Raul O. Parra

Laparoscopic cystectomy : initial report on a new treatment for the retained bladder

The retained bladder of a 27-year-old paraplegic woman suffering from recurrent pyocystis was removed laparoscopically. Operative time was 130 minutes. Postoperative hospital stay was 5 days, which was significantly less than that in 5 similar patients undergoing open cystectomy for vesical empyema in whom the mean hospital stay was 20.6 days. We believe that laparoscopic cystectomy represents a plausible, minimally invasive alternative to standard cystectomy for the symptomatic bladder left behind after supravesical urinary diversion.

Staging Laparoscopic Pelvic Lymph Node Dissection: Comparison of Results with Open Pelvic Lymphadenectomy

A total of 24 men scheduled for radical prostatectomy was alternately designated to undergo either a modified open (12 men) or laparoscopic (12 men) lymphadenectomy. Both groups were similar in regard to age and clinical stage. Tumor grade and serum prostate specific antigen level for each group are reported. Nodal metastases were found in 1 patient in the open and 3 in the endoscopic group. The average total number of lymph nodes retrieved by open dissection was 11 +/- 5.7, which was not statistically different from the average number of 10.7 +/- 5.7 obtained laparoscopically. No statistically significant variance in the number of nodes harvested in regard to site of dissection was observed. In the 9 men who underwent radical prostatectomy after laparoscopic dissection no additional lymphatic tissue was obtained from the surgical margins. No morbidity related to either procedure occurred. The data suggest that laparoscopic pelvic lymphadenectomy offers a reliable and minimally invasive alternative to open node dissection in selected patients.

Laparoscopic Varicocelectomy: Preliminary Report of a New Technique

The use of varicocelectomy for the treatment of subfertility seems to be incontrovertible. However, there is a difference of opinion as to the proper surgical method of varicocele ablation. The inguinal and high retroperitoneal approaches are the most commonly accepted methods to date. However, significant postoperative morbidity is common and return to normal activity often is prolonged. Also, bilateral operations are being performed more commonly. These considerations have prompted many to search for alternative techniques. We developed a laparoscopic procedure that is as simple and effective as more traditional methods. In addition, it offers lower morbidity, allows for microscopic dissection with preservation of the spermatic artery and is amenable to bilateral ligation without a second incision. Ten patients 16 to 54 years old underwent laparoscopic ligation of the spermatic veins at the internal inguinal ring. The diagnosis was based on physical examination. Indications for the operation were infertility with a stress sperm pattern in 5 patients, testicular atrophy in 4 and scrotal pain in 1. Four patients underwent bilateral ligation. Preliminary followup showed resolution of the varicocele in all patients and disappearance of pain in the patient treated for this symptom. No morbidity related to this procedure has been encountered and all patients resumed normal activity within 2 days. We believe that this new method is a viable alternative for varicocelectomy.

Incidence and severity of sexual adverse experiences in finasteride and placebo-treated men with benign prostatic hyperplasia.

OBJECTIVES To evaluate the incidence and resolution of sexual adverse experiences (AEs) in men with benign prostatic hyperplasia treated with finasteride 5 mg compared with placebo. METHODS The Proscar Long-term Efficacy and Safety Study (PLESS) was a 4-year, randomized, double-blind, placebo-controlled trial assessing the efficacy and safety of finasteride 5 mg in 3040 men, aged 45 to 78 years, with symptomatic benign prostatic hyperplasia, enlarged prostates, and no evidence of prostate cancer. Patients completed a questionnaire at screening regarding their history of sexual dysfunction. During treatment, spontaneously self-reported sexual AEs were recorded. RESULTS At screening, 46% of patients in each treatment group reported some history of sexual dysfunction. During year 1 of the study, 15% of finasteride-treated patients and 7% of placebo-treated patients had sexual AEs that were considered drug related by the investigator (P <0.001). During years 2 to 4, no between-group difference was noted in the incidence of new sexual AEs (7% in each group). The drug-related sexual AE profile for finasteride was similar for men with or without a history of sexual dysfunction. Sexual AEs resolved while continuing therapy in 12% of finasteride patients and 19% of placebo patients. Only 4% of finasteride and 2% of placebo patients discontinued the study because of sexual AEs. In men who discontinued with a sexual AE, 50% and 41% experienced resolution of their sexual AE after discontinuing finasteride or placebo therapy, respectively. CONCLUSIONS Compared with placebo, men treated with finasteride experienced new drug-related sexual AEs with an increased incidence only during the first year of therapy.

Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery

OBJECTIVES Laparoscopy may be complicated by neuromuscular injuries, both to the patient and to the surgeon. We used a survey to estimate the incidence of these injuries during urologic laparoscopic surgery, to assess risk factors for these injuries, and to determine preventive measures. METHODS A survey of neuromuscular injuries associated with laparoscopy submitted to 18 institutions in the United States was completed by 18 attending urologists from 15 institutions. RESULTS From among a total of 1651 procedures, there were 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2). Neuromuscular injuries were twice as common with upper retroperitoneal as with pelvic laparoscopy (3. 1% versus 1.5%). Among patients with neuromuscular injuries, those with rhabdomyolysis were heavier (means 91 versus 80 kg) and underwent longer procedures (means 379 versus 300 minutes), and those with motor deficits were older (means 51 versus 42 years of age). Of the surgeons, 28% and 17% reported frequent neck and shoulder pain, respectively. CONCLUSIONS Although not common, neuromuscular injuries during laparoscopy do contribute to morbidity. Abdominal wall neuralgias, injuries to peripheral nerves, and joint or back injuries likely occur no more frequently than during open surgery, but risk of rhabdomyolysis may be increased. Positioning in a partial rather than full flank position may reduce the incidence of some injuries. Measures to reduce neuromuscular strain on the surgeon during laparoscopy should be considered.

Does long-term finasteride therapy affect the histologic features of benign prostatic tissue and prostate cancer on needle biopsy?

Abstract Objectives. Finasteride, a common agent used to treat benign prostatic hyperplasia (BPH), inhibits 5-alpha-reductase. Testosterone is converted by 5-alpha-reductase to the more potent dihydrotestosterone, which is the primary androgen in the prostate. Leuprolide is a stronger antiandrogen that is used to downstage prostate cancer before radical prostatectomy. Leuprolide induces marked atrophy of prostate carcinoma cells, which sometimes makes pathologic diagnosis of cancer difficult, although evaluation at radical prostatectomy is easier than at biopsy. It is unknown whether finasteride produces similar changes, which would result in greater diagnostic difficulty because such changes would be seen on biopsy to rule out cancer in men with suspicious clinical findings treated for BPH. The current study investigated the histologic effects of finasteride therapy on human prostate cancer and benign prostatic tissue on needle biopsy. Methods. In blinded manner, we reviewed 53 needle biopsy specimens showing prostate carcinoma (35 treated with finasteride, 18 with placebo). Also reviewed in blinded manner were 50 benign needle biopsy specimens (25 treated with finasteride, 25 with placebo). The Gleason score, number of cores involved, percentage cancer involvement in a core, percentage of atrophic changes in cancer cells, presence of mitoses, blue-tinged mucinous secretions, prominent nucleoli, and high-grade prostatic intraepithelial neoplasia were documented for each case in the cancer group. The percentage of atrophy, basal cell hyperplasia, transitional metaplasia, chronic inflammation, and stromal proliferation was documented for each case in the benign group. Results. No significant histologic differences were present in either the benign or cancer group between cases treated with finasteride and placebo. Conclusions. We conclude that finasteride treatment for BPH does not cause difficulty in the diagnosis of cancer in prostate needle specimens. It is possible that there are severely atrophic areas resulting from finasteride treatment that are undersampled. However, the conclusion that cancer seen on needle biopsy in men treated with finasteride is unaltered and readily identified as cancer remains valid.

Laparoscopic Diverticulectomy: Preliminary Report of a New Approach for the Treatment of Bladder Diverticulum

Laparoscopic techniques have expanded the possibilities of endo-surgically approaching urological abnormalities that would otherwise be managed via an open operation. We report on another useful application of the laparoscope, bladder diverticulectomy. A large bladder diverticulum, responsible for incomplete bladder emptying and recurrent urinary tract infections in an 87-year-old man, was successfully excised endoscopically. The technique and possible future indications are described.

COMPARISON BETWEEN STANDARD FLANK VERSUS LAPAROSCOPIC NEPHRECTOMY FOR BENIGN RENAL DISEASE

To evaluate the role of laparoscopic nephrectomy in the management of benign renal diseases, 12 patients undergoing laparoscopic nephrectomy were compared to 13 undergoing a classical flank nephrectomy. Both groups were similar in regard to patient age and indications for surgery. The underlying pathological conditions included vesicoureteral reflux, tuberculosis, hydronephrosis, hypertension and failed pyeloplasty. Overall, operative time ranged from 105 to 360 minutes (mean 145) for the laparoscopic group and 60 to 240 minutes (mean 156.6) for the open surgery group. Hospital stay and interval to return to regular preoperative activities were 2 to 6 days (mean 3.5) and 10 to 21 days (mean 16) for patients undergoing laparoscopic nephrectomy, which was significantly shorter than for those undergoing a flank procedure, 3 to 16 days (mean 8) and 35 to 84 days (mean 32.3), respectively. Pain medication requirements were also markedly decreased after laparoscopic nephrectomy. Of the patients in the laparoscopic group 2 experienced complications with only 1 requiring conversion to open nephrectomy. The laparoscopic technique is an effective as the flank approach for benign renal conditions, while providing a more rapid recuperation and superior cosmetic result.

Transurethral Collagen Injections in the Therapy of Post-Radical Prostatectomy Stress Incontinence

PURPOSE We report on our initial results with glutaraldehyde cross-linked collagen used as an injectable bulking agent for the therapy of post-radical prostatectomy stress incontinence. MATERIALS AND METHODS A total of 19 men underwent collagen injection for treatment of post-radical prostatectomy stress incontinence. RESULTS Of the 19 patients treated 11 had either a good (4) or improved (7) result, for an overall satisfaction rate of 58% with a followup of 3 to 15 months (mean 10.4). Failure correlated with presence of bladder neck contracture or scarring and severity of incontinence. CONCLUSIONS Injection of collagen for stress incontinence after radical prostatectomy has an acceptable short-term success rate, particularly in men with milder incontinence and lack of bladder neck scarring.

Leak Point Pressures in Women With Urinary Stress Incontinence: Correlation With Patient History

PURPOSE We examined the relationship between historical factors in women with urinary stress incontinence and the Valsalva leak point pressure. MATERIALS AND METHODS Valsalva leak point pressure measurements in 57 women with urinary stress incontinence were compared to findings in the history. RESULTS Valsalva leak point pressure was low in 83% of women with severe leakage and previous surgery. Interestingly, 47% of patients without predisposing factors had low Valsalva leak point pressures. CONCLUSIONS Women with severe leakage and previous bladder neck surgery are likely to have urethral dysfunction as demonstrated by Valsalva leak point pressure testing. A significant incidence of low Valsalva leak point pressures in patients without predisposing factors could account for many failures of routine suspension procedures.