Laparoscopic ureteral reimplantation for a distal ureteral injury detected after laparoscopic radical prostatectomy

@#Distal ureteral injury is a rare complication of laparoscopic radical prostatectomy (LRP). The authorsreport such a case which was repaired successfully with an exclusively laparoscopic approach. Theyalso describe the advantages of the flank position when performing this minimally invasive approach.@*THE CASE@# 61-year-old Filipino male, with a PSA of 10 ng/cc, diagnosed with localized prostatecancer undergoes LRP, utilizing a posterior approach to the seminal vesicles. Intraoperatively, alarge intravesical median lobe was noted which was dissected meticulously after the division of thebladder neck. The excision of the 60gm prostate was completed in the conventional manner followedby a urethrovesical anastomosis. Blood loss was minimal with no apparent intraoperative events.Histopathology confirmed prostate cancer, Gleason score (4+3) with negative margins. Postoperatively,he had progressively high pelvic drain output and noticeably a relatively low urethral catheter output.CT urogram done on POD 8 showed a distal left ureteral disruption with intraabdominal extravasation.The authors performed a laparoscopic left ureteroneocystostomy on POD 9. The patient did wellafter the repair. After removing the indwelling catheter on postoperative day 14, he was dischargedin a good clinical condition. The ureteral stent was removed one month after the reimplantation.Follow-up CT urogram showed unobstructed flow through the reimplanted left ureter. Follow-upPSA at this time was 0.01ng/cc.@*CONCLUSION@#Ureteral injury following LRP is a devastating complication which may go undiagnosedintraoperatively. Prompt recognition, followed by a timely minimally invasive repair through alaparoscopic approach is needed to correct this problem.

Robot-assisted laparoscopic radical prostatectomy on a very large prostate gland

@#This is a case of a 74-year-old obese male presented with moderate lower urinary tract symptoms and an elevated prostate specific antigen (PSA) of 48.21ng/ml. Multiparametric MRI of the prostate revealed a markedly enlarged prostate (225grams) with a PIRADS 5 lesion at the left posterior peripheral zone. Prostate biopsy done revealed prostate adenocarcinoma Gleason 7(3+4). Metastatic workup was negative for distant metastasis hence the patient was advised robot-assisted laparoscopic prostatectomy (RALP).Several difficulties were encountered during the surgical technique. The usual posterior approach was not feasible because incising the peritoneum over the rectovesical pouch would not be able to expose the vas deferens and seminal vesicles. An anterior approach was instead done, but this was still difficult due to the lack of space for proper exposure and movement of instruments. The posterior dissection was also challenging; three successive suspension stitches were necessary in order to expose and mobilize the lateral and posterior surface of the prostate. Urethrovesical anastomosis had to be modified by performing a modified posterior repair in order to reduce tension caused by the large gap left by the excised prostate. RALP is a safe and feasible operative technique for very large prostates as long as the difficulties are foreseen and the necessary adjustments are made.Robot-assisted laparoscopic prostatectomy (RALP) has emerged as the preferred option in the treatment of localized prostate cancer. As more cases are being performed, more surgeons are encountering challenging cases, such as those with difficult anatomy, prior abdominal surgery and prior radiation therapy. Large prostate glands increase the technical difficulty of performing robot-assisted laparoscopic prostatectomy.1 Reported is a case of RALP in a patient with prostate size >200. The difficulties and concerns in such situations are also delineated.

Effect of recruitment maneuver on arterial oxygenation in patients undergoing robot-assisted laparoscopic prostatectomy with intraoperative 15 cmH₂O positive end expiratory pressure / 대한마취과학회지

BACKGROUND: This randomized, controlled study was designed to compare the effects of recruitment maneuvers (RMs) with a 15 cmH₂O positive end-expiratory pressure (PEEP) on the systemic oxygenation and lung compliance of patients with healthy lungs following robot-assisted laparoscopic prostatectomy (RALP). METHODS: Sixty patients undergoing a RALP with an intraoperative 15 cmH₂O PEEP were randomly allocated to an RM or a Control group. The patients in the RM group received a single RM through the application of a continuous positive airway pressure of 40 cmH₂O for 40 s 15 min after being placed in the Trendelenburg position. The arterial oxygen tension (PaO₂, primary endpoint) and the pulmonary dynamic and static compliances (secondary endpoints) were measured 10 min after the anesthetic induction (T1), 10 min after establishment of the pneumoperitoneum (T2), 10 min after establishment of the Trendelenburg position (T3), 10 min after the RM (T4), 60 min after the RM (T5), and 10 min after deflation of the pneumoperitoneum in the supine position (T6). RESULTS: The intergroup comparisons of the PaO₂ showed significantly higher values in the RM group than in the Control group at T4 and T5 (193 ± 35 mmHg vs. 219 ± 33 mmHg, P = 0.015, 188 ± 41 mmHg vs. 214 ± 42 mmHg, P = 0.005, respectively). However, the PaO₂ at T6 was similar in the two groups (211 ± 39 mmHg vs. 224 ± 41 mmHg, P = 0.442). Moreover, there were no statistical differences between the groups in the dynamic and static compliances of the lungs at any time point. CONCLUSIONS: The arterial oxygenation of the patients with a healthy lung function who had undergone a RALP with intraoperative 15 cmH₂O PEEP was improved by a single RM. However, this benefit did not last long, and it did not lead to an amelioration of the lung mechanics.

Hemodynamic parameters during robotic radical prostatectomy in elderly patients with increased cardiac risk

BACKGROUND: We studied the hemodynamic changes associated with steep Trendelenburg position and prolonged pneumoperitoneum during robot-assisted laparoscopic prostatectomy in elderly patients with cardiac diseases. METHODS: Hemodynamic variables were measured at baseline supine position, at 30 min, 1, 2, 3 and 4 h during CO2 insufflation in post-Trendelenburg position, and after deflation in the supine position. RESULTS: In comparison with normal subjects, the cardiac index and systemic vascular resistance index of patients with cardiac diseases were significantly affected by the Trendelenburg position and pneumoperitoneum (P < 0.001). However, other variables of heart rate, mean arterial pressure and central venous pressure were not differed between the groups. CONCLUSIONS: We conclude that attention should be paid to maintain adequate hemodynamic status during prolonged pneumoperitoneum in the Trendelenburg position, and which is unfeasible in patients with severe heart failure and unstable angina.

Is there any evidence of superiority between retropubic, laparoscopic or robot-assisted radical prostatectomy?

PURPOSE: To compare the perioperative, short-term and long-term postoperative results of radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robotic assisted laparoscopic prostatectomy (RALP) in the most recent studies evaluable. MATERIALS AND METHODS: Using PubMed we have undertaken a search based on references from major and recent articles with considerable sample sizes. RESULTS: The operative blood loss and the risk of transfusion were lower in the laparoscopic and robotic-assisted approaches. The surgical duration was shorter in the open and robotic group. Regarding the positive margins, continence and potency no substantial differences between the RRP, LRP, and RALP were found. CONCLUSIONS: Our results suggest that no one surgical approach is superior in terms of functional and early oncologic outcomes. Potential advantages of any surgical approach have to be confirmed through longer-term follow-up and adequately designed clinical studies.

Prostatectomia radical laparoscópica / Radical laparoscopic prostatectomy

Radical laparosocpic prostatectomy (RLP) is an attractive therapeutic modality for localized prostate cancer. The results obtained with this technique are similar to those obtained with open radical prostatectomy, which continues to be the gold standard for the treatment of prostate cancer. The surgical access for RLP can be extra-peritoneal or trans-peritoneal. The advantages of laparoscopy are lower bleeding rates, less need for transfusion and shorter recuperation time and hospital stay. The oncological results of RLP are similar, but in any case better, that those obtained with open retropubic radical prostatectomy. Recent reports raised the concern that laparoscopic prostatectomy could have higher rates of relapse of cancer. However this opinion is questionable. RLP is a difficult technique and should be performed by experienced teams. Robot assistance facilitates the procedure and could improve functional and oncological results. Therefore RLP is nowadays an alternative to traditional retropubic prostatectomy.

La Prostatectomia radical laparoscópica (PRL) se ha convertido en una técnica atractiva para el tratamiento quirúrgico del cáncer de próstata localizado. Si bien, los resultados actuales son inicialmente comparables a la prostatectomia radical abierta, es importante mencionar que la tendencia quirúrgica en cáncer de próstata, se ha modificado a pesar de que no hay estudios que confirmen la superioridad del método endoscópico y hoy, el estándar dorado sigue siendo la prostatectomia radical abierta. Dos rutas de acceso quirúrgico pueden ser utilizadas para la realización de PRL, la vía extraperitoneal y la transperitoneal. Un menor sangrado y menor tasa de transfusión, así como, tiempo de hospitalización y recuperación más cortos, son ventajas incuestionables para los procedimientos laparoscópicos. Los resultados oncológicos y funcionales de la prostatectomia laparoscópica son hoy en día comparables, pero en ningún caso mejores que la técnica retropúbica abierta estándar. Recientemente, Hu y colaboradores, en base a una revisión de cerca de 3.000 pacientes tratados en los Estados Unidos, plantean la posibilidad de que los pacientes tratados con prostatectomia laparoscópica (pura o asistida por robot), pudiesen tener mayor riesgo de recurrencia de la enfermedad. Esta es una posición discutible, ya que el análisis, a pesar de ser extenso es limitado para establecer conclusiones finales en el tema. Es importante recordar que la PRL sigue siendo una intervención técnicamente difícil y debiera ser realizada en centros seleccionados con equipos experimentados. La prostatectomía laparoscópica asistida por Robot, facilita el procedimiento y en suma, pareciera mejorar los resultados oncológicos y funcionales. La PRL es hoy en día una alternativa válida a la prostatectomía retropúbica tradicional, con ciertas ventajas adicionales.

Re-insufflation after deflation of a pneumoperitoneum is a risk factor for CO2 embolism during laparoscopic prostatectomy: A case report / 대한마취과학회지

Although symptomatic carbon dioxide (CO2) embolism is rare, it recognized as a potentially fatal complication of laparoscopic surgery. Sudden hemodynamic instability could be a CO2 embolism especially during insufflation. A 65-year-old man received laparoscopic prostatectomy for 5 hours under CO2 pneumoperitoneum without any problem. After resection of prostate, it was stopped following deflation. Thirty minutes later, peumoperitoneum was re-induced to continue the operation. Shortly after re-insufflation, the patient revealed hemodynamic instability suggested a CO2 embolism; severe hypotension, tachyarrythmia, hypoxemia, increased CVP, and changed end-tidal CO2. Gas insufflation was stopped. He was managed with Durant's position, fluid and cardiotonics for 20 minutes. The residual was completed by open laparotomy. Re-insufflation, inducing gas entry through the injured vessels, might be a risk factor for CO2 embolism in this case. The risk to the patient may be minimized by the surgical team's awareness of CO2 embolism and continuous intra-operative monitoring of end-tidal CO2.

Prostatectomía radical laparoscópica de rescate post radioterapia externa: reporte de un caso y revisión de la literatura / Salvage laparoscopic radical prostatectomy after failed radiotherapy: a case report and review of the literature

Objetivo: Reportar un caso de prostatectomía radical laparoscópica de rescate (PRLR) indicada por una falla local post radioterapia, y realizar una revisión de la técnica quirúrgica y sus resultados. Métodos/Resultados: Varón de 68 años de edad, con antecedentes de cáncer prostático incidental (pT1b) manejado con radioterapia externa, que presenta recidiva bioquímica al quinto año post-irradiado. Tras estudio se realiza PRLR sin incidentes. Estudio patológico demuestra un adenocarcinoma Score Gleason 7, estadío pT2. Evoluciona continente a las 3 semanas de postoperado. La Prostatectomía Radical de Rescate es la única alternativa curativa y con resultado oncológico demostrado a largo plazo. Su morbilidad cada vez es menor, pero se mantiene con mayores tasas de incontinencia y estrechez de anastomosis con respecto a la Prostatectomía Radical realizada como tratamiento primario. La vía laparoscópica ha demostrado ser efectiva, sin agregar morbilidad a la técnica. Conclusiones: la PRLR es una alternativa de tratamiento en los pacientes con falla local post radioterapia, que no aumenta la morbilidad con respecto a la cirugía abierta.

Objective: report a case of salvage laparoscopic radical prostatectomy (SLRP) after radiation failure, and review the literature about the surgical technique and his results. Method/Results: 68 old, with history of incidental prostate cancer (pT1B), treated with external beam radiation, who presented a local failure after 5 years. Metastatic disease was ruled out preoperatively by bone scintigraphy, and computed tomography. SLRP was done, without complications. Histologic analysis revealed prostate cancer score Gleason 7, pT2. The patient was continent at three weeks. Currently, Salvage Radical Prostatectomy represents the only curative treatment option for these patients, with long term oncologic results. His morbidity has decreased, but still shows more incontinence and anastomotic stricture, compared to radical prostatectomy de novo. SRLP has been shown to be effective, and with no mayor complications. Conclusions: SLRP is safe surgical technique to treat a local failure after radiationtherapy, without increase in morbidity compared with open surgery.