Thierry G. Vancaillie

Transperitoneal Endosurgical Lymphadenectomy in Patients with Localized Prostate Cancer

The main appeal of radiotherapy for carcinoma of the prostate lies in the low morbidity and good subsequent quality of life. The handicap of this approach is the absence of adequate staging through pelvic lymphadenectomy. A new operation with minimal morbidity for the patient is presented and described in detail: endosurgical (laparoscopic) pelvic lymphadenectomy. This operation can be performed on an outpatient basis and is extremely well tolerated by the patient. The results of the first 12 consecutive cases indicate that, with experience, the procedure can be performed within a reasonable time limit (90 to 205 minutes) and that the number of lymph nodes removed (right and left obturator fossae mean 7.6 and 7.1, respectively) is adequate. Endosurgical lymphadenectomy adds only minimal morbidity to the radiotherapeutic treatment of prostatic cancer but permits more accurate staging and, therefore, counseling of the patients.

Pilot study of botulinum toxin type A in the treatment of chronic pelvic pain associated with spasm of the levator ani muscles

Objective:  To investigate whether botulinum toxin type A (BOTOX) injected into the levator ani muscles of women with objective pelvic floor muscle spasm decreases pain symptoms and improves quality of life.

Diagnosis and management of serious urinary complications after major operative laparoscopy.

Objective To evaluate the incidence, diagnosis, and management of serious urinary complications after major operative laparoscopy. Methods For this retrospective study of 953 consecutive cases of major operative laparoscopy from January 1, 1990, to December 31, 1994, we reviewed incidence, method of diagnosis, and management of complications. Urinary complications included bladder injuries, urinary fistulas, and ureteral injuries. Major operative laparoscopic procedures included hysterectomy, adnexectomy, treatment of tubal pregnancy, ovarian cystectomy, and ablation-fulguration of severe endometriosis (stage IV). Results Serious urinary complications were found during or after operative laparoscopy in 15 of 953 patients (1.6%, 95% confidence interval [CI] 0.8–2.4). Four ureteral injuries, three bladder fistulas, and eight bladder perforations were documented in this series. Eight cases of urinary complications were recognized during the original surgery (one ureteral injury and seven bladder injuries) and repaired at that time. Laparotomy or additional major surgery was performed in seven patients (three ureteral injuries, two bladder fistulas, and two bladder perforations). Conclusion Serious urinary complications after major operative laparoscopy were discovered in 1.6% of patients. This incidence compares favorably to serious urinary complications after standard gynecologic surgery. Intraoperative recognition of these complications will likely avoid additional surgery.

The Assessment of Levator Muscle Strength: A Validation of Three Ultrasound Techniques

Abstract: Levator ani muscle function is traditionally evaluated by palpation or perioneometry. Recently, three different techniques of performing this task by translabial ultrasound have been described. The authors intended to validate these new methods by correlating results with assessments performed by perineometry and palpation. One hundred consecutive women were evaluated prospectively by a physiotherapist and a gynecologist. The physiotherapist undertook an assessment by palpation (Oxford grading) and perineometry (PeritronTM). The gynecologist performed translabial ultrasound. Both were blinded against each other’s results. Correlations between ultrasound and palpation were between 0.52 and 0.62, with displacement of the bladder neck agreeing most closely with palpation. As regards perineometry, correlations were 0.38 to 0.52, and again bladder neck displacement agreed best with the physiotherapeutic assessment. All correlations were highly significant. It appears that the assessment of levator function by ultrasound correlates strongly with vaginal palpation of muscle strength and perineometry.

Laparoscopic Ablation of Symptomatic Renal Cysts

We report a laparoscopic approach to the drainage and ablation of symptomatic simple renal cysts. Ten patients with chronic pain, 6 of whom failed primary aspiration, underwent laparoscopic cyst ablation: 6 had solitary renal cysts, 3 had multiple cysts and 1 had a peripelvic cyst. The approach was transabdominal in 9 patients and extraperitoneal in 1. Intraoperatively, cyst fluid was obtained for cytological examination, and cyst walls were excised and sent for pathological examination. When possible, the remaining inner cyst walls were fulgurated to prevent recurrence. Mean total operating room time was 2 hours 27 minutes and blood loss was minimal. The sole complication was a postoperative retroperitoneal hematoma, which was managed conservatively. Malignancy was diagnosed in 2 patients, each of whom had a negative preoperative aspiration. These patients subsequently underwent radical nephrectomy. All remaining patients were asymptomatic at a mean followup of 10 months. Laparoscopic ablation of renal cysts is a safe and effective alternative to open surgery in patients who have failed conservative measures. Preoperative and intraoperative evaluation for malignancy should be performed.

Laparoscopic Approach to the Seminal Vesicles

The seminal vesicles can be approached laparoscopically and completely dissected free via the rectovesical cul-de-sac. This approach may be helpful during a perineal prostatectomy or when treating primary seminal vesicle pathological conditions.

Female Pelvic Organ Prolapse and Voiding Function

Abstract It is accepted that pelvic organ prolapse impairs voiding, in particular as regards the anterior vaginal wall. The influence of central and posterior prolapse is more controversial. Mechanical effects, i.e. urethral distortion and compression, have been advanced as causative mechanisms. This study attempts to further elucidate the effect of prolapse on voiding. We investigated 228 patients with symptoms of lower urinary tract dysfunction and/or prolapse using independent flowmetry, clinical and ICS prolapse assessment and translabial ultrasound. As expected, age (P<0.001), previous hysterectomy (P= 0.002) and/or incontinence surgery (P<0.001) negatively influenced flow. As regards prolapse, only enterocele had a consistently negative effect on flow (P<0.001 for clinical staging, P= 0.002 for ICS assessment, P= 0.005 for ultrasound imaging). The relationship between anterior vaginal wall prolapse and voiding was complex: funneling and opening of the retrovesical angle on ultrasound was associated with improved voiding (P<0.001), but a cystocele with intact retrovesical angle had the opposite effect (P<0.001).

Laparoscopic Standard Pelvic node Dissection for Carcinoma of the Prostate: Is it Accurate?

The acceptably low morbidity of laparoscopic pelvic lymphadenectomy has allowed us to perform the procedure systematically on all patients who presented with localized adenocarcinoma of the prostate. Data on 147 consecutive cases enable us to state that the overall accuracy and morbidity of this method are equal if not better than the rates available in the literature for open procedures. In addition, analysis shows that the standard dissection is more accurate than the obturator dissection because in 30% of the patients with positive nodes malignant infiltrates were found in the iliac specimen only. Finally, it appears that patients in whom the malignancy was detected by ultrasound only may not require lymphadenectomy because in our group of 28 patients no positive nodes were detected.

COMPLICATIONS OF MAJOR OPERATIVE LAPAROSCOPY : A REVIEW OF 452 CASES

OBJECTIVE To evaluate complications of operative laparoscopy. STUDY DESIGN Operative and postoperative complications in 452 consecutive cases from January 1, 1991, to August 31, 1993, were evaluated. The series was divided into three time segments--8, 12 and 12 months. Common and serious complications were classified and reviewed. RESULTS Complications developed during and after major operative laparoscopy in 47 (10.4%) patients in the series; 24 (5.3% of cases, or 51% of total complications) were serious, such as hemorrhage, ureteral injuries and fistulas, and intestinal obstruction. Seventeen (3.8%) patients required unplanned surgery for management of complications. During the initial learning period of eight months, the rate of complications averaged 17.3%, decreasing to 7.7% and 10.1%, respectively, in the second and third periods in the series. There were no cases of death, postoperative ileus, thrombophlebitis or pulmonary complications. CONCLUSION The overall incidence of complications in major operative laparoscopy was 10.4%. Serious complications accounted for half the complications. Surgical experience reduced the incidence of complications. Ovarian cystectomy produced the lowest rate of common complications and no serious ones. Laparoscopically assisted vaginal hysterectomy had the highest rate of serious complications.

Peri‐operative physiotherapy improves outcomes for women undergoing incontinence and or prolapse surgery: Results of a randomised controlled trial

Background:  Urinary incontinence and pelvic organ prolapse are common complaints in women. Physiotherapy and surgery to correct these conditions are often seen as mutually exclusive. No study has yet investigated their synergistic potential.