Pierre Plante

Multi-institutional study of complications in 1085 laparoscopic urologic procedures

OBJECTIVES To assess the incidence of the complications in laparoscopic urologic procedures with regard to clinical presentation, etiology, and treatment. METHODS From January 1994 to December 2000, 1085 laparoscopic procedures were performed at three institutions in 1075 patients (702 men, 373 women). A referent surgeon for laparoscopy was at each institution. The major procedures were radical prostatectomy (n = 232), different types of nephrectomy (n = 171) and nephroureterectomy (n = 15), adrenalectomy (n = 130), pyeloplasty (n = 61), pelvic lymph node dissection (n = 130), genitourinary prolapse repair (n = 86), bladder neck suspension (n = 104), and treatment of benign kidney pathologic findings (lithiasis, cysts, and diverticula, n = 55). The complications were listed by incidence and etiology according to the procedure attempted. RESULTS A total of 75 complications (6.9%) occurred in this multi-institutional series. The mortality rate was 0.09%, and the conversion rate was 2.1%. Vascular (n = 7) and visceral injuries (n = 11) occurred in 24% of complications. Hematomas (n = 10), urinomas (n = 8), and wound infections (n = 7) at the trocar sites were the most frequent postoperative surgical complications. Pulmonary disorders (n = 9) and urinary infections (n = 9) were predominant in the postoperative medical problems. CONCLUSIONS Even though it appears to be minimally invasive, laparoscopy remains major surgery, with serious complications possible. These complications should be preventable with better mastery of the different steps of the procedures. Increased knowledge of the possible complications is essential for urologists in laparoscopic training and may help them improve their learning curve.

Radical cystectomy in patients older than 75 years: assessment of morbidity and mortality.

Objective: We have reviewed our surgical experience to assess intra– and postoperative morbidity and mortality in 25 patients 75 years old or older with invasive bladder cancer who underwent radical cystectomy and urinary diversion or bladder substitution. Methods: Between January 1993 and February 1999, of 190 patients who underwent radical cystectomy, 23 men and 2 women were aged from 75 to 87 (median 79) years. Urinary diversion was performed in 23 cases and bladder substitution in 2. All patients had significant comorbidity and 15 patients were ASA II and 10 ASA III. Results: Median operating time was 4 h. Perioperative mortality rate was 4%. Intraoperative, early and late postoperative complications occurred in 15, 16 and 6 patients, respectively. The most common early complications were pyelonephritis (32%), disorientation (20%), additional pulmonary infection (20%) and prolonged ileus (32%). No secondary procedures were necessary. The most common late complication was ureteroileal anastomotic stricture (16%). The median hospital stay and intensive care unit stay were 24 and 14 days, respectively. With a median follow–up of 14 (5–50) months the overall mortality rate was 32%. Conclusions: Radical cystectomy can be performed in elderly patients with acceptable perioperative mortality and morbidity. However, because of the high incidence of minor medical complications, hospital stay is often prolonged.

Retroperitoneal laparoscopic adrenalectomy: clinical experience in 52 procedures

OBJECTIVES Laparoscopic adrenalectomy has become an effective option for removal of small adrenal tumors. The aim of this prospective study was to evaluate the retroperitoneal approach with regard to intraoperative complications, morbidity, and length of hospital stay. METHODS Between September 1996 and October 1999, we performed 52 laparoscopic adrenalectomies (31 left, 21 right) for benign lesions by a retroperitoneal approach in 44 patients (27 women, 17 men) with a mean age of 46.9 years (range 17 to 74). The average adrenal tumor size was 32 mm (range 10 to 63). All procedures required four trocars and a mean operative time of 135 minutes (range 75 to 240). RESULTS There was no mortality, conversion rate to open surgery was 1.9%, and estimated blood loss was 80 mL (range 30 to 200). With a mean follow-up of 16 months, morbidity was 17.2%, which included intraoperative complications (5. 7%) with two vascular injuries, and postoperative complications (11. 5%) with wound infections, deep hematoma, and parietal dehiscence. Average length of hospital stay was 5 days with a mean analgesic consumption of 2 days (range 1 to 5). CONCLUSIONS The retroperitoneal approach in laparoscopic adrenalectomy appears to be a minimally invasive and safe therapeutic option that may become the standard for unilateral or bilateral adrenal tumors not larger than 7 cm. However, a learning curve in laparoscopy is indispensable before starting this type of procedure.

Second non-germ cell malignancies in patients treated for stage I-II testicular seminoma.

PURPOSE To measure the incidence of second non-germ cell malignancies (SNGCM) in patients treated for a stage I-II testicular seminoma. MATERIALS AND METHODS From 1970 to 1992, 131 evaluable patients received in the Institut Claudius Regaud a post-orchiectomy treatment for a stage I-II testicular seminoma. The therapeutic modalities, including salvage treatment for six recurrences, were as follows: infradiaphragmatic radiotherapy (IDRT) (n = 55); infra- and supradiaphragmatic radiotherapy (IDRT + SDRT) (n = 64); IDRT + SDRT with chemotherapy (n = 12). The mean follow-up was 11 years. The cumulative incidence of SNGCM was compared to the overall cancer incidence in the general male population on the basis of the Tarn Cancer Registry; the relative risk was expressed as a standardized incidence ratio (SIR). RESULTS Overall, the cumulative incidence of SNGCM was 10.7% (14/131 cases). The SIR was equal to 2.81 (95% confidence interval (CI) 1.54-4.72; P < 0.001) and increased with follow-up duration. The SIR was significantly increased in 64 patients treated with IDRT + SDRT (SIR = 3.08; 95% CI 1.47-5.66; P = 0.002) but not in 55 patients treated with IDRT alone (SIR = 0.62; 95% CI 0.01-3.43; P = 0.8). The 12 patients who received chemotherapy had an SIR of 26.2 (95% CI 5.48-77.69; P < 0.001), while the SIR was 2.26 in the 119 patients who did not receive any chemotherapy (95% CI 1.13-4.04; P = 0.01 ). Of four hematologic malignancies, three appeared in the 12 patients who received chemotherapy. CONCLUSIONS An increased risk of SNGCM after SDRT + IDRT has been demonstrated. After IDRT alone, the risk of second cancer is not incremented after a median follow-up of 6 years, but further observation of the patients is necessary to achieve final conclusions. Our results suggest that the risk of second cancer and especially of hematologic malignancy is increased by the association of chemotherapy and radiation.

Assessment of morbidity and functional results in bladder replacement with Hautmann ileal neobladder after radical cystectomy: a clinical experience in 55 highly selected patients

OBJECTIVES To analyze the morbidity and functional results of the ileal neobladder in a series of 55 highly selected patients. The ileal neobladder is a commonly used technique for orthotopic bladder reconstruction after radical cystectomy in both sexes. Good results have been published from Ulm University, where the technique was popularized. METHODS From February 1994 to June 2000, 55 patients (47 men and 8 women), 32 to 75 years old (mean age 58) with good performance status (American Society of Anesthesiologists score 1 and 2), underwent radical cystectomy for bladder cancer and Hautmann ileal neobladder reconstruction. Functional assessments were done at 3 months and every 6 months thereafter, with special attention to urinary continence and upper urinary tract status. RESULTS The median follow-up was 28.8 months (range 8 to 96). One perioperative death occurred. Early complications occurred in 23.6% without repeated surgery and late complications occurred in 25.4%, with three repeated operations for occlusive syndromes. The daytime and nighttime continence rates at 3, 6, and 12 months were 59.6%, 80.8%, and 88.5% and 38.5%, 61.5%, and 78.8%, respectively. The overall continence rate in patients younger than 70 years old was 80.8%. Three patients required self-catheterization to empty their neobladder. Eleven patients died of metastatic evolution of their bladder cancer or intercurrent disease at 6 to 36 months. CONCLUSIONS In highly selected patients, the ileal neobladder provides good functional results regarding continence with an acceptable complication rate. In this series, the results were comparable to those reported in the referent institution.

Role of Preoperative Positive Apical Biopsies in the Prediction of Specimen–Confined Prostate Cancer after Radical Retropubic Prostatectomy: A Multi–Institutional Study

Objectives: A multi–institutional study of 280 radical prostatectomy specimens obtained from three independent academic hospitals was undertaken to validate a nomogram developed for the prediction of specimenconfined protstate cancer after prostatectomy. Methods: Three preoperative factors – the Gleason score, prostatespecific antigen (PSA) and apical location of positive biopsies – that were identified with a previous logistic regression formula were collected. Links between margin status and preoperative criteria were confirmed by univariate methods. Subsequently, the predictive indexes of positive margins were calculated and compared to the actual margin status in terms of predictive characteristics. Results: This control series, independent of the initial series that was used to identify the relevant preoperative factors, confirmed that positive apical biopsies(p<0.001), PSA (p<0.005) and the Gleason score (p<0.005) were strongly linked to the occurrence of positive margins. Different cutoff values for the predictive index were compared in a receiver operating characteristic curve. A value of 0.5, similar to the one described in the original series, gave an adequate compromise between sensitivity and specificity with respective values of 68 and 73% and a test accuracy of 72%. In practical terms, it was possible to predict 85% of negative margins, and to delineate two groups with different rates of positive margins (14.5 vs. 50%). Conclusions: We demonstrated that PSA, the Gleason score and apical biopsy status are cumulative risk factors for positive margins. Risk of positive margins increases when it is not possible to obtain a wide excision of periprostatic fascia, as at the apex. This study substantiates the independent prognostic value of positive preoperative apical biopsies for predicting positive surgical margins.

Retroperitoneoscopic Adrenalectomy: Comparison of Retrograde and Antegrade Approach Among a Series of 279 Cases

OBJECTIVE To compare the results of retroperitoneal laparoscopic adrenalectomy using the antegrade and retrograde approach. MATERIALS AND METHODS We performed an analysis of a single-center series of 279 retroperitoneal laparoscopic adrenalectomies from 1996 to 2010. We compared 172 cases performed with an antegrade approach and 107 with a retrograde approach without dissection of the renal hilum and initial control of the adrenal vein in comparable populations. RESULTS The operative time was shorter in the group treated with the retrograde technique, 101±51 vs 140±40 minutes, respectively (Students t test, P<.001). Blood loss was similar in both groups, 85±224 vs 80±126 mL, respectively (P=NS). Hemodynamic instability was defined as the maximal systolic blood pressure minus the minimal systolic blood pressure divided the maximal systolic blood pressure. It was lower in the group who underwent the retrograde technique (32.7 vs 37.6 mL; Students t test, P=.005) with a lower perioperative consumption of ephedrine (2.2 vs 5.1 mg, P=.004) and atropine (0.09 vs 0.22 mg, P=.026). No difference was found between the 2 groups in the frequency of perioperative complications or postoperative mortality (1 death in each group of causes unrelated to the surgery). CONCLUSION Retroperitoneal laparoscopic adrenalectomy using a retrograde approach is a safe and reproducible technique. It makes it possible to perform adrenalectomy without dissection of the renal hilum, with a reduction in the operative time. The good hemodynamic stability observed with this technique makes it very attractive for the treatment of pheochromocytoma.

Cancer de la prostate de stade pT3 après prostatectomie totale : étude rétrospective de 246 cas

OBJECTIVE To determine the survival and prognosis criteria of pT3NxM0 prostate tumours (TNM 2002) after radical retropubic prostatectomy (RRP). MATERIAL AND METHODS Between 1988 and 2000, 606 consecutive RRP were performed for T1-3 tumours, whose 246 (40.6%) specimens were classified pT3, followed in 53 cases by adjuvant radiotherapy and in 71 cases by salvage radiotherapy. Fifty-five patients received postoperative hormonotherapy at the time of biochemical recurrence. Biochemical recurrence was determined by two PSA values greater than 0.2 ng/ml. RESULTS Mean age of this group was 65 years at surgery. Mean follow-up was 91.4 months. Mean preoperative PSA was 12.8 ng/ml. Distribution of cases was 170 pT3a (69.1%) and 76 (30,9%). At 10 years, the biochemical progression-free, metastasis-free, specific and overall survival was 54, 86, 92 and 75% respectively. Worse biochemical prognostic factors were lymph node extension, high Gleason score, high preoperative PSA, seminal vesicles involvement, positive surgical margins and adjuvant radiotherapy absence. CONCLUSION This study shows that pT3 tumours treated with therapeutic associations including RRP presents an excellent specific survival at 10 years. The determination of biochemical recurrence prognostic factors could help to select patients who need complementary treatments after surgery.

Prise en charge du tératome pur testiculaire postpubertaire à propos d’une série multicentrique sur 15 ans☆

OBJECTIVE To analyze cases of pure teratoma of the testis (PTT) of a large population-based study, as such tumors are rare, and to make an update on the topic. PATIENTS AND METHODS We retrospectively reviewed the records of patients treated for PTT from 1987 to 2003 in the French Midi-Pyrenees region (southwestern France) and in the Val-de-Grâce military hospital, Paris. Among more than 1000 cases of testis cancer, we identified 20 cases of PTT (4% of the whole population). For each patient, the orchiectomy specimen was reviewed and a clinical and imaging re-evaluation was performed. RESULTS The pathological re-evaluation revealed non-teratomatous components in three patients (excluded from a following analysis). For the localized PTT patients, four out of eight out of 8 were on surveillance only after the orchiectomy, and the remaining four received adjuvant chemotherapy. None of them received any lymphadenectomy for staging. All patients with the metastatic disease were treated by chemotherapy followed by surgical removal of residual tumor masses. With a mean of 125 months follow-up, 85% of the population did not relapse after treatment. At the last contact, all were alive, without the disease. CONCLUSION We confirm that PTT is a malignant disease with a good prognosis. As its management differs from the other non-seminomatous germ cell tumors, the diagnosis of PTT must be with certainty. The retrospective analysis of a series over two decades highlights the deviations from current guidelines. We propose that this rare tumor of young man should be treated in specialized centers to get the optimal management.

Fertilité après cancer du testicule

ResumeObjectifsEtudier la fertilité des patients atteins de cancer du testicule et analyser les facteurs prédictifs de la fertilité après traitements anti-cancéreux.Population et methodela série consécutive des 293 hommes suivis au CECOS Midi-Pyrénées entre 1978 et 1998 pour une tumeur germinale du testicule ont fait l’objet d’une analyse rétrospective à partir de leurs dossiers chirurgicaux, oncologiques et andrologiques, et ont été explorés du point de vue de la fertilité grâce à un questionnaire par courrier. Deux relances par courrier ont été réalisées, suivies d’un entretien téléphonique. Le taux de participation a été de 92%.ResultatsLa fertilité après traitement de 277 hommes était connue: 138 d’entre eux avaient cherché à avoir une grossesse. 91 (66%) ont eu une grossesse naturellement et 47 (34%) n’y sont pas parvenu.Les facteurs de mauvais pronostiques de la fertilité après traitement étaient: avoir un âge supérieur à 25 ans (p<0.004), un antécédent de cryptorchidie (p<0.01), une concentration de spermatozoïdes par ml avant traitement inférieure à 10 millions (p<0.0001). Par contre il n’existait aucune relation significative entre la fertilité et le fait d’être traité par chimiothérapie (p<0.6), ou radiothérapie (p<0.6).ConclusionLa population des hommes traités pour un cancer du testicule est à risque d’infertilité. Le fait d’être traité par radiothérapie ou chimiothérapie ne modifie pas la fertilité. Les facteurs prédictifs de la fertilité après traitement sont préexistants aux traitements.AbstractObjectivesTo study the fertility of patients treated for testicular cancer and to identify predictive factors of infertility after treatment.Material and Methods314 men with germ cell tumor, followed by the CECOS Midi-Pyrénées center between 1978 and 1998, were included in the study. They were evaluated retrospectively and interviewed by a mailed questionnaire concerning their reproductive history. If they failed to respond to the questionnaire, they were contacted twice by mail, and once by telephone. The response rate was 92%.ResultsThe reproductive history of 277 men was known: 138 men had tried to have a child. 91 (66%) succeeded and 47 (34%) failed to achieve a “spontaneous” pregnancy. Age greater than 25 (p<0.004), a history of undescended testis, and a sperm count lower than 10 million per ml were inversely correlated with fertility (p<0.004, p<0.01, p<0.0001, respectively). However, no relationship was found between radiotherapy or chemotherapy and fertility after treatment.ConclusionMen treated for testicular cancer are at high risk of infertility. We identified various prognostic factors for fertility after treatment for testicular cancer: radiotherapy and chemotherapy had no significant effect on fertility.