Roberto Vaz Juliano

Can video endoscopic inguinal lymphadenectomy achieve a lower morbidity than open lymph node dissection in penile cancer patients

BACKGROUND AND PURPOSE Radical lymphadenectomy improves survival in penile cancer patients, but the morbidity of the classic open procedure exceeds 50%. We report the updated results of Video Endoscopic Inguinal Lymphadenectomy (VEIL), an original minimally invasive procedure recently reported for extended inguinal node dissection in clinical settings. PATIENTS AND METHODS Fifteen consecutive patients who underwent the VEIL technique were prospectively followed and included in this study. The first 10 patients underwent bilateral inguinal dissection for nonpalpable lymph nodes: VEIL at one side and standard open lymph node dissection at the other side. A second cohort consisted of five patients who underwent bilateral VEIL, either for nonpalpable or for palpable (N1) inguinal nodes. Operative data and postoperative outcomes were assessed, and VEIL and the open technique were compared. RESULTS Twenty limbs underwent VEIL and 10 limbs underwent the open procedure. Mean operative time was 120 minutes for VEIL and 92 minutes for the open procedure. There was no difference in the number of nodes removed or in the positivity for metastatic lymph nodes. Complications were observed in 70% of limbs that underwent open surgery and in 20% of limbs that underwent VEIL (P 0.015). Patients who underwent a bilateral VEIL could be discharged from the hospital after an average of 24 hours (range 12-36 hrs), while patients who underwent an open dissection in addition to contralateral VEIL were discharged after an average of 6.4 days (range 5-10 d) There were no recurrences detected during a mean follow-up of 31.9 months (median 33 months). CONCLUSION This preliminary series suggests that VEIL can reduce morbidity, including hospitalization times,compared with standard open surgery. Oncologic results are premature but seem similar to the results from the conventional open operation. VEIL is a promising minimally invasive approach for radical inguinal dissection in penile cancer patients with nonpalpable or low-volume palpable inguinal disease.

Video endoscopic inguinal lymphadenectomy (VEIL): minimally invasive resection of inguinal lymph nodes

OBJECTIVES Describe and illustrate a new minimally invasive approach for the radical resection of inguinal lymph nodes. SURGICAL TECHNIQUE From the experience acquired in 7 operated cases, the video endoscopic inguinal lymphadenectomy (VEIL) technique was standardized in the following surgical steps: 1) Positioning of the inferior member extended in abduction, 2) Introduction of 3 work ports distal to the femoral triangle, 3) Expansion of the working space with gas, 4) Retrograde separation of the skin flap with a harmonic scalpel, 5) Identification and dissection of the long saphenous vein until the oval fossa, 6) Identification of the femoral artery, 7) Distal ligature of the lymph node block at the femoral triangle vertex, 8) Liberation of the lymph node tissue up to the great vessels above the femoral floor, 9) Distal ligature of the long saphenous vein, 10) Control of the saphenofemoral junction, 11) Final liberation of the surgical specimen and endoscopic view showing that all the tissue of the region was resected, 12) Removal of the surgical specimen through the initial orifice, 13) Vacuum drainage and synthesis of the incisions. COMMENTS The VEIL technique is feasible and allows the radical removal of inguinal lymph nodes in the same limits of conventional surgery dissection. The main anatomic repairs of open surgery can be identified by the endoscopic view, confirming the complete removal of the lymphatic tissue within the pre-established limits. Preliminary results suggest that this technique can potentially reduce surgical morbidity. Oncologic follow-up is yet premature to demonstrate equivalence on the oncologic point of view.

Video endoscopic inguinal lymphadenectomy (VEIL): Initial case report and comparison with open radical procedure

OBJECTIVES Inguinal metastases are one of the major determinants of mortality in patients with penile cancer. In high risk patients, while prophylatic inguinal lymphadenectomy may offer survival advantages, it still carries a relatively high morbidity. We describe in this paper the first report of the Video Endoscopic Inguinal Lymphadenectomy (VEIL) in the clinical practice, a technique which aims at reducing the morbidity of the procedure without compromising the cancer control or reducing the template of the dissection. METHODS A 40 year old male with a pT2 penile cancer underwent prophylatic bilateral inguinal lymphadenectomy 6 weeks after partial penectomy. We performed the VEIL technique at the right and a standard radical inguinal lymphadenectomy through an inguinal incision at the left (control). After developing a plane deep to Scarpas fascia, locating 3 ports and infusing gas at 5-10 mmHg, a retrograde dissection with the same limits as the standard open surgery was performed. Intraoperative data, patology, post operatory evolution and oncological follow-up is described for both sides. RESULTS Operative time was 130 min for the VEIL and 90 min for open surgery. Eight and 7 lymphnodes were retrieved at the VEIL side and open side, respectively, and none of then showed positivity at pathology. There were no complications in the limb which underwent the VEIL and there was skin necrosis in the side of the open surgery. After 25 months of follow up, no signs of disease progression were noted. Asked about how he felt about both surgeries, the patient chose the endoscopic approach. CONCLUSION VEIL is feasible in clinical practice. New studies with a greater number of patients and long-term follow-up may confirm the oncological efficacy and possible lower morbidity of these new approach.

Laparoscopic surgery for treatment of incisional lumbar hernia.

OBJECTIVE To present results obtained with laparoscopic correction of incisional lumbar hernia in patients with minimum follow-up of 1 year. MATERIALS AND METHODS We prospectively studied 7 patients diagnosed with incisional lumbar hernia after physical examination and computerized tomography. We used laparoscopic transperitoneal access through 3 ports. One polypropylene mesh was introduced in the abdominal cavity and fixed by titanium clamps to the margins of the hernia ring following release of the peritoneum. RESULTS All cases were successfully completed with no conversion required. Mean surgical time was 120 minutes and discharge from hospital occurred between the 1st and the 2nd postoperative days. There were no intraoperative complications or hernia recurrence in any case. Postoperatively, we had 2 minor complications: one case of seroma that resolved spontaneously after 60 days and one patient presenting lumbar pain that persisted until the 3rd postoperative month. The return to usual activities occurred on average 3 weeks following intervention. Of the 7 patients, 6 were satisfied with the esthetical and functional effect produced by the procedure. CONCLUSIONS The surgical correction of incisional lumbar hernia by laparoscopic access is an excellent option for a minimally invasive treatment, with adequate long-term results.

Laparoscopic nephrectomy in inflammatory renal disease: proposal for a staged approach

INTRODUCTION The present study shows and discusses the preliminary experience of customized and staged approach in the minimally invasive treatment of inflammatory renal diseases, using either pure laparoscopic surgery or the hand-assisted technique. MATERIALS AND METHODS We prospectively assessed 17 patients with inflammatory renal diseases operated by laparoscopic approach. Mean age was 41 years and the surgical indication was repeated pyelonephritis in 8 cases, pyonephrosis in 4 cases and renal exclusion due to staghorn stone in 5 cases. The staged laparoscopic approach was chosen based on kidney size and on the presence or not of tomographic findings showing significant perirenal infiltration. Thus, retroperitoneal access was chosen in cases where the kidney was smaller than 12 cm or in the absence of signs of significant perirenal infiltration on the computerized tomography. For the remainder, transperitoneal access was employed. RESULTS Of the 17 patients, 11 underwent laparoscopic nephrectomy by retroperitoneal access, and all cases were successful. Mean surgical time was 160 minutes. In 6 cases where the nephrectomy was performed by laparoscopic transperitoneal access, the use of hand assistance was required. Four surgeries were successfully completed with mean time of 190 minutes and 2 were converted to open surgery with mean time of 220 minutes. CONCLUSION The laparoscopic nephrectomy for inflammatory renal disease is feasible, but presents a high degree of complexity, requiring a customized approach. The use of hand assistance is an attractive option when the inflammatory process is intense, and can avoid conversions, maintaining the advantages of minimally invasive treatments.

Long-Term Outcome of Laparoscopic Pyeloplasty: Multicentric Comparative Study of Techniques and Accesses

PURPOSE The aim of the present study was to analyze long-term follow up (18-108 months) of different techniques and routes for laparoscopic repair of uretero-pelvic junction obstruction comparing efficacy and results. MATERIALS AND METHODS A retrospective analyses of 133 laparoscopic pyeloplasties in 132 patients (mean age 35 years) between August 1995 and November 2008 was performed. Transperitoneal route was performed in 114 patients, and retroperitoneal route was performed in 19 patients. Different repair techniques (dismembered and non-dismembered) were applied at the surgeons discretion. RESULTS Average operative time was 127 minutes (range 45-370). Average blood loss was 127 mL, and mean hospital stay was 24 hours. Complications occurred in 9.6% of surgeries, and conversion rate was 1.7%. Urinary leak occurred after eight (6.1%) surgeries, all managed conservatively. Overall success rate of laparoscopic repair was 96%, higher for dismembered versus non-dismembered procedures (97% versus 89%, P = .04). CONCLUSION Laparoscopic pyeloplasty is a reproducible, highly effective, and minimally invasive treatment for uretero-pelvic junction obstruction. Surgical technique affects operative time and long-term success rates. Dismembered techniques seem to remain more effective after a long-term follow up. Surgical route does not seem to affect success rates.

Single-Site Video Endoscopic Inguinal Lymphadenectomy: Initial Report

Techniques that attempt to further reduce the morbidity and improve cosmesis of laparoscopic surgery have particularly generated interest. Since its initial urologic description in 2007, there has been a surge of interest in laparoendoscopic single-site surgery, which is now an emerging technique within the field of minimally invasive urologic surgery. This report describes a preliminary experience with single-site video endoscopic inguinal lymphadenectomy (SSVEIL) compared with conventional video endoscopic inguinal lymphadenectomy (VEIL) on inguinal nodes management in a 45-year-old man with pT(2) grade 2 squamous cell penile carcinoma and impalpable inguinal nodes. VEIL with saphenous vein preservation in the left leg and SSVEIL on the other side presented no difference concerning operative time (100 vs 120 min), blood loss (50 mL), drainage volume, number of nodes retrieved (8), pain, and oncologic outcome. The patient had an uneventful postoperative course, was discharged 12 hours after the procedure, and preferred the aesthetic result of SSVEIL. Further refinements in technology will likely alleviate many of the persistent technical problems. Additional rigorous comparison studies are needed to evaluate the true benefits of the technique and the extent of its clinical application, mainly oncologic results, before the widespread adoption of SSVEIL. Ultimately, advance breakthroughs in fields of in-vivo instrumentation, robotics, and purpose-built robotic platforms will bring its potential to full clinical realization.

Laparoscopic radical prostatectomy by extraperitoneal access with duplication of the open technique

INTRODUCTION The laparoscopic radical prostatectomy is a continually developing technique. Transperitoneal access has been preferred by the majority of centers that employ this technique. Endoscopic extraperitoneal access is used by a few groups, nevertheless it is currently receiving a higher acceptance. In general, the antegrade technique is used, with dissection from the bladder neck to the prostate apex. The objective of the present paper is to describe the extraperitoneal technique with reproduction of the open surgerys surgical steps. SURGICAL TECHNIQUE With this technique, the dissection of the prostate apex is performed and, following the section of the urethra while preserving the sphincteric apparatus, the Foley catheter is externally tied and internally recovered, which allows cranial traction, similarly to the way it is performed in conventional surgery. The retroprostatic space is posteriorly dissected and the seminal vesicles are identified by anterior and posterior approach, obtaining with this method an optimal exposure of the posterolateral pedicles and the prostate contour. The initial impression is that this technique does not present higher bleeding rate or difficulty level when compared with antegrade surgery. Potential advantages of this technique would be the greater familiarity with surgical steps, isolated extraperitoneal drainage of urine and secretions and a good definition of prostate limits and lateral pedicles, which are critical factors for preserving the neurovascular bundles and avoiding positive surgical margins. A higher number of cases and a long-term follow-up will demonstrate its actual value as a technical option for endoscopic access to the prostate.

Retroperitoneoscopic adrenalectomy in an infant with adrenocortical virilizing tumor

CONTEXT Adrenocortical virilizing tumors are rare in the pediatric age group. Laparoscopic surgery is the gold standard method for treatment of adrenal functional tumors under 6 cm in size, in adults. There has been very little use of laparoscopy in children and there is no report of its application in the treatment of adrenal carcinoma in childhood. DESIGN Case report. CASE REPORT We performed the first laparoscopic resection using retroperitoneal access for the treatment of an adrenocortical virilizing tumor in a pediatric patient. We believe that retroperitoneoscopic access is a viable and promising option for the treatment of adrenal tumors in children.

Duodenal damage complicating percutaneous access to kidney

CONTEXT Since the first percutaneous nephrostomy performed by Goodwin in 1954, technical advances in accessing the kidneys via percutaneous puncture have increased the use of this procedure and thus the complications too. Among these complications, digestive tract damage is not common. DESIGN Case report. CASE REPORT We report a duodenal lesion that was corrected using surgical exploration and we touch on the therapeutic options, which may be conservative or interventionist. We chose conservative treatment, which has been approached in diverse manners in the literature.