood of a single additional port. Anatomic tumor characteristics as determined by the PADUA score are independent predictors of a favorable surgical outcome. Thus patients presenting tumors with low PADUA scores represent the best candidates for LESS-PN. The application of a robotic platform is likely to reduce the overall risk of postoperative complications.