Retroperitoneoscopic nephrectomy in dialysis dependent patients and comparison with open surgery.

OBJECTIVE: To evaluate the surgical outcomes and morbidity of retroperitoneoscopic nephrectomy compared with open nephrectomy for dialysis dependent patients. MATERIAL AND METHOD: Between November 2002 and August 2007, 14 hemo or peritoneal dialysis patients underwent nephrectomy or nephroureterectomy at Siriraj Hospital. Of the 14 patients, seven were treated with retroperitoneoscopic nephrectomy and seven with open nephrectomy. A retrospective review and data were carried out. The patient factors, type of surgery, perioperative outcomes and complications were analyzed. RESULTS: There was no conversion rate in the retroperitoneoscopic group. The mean estimated blood loss, analgesic requirement and time before starting oral intake were lower in the retroperitoneoscopic group (141.4 +/- 95 versus 292.8 +/- 226 ml, 5.0 +/- 4.5 versus 7.6 +/- 1.9 mg and 14.5 +/- 16.1 versus 23.1 +/- 23.3 hours, respectively). On the other hand, the mean operative time in the retroperitoneoscopic group was longer than the open group but with no significant difference (177.14 +/- 51 versus 160.71 +/- 84 min, p = 0.521). Two patients in the open group required intraoperative blood transfusion. There were two complications. One patient developed a large retroperitoneal hematoma after retroperitoneoscopic nephrectomy. Another had a perivesical collection in the open nephrectomy group. No mortality related to the procedures occurred. CONCLUSION: Retroperitoneoscopic nephrectomy should be considered as the procedure of choice for dialysis dependent patients. This has all the benefits of minimally invasive surgery such as reduced blood loss, minimal post operative pain leading to faster convalescence.

Early experience of robotic assisted laparoscopic radical prostatectomy.

INTRODUCTION: Quality of life after laparoscopic radical prostatectomy has been a discussed issue among patients. Robotic Assisted Laparoscopic Radical Prostatectomy (RALRP) has been shown to provide the best surgical outcomes in terms of potency and continence. The program of robotic prostatectomy was started at Siriraj Hospital. Early result of the author's experience was evaluated. OBJECTIVE: To evaluate the feasibility of Robotic Assisted Laparoscopic Radical Prostatectomy done at Siriraj Hospital. MATERIAL AND METHOD: From March 2007 to November 2007, 34 patients (Group 1) with localized prostate cancer underwent Robotic Assisted Laparoscopic Radical Prostatectomy (RALRP). Perioperative data was evaluated and compared to those of 34 patients (group 2) who underwent Laparoscopic Radical Prostatectomy (LRP) during the same period by the same surgeon. RESULTS: There were no demographic differences between the two groups. Catheterization time was significantly shortened in the RALRP group (p < 0.05). There was no major complication in the RALRP group, one LRP patient suffered bilateral ureteric injuries and required bilateral reimplantation. In pathological T2 patients of the last 17 consecutive cases, positive surgical margin rate was similar (14%) in both groups. CONCLUSION: The author early experience has shown that RALRP is feasible and safe. Oncological outcome can be improved with more experience and long term follow up is needed to evaluate functional outcome including potency rate and incontinence rate.

Laparoscopic radical prostatectomy: transperitoneal laparoscopic radical prostatectomy versus extraperitoneal endoscopic radical prostatectomy.

OBJECTIVE: To compare the perioperative results between Transperitoneal Laparoscopic Radical Prostatectomy (T-LRP) and Extraperitoneal Endoscopic Radical Prostatectomy (E-LRP). MATERIAL AND METHOD: Retrospective reviews of 125 patients who underwent laparoscopic radical prostatectomy by single surgeon (C.N) for stage T2-T3 adenocarcinoma of the prostate between May 2001 and July 2006 at Siriraj Hospital. Fifty-six cases had T-LRP and 69 cases had E-LRP The preoperative data (age, presenting PSA, and Gleason score), perioperative data (prostatic weight, operative time, intraoperative blood loss, the day of full oral diet, length of drain, and catheter time), pathologic stage, and margin status were compared. RESULTS: Mean age and Gleason score were comparable in both groups. Mean presenting PSA was lower in T-LRP (9.93) as compared to E-LRP (21.84) (p = 0.046). The mean prostatic weight was comparable in both T-LRP and E-LRP. The mean operative time of T-LRP (350) was significant longer than E-LRP (220) (p < 0.001). Mean intraoperative blood loss was more in T-LRP (883) as compared to E-LRP (605) (p = 0.001). Average blood transfusion was higher in T-LRP (1.23 unit) as compared to E-LRP (0.32). Postoperative full oral diet, length of drain, and catheter time in E-LRP were shorter than T-LRP (full diet: median 2 days vs. 3 days, p = 0.001) (length of drain: 4.98 days vs. 6.69 days, p = 0.002) (Catheter time: 8.9 days vs. 11.9 days, p = 0.002). Margin status were comparable in both groups but mean postoperative Gleason score was higher in E-LRP as compared to T-LRP (7.2 vs. 6.85, p = 0.022). CONCLUSIONS: E-LRP resulted in significant less operative time, intraoperative blood loss, postoperative oral diet, length of drain and catheter time where as the pathological margin status was the same in both T-LRP and E-LRP.

Conventional laparoscopic partial nephrectomy for a small renal mass.

The authors report the first case series of conventional laparoscopic partial nephrectomy in Thailand Laparoscopic partial nephrectomy was successfully performed in two patients with small renal tumors. The first patient underwent transperitoneal laparoscopic partial nephrectomy for a 3.8 x 3.3 cm renal mass. Intraoperative blood loss was 100 ml with warm ischemic time of 38 minutes. Pathological report showed renal cell carcinoma. The patient proceeded with laparoscopic radical nephrectomy, as surgical margin was not free. The second patient underwent retroperitoneal laparoscopic partial nephrectomy for a 1.8 x 2.4 cm renal mass. Intra-operative blood loss was 200 ml with clamping time of 45 minutes. Pathological report showed angiomylipoma. Using two different approaches of laparoscopy, namely, transperitoneal and retroperitoneal approaches, patients gained benefit from small incision and fast recovery.

Nerve-sparing laparoscopic radical prostatectomy at Siriraj Hospital.

BACKGROUND: Quality of life after laparoscopic radical prostatectomy has been a discussed issue among patients. Nerve-sparing radical prostatectomy has been shown to be superior to non-nerve-sparing radical prostatectomy in terms of potency and continence. The authors have reported their experience of laparoscopic radical prostatectomy and now developed our technique of nerve-sparing laparoscopic radical prostatectomy. OBJECTIVE: To evaluate the feasibility of nerve-sparing laparoscopic radical prostatectomy done at our institute. MATERIAL AND METHOD: From December 2005 to August 2006, 28 patients with localized prostate cancer underwent a nerve-sparing laparoscopic radical prostatectomy. Perioperative data was compared to those 34 patients who underwent non-nerve-sparing laparoscopic radical prostatectomy during the same period. All patients had PSA of less than 10 and pre-operative Gleason Score of 7 or less. Quality of life including incontinence and impotency rates was analyzed during three months post-operation. RESULTS: Patients' dermographic data, except ages, was similar in the two groups. Operating time was not different (217 vs. 212 minutes in favor of nerve-sparing). Blood loss was significantly high in nerve-sparing laparoscopic radical prostatectomy (814 mls vs. 543 mls, p = 0.01). Tumor control was not different within both groups. Three months after surgery incontinent rates of both groups were not different. 43.75% of patients with nerve-sparing technique had experienced erection at three months after surgery. CONCLUSION: The authors' early experience has shown that nerve-sparing laparoscopic radical prostatectomy does not compromise cancer control, although blood loss is higher. This operation should be encouraged in cancer-localized patients as the patients may gain benefit of better quality of life.

Endoscopic extraperitoneal radical prostatectomy (EERPE): a new approach for treatment of localized prostate cancer.

Laparoscopic radical prostatectomy is usually performed by transperitoneal approach. Patients may encounter; intraperitoneal organs injury, and prolonged ileus during recovery period. The authors firstly performed endoscopic extraperitoneal radical prostatectomy (EERPE) in Thailand, which is mimicking open radical prostatectomy, the gold standard for treatment of localized prostate cancer. OBJECTIVE: Assess and evaluate the feasibility and early outcomes of the authors' experience in endoscopic extraperitoneal laparoscopic radical prostatectomy (EERPE). MATERIAL AND METHOD: From December 2005 to May 2006, 27 cases of EERPE were performed at the authors' institute for clinically localized prostate cancer by one surgeon (group I). Operative data was compared to those 55 patients who underwent open radical prostatectomy from February 2001 to August 2005 for early prostate cancer by the same surgeon (group II). Early postoperative results, clinical outcomes and complication were analyzed between the two groups using Chi-Square, student unpaired t-test and Mann-Whitney U tests. RESULTS: Patients' age and clinical staging were not different between the two groups. Mean operative time was longer in the EERPE group (268 minutes vs 157 minutes; p < 0.01). Median blood loss was 500 mls and 1000 mls in the EERPE and open groups, respectively (p < 0.001). The likelihood of transfusion rate in the open group was higher than the EERPE group, with odd ratio of 8.75 (95%CI = 2.09-39.86), p = 0.001. Hospitalization time and pathological stage were not different between the two groups. In the EERPE group, there were two rectal complications, including rectal injury and rectal necrosis, which were treated laparoscopically and conservatively without long-term problems. CONCLUSION: The authors' early experience has shown that EERPE is feasible. Although operative time was longer; the patients may gain benefit of minimally invasive surgery and decreased operative blood loss. In EERPE group, oncological outcomes are equal to open surgery, however more cases and long-term follow up are required to evaluate the efficacy of such an approach.

Laparoscopic radical prostatectomy: preliminary result of Thailand series.

OBJECTIVES: Several published series from Western countries have demonstrated that laparoscopic radical prostatectomy is a safe and feasible approach to the management of localized prostate cancer. The authors report the initial experience with the first 56 cases of laparoscopic radical prostatectomy. MATERIAL AND METHOD: Between June 2001 and November 2005, 56 patients with clinically localized prostate cancer underwent transperitoneal laparoscopic radical prostatectomy. Their mean (range) age was 64.98 (50-77) years, prostate specific antigen (PSA) level was 9.92 (2.1-33.8) ng/ml, and Gleason sum was 6.28 (3-8). RESULTS: Complete laparoscopic removal of the prostate was achieved in 47 cases and conversions to open surgery were needed in 9 cases. The mean (range) operating time was 350 (200- 750) min. and blood loss was 883 (200-2050) ml. The transfusion rate was 27.6%. Laparoscopic pelvic lymphadenectomy was done in 31 cases and all were negative. The positive surgical margin rate was 29.8%. There were 20 postoperative complications; catheter dislodged (2), urine leakage more than 2 weeks (5), peroneal nerve numbness (1), flank hematoma (1), pelvic collection (1), late recto-urethral fistula (1), anastomotic stricture (2), port site hernia (1), and inguinal hernia (6). Median catheter time was 7 (6-90) days. The complete continence rate at 3, 6 and 12 months were 27.7%, 55.9% and 72.2%. CONCLUSION: Laparoscopic radical prostatectomy is a demanding procedure that is a feasible option for the surgical treatment of localized prostate cancer Intraoperative results were improved once experience was gained. Some parameters of the present results, i.e. transfusion rate, positive surgical margin and continence rate were still inferior compared to those reported by other centers.

Prevalence of prostate cancer in aging males receiving PSA (prostate specific antigen) screening test (A campaign for celebration of Siriraj Established Day).

Prostate cancer is a potential men's health problem. The prevalence of prostate cancer continues to rise. Serum PSA (Prostate Specific Antigen) can be used as a screening tool for detection of early prostate cancer However, a screening program for prostate cancer has not yet been accepted as cost-effective and long term survival benefits have not been shown. Nevertheless, some doctors request PSA testing in men who present with lower urinary tract symptoms (LUTS) to detect prostate cancer OBJECTIVE: To study for prevalence of prostate cancer in healthy men seeking medical check-up for prostate cancer. MATERIAL AND METHOD: During the anniversary celebration of Siriraj established day (26/07/1888), a cohort study of Prevalence of prostate cancer in aging males using PSA Screening Test was carried out, 200 men over 45 years of age were invited to PSA testing and prostate glands check-up including, IPSS (international prostatic symptoms score), QOL (quality of life score) and DRE (digital rectal examination). Patients with elevated PSA were advised to undergo transrectal-ultrasound-guided-biopsy of the prostate (TRUS-biopsy). Cancer detection rate was calculated according to symptoms described by patients, IPSS and age groups. Data was compared using Chi-Square test. RESULTS: Median values from data of men's ages, IPSS, QOL and PSA were 63 years, 11, 2, and 1.23 ng/ml, respectively. 9 of 200 patients (4.5%) were found to have prostate adenocarcinoma on biopsy. Most of the cancer cases showed a localized lesion. Prostate cancer was found more common in patients who described themselves as having abnormal urination. There was no prostate cancer found in patients with a mild degree of LUTS (IPSS less than 8). Prostate cancer tended to be more common in men with high IPSS. CONCLUSION: Screening prostate cancer by PSA testing detected the cancer in 4.5%. Most cancers were found on symptomatic patients. Patients with LUTS should be made aware of prostate cancer and PSA testing may be offered in such patients. However screening of prostate cancer in all men regardless of symptoms must wait for a larger study looking at long term survival benefit, cost-effectiveness of screening, and lastly, quality of life of patients on a screening program.

Is radical prostatectomy in thai men a high morbidity surgery for localized or locally advanced prostate cancer?

OBJECTIVE: To assess the morbidity of radical prostatectomy in Thai patients with localized or locally advanced prostate cancer MATERIAL AND METHOD: A total of 151 patients with prostate cancer underwent radical prostatectomy at Faculty of Medicine Siriraj Hospital, Bangkok, between 1994 to 2003. Operative complications and long term morbidity were evaluated with clinical stage T1, T2 and T3. RESULTS: Mean operative duration, blood loss and blood transfusion were 162 minutes (range 71-540), 1088 ml (range 200-4000) and 1.7 unit (range 0-12), respectively. Of 151 patients, 139 (92.6%) did not have perioperative complications and 42 (2 7.8%) did not have blood transfusion. Of 12 patients with morbidity, all patients were safely managed. There was no mortality. Of 140 patients with follow up results, 131 (93.7%) had no incontinence. Seven patients had mild stress incontinence. Only 2 patients had a significant incontinence. Eight patients had stricture of anatomosis. Strictures were simply managed with dilatation. There was no significant difference of operative time, blood loss, blood transfusion, incontinence and stricture parameters among clinical T stage (all p value > 0. 05). CONCLUSION: Radical prostatectomy in Thai men is not a high morbidity surgery in terms of immediate complications and long term morbidity. For clinical T3 prostate cancer, morbidity is not significantly higher than in patients with clinical localized disease.

Cystography helps Shorten urethral catheterization time after radical retropubic prostatectomy.

Objective: Post operative urethral drainage after radical retropubic prostatectomy is bothersome to patients. We assessed the possibility of using cystography to determine the feasibility and safety of early removal of urinary catheter. Methods: 56 patients who underwent radical retropubic prostatectomy from February 2001- December 2004 by one surgeon using one operative technique were reviewed. Cystography was performed on post-operative day 7 in the last 14 consecutive cases (group 1). The control group included 42 patients who had the urinary catheter removed 14 days postoperatively without cystography (group 2). In group 1, the urinary catheter was removed if cystogram showed no contrast media leakage. Data of the operations, pathological reports, complications and incontinence rate were compared between the two groups. Results: In group 1, the urinary catheter was removed on post-operative day 7 in 71% of the patients. The median catheterization time was 7 days and 14 days in group 1 and group 2, respectively (p<0.001). The incontinence rate was not significantly different in the two groups. There was no voiding difficulty or urinary retention reported in group 1. Conclusion: Cystography alleviates urethral discomfort after radical retropubic prostatectomy by shortening urinary catheterization time. Cystography should be considered in all patients who undergo radical retropubic prostatectomy on post-operative day 7. A meticulous urethrovesical anastomosis is required to reduce urinary catheterization time.

Is radical prostatectomy after transurethral resection of prostate (TUR-P) feasible.

Objective: Radical prostatectomy (RP) is usually difficult after TUR-P. We assessed the possibility and studied the outcomes of RP in patients who had previously received TUR-P. Methods: From August 2001 to April 2005, we performed 11 cases (group 2) of RP in localized cancer patients who had previously received TUR-P. The patients’ operative data and outcomes of the operation were compared to another 47 cases (group 1) of RP without earlier TUR-P. The operation was performed by one surgeon using the bladder-neck sparing technique. Results: The patients in group 2 had median operative time of 180 minutes, which was 30 minutes longer than that of group 1. Median operative blood losses were 1,100 ml and 1,000 ml in group 1 and 2, respectively. Median catheterization time was 14 days in both groups. Using Mann Whitney U-test, there were no differences among the two groups in terms of operative time, blood loss, catheterization time, hospital stay and serum PSA after the operation. The likelihood of bladder neck involvement and anastomosis stricture rate were higher in the patients who had received TUR-P with odd ratios of 3.06 and 3.15 respectively; nevertheless, these had no statistically significant difference. Conclusion: Radical prostatectomy after TUR-P is therefore feasible; however, meticulous surgical technique is needed to prevent complication.

Tension free vaginal tape (TVT) : Experience in Siriraj Hospital.

Early experience of a TVT operation in 39 patients was reported. Retrospective data was collected from patients’ files. All of the patients experienced symptoms of stress incontinence and 9 patients had stress incontinence and overactive bladder. Of 39 patients, 8 patients and 6 patients underwent A-P Repair and Anterior repair in the same setting of the TVT operation, respectively. Mean operative time was 51.41 minutes. Estimated blood loss was 65 mls. with average catheterization time of 3.1 days. Only minor complications were reported, including urge incontinence2, urinary retention 1, bladder perforation 1 and urethral injury 1. Stress incontinence was cured in 36 patients after 1 month follow up. The TVT operation was safe, simple and suitable for treatment of stress urinary incontinence.

Bladder perforation from capsaicin infusion : A case report.

We reported a 36 year old patient, with a spinal cord lesion who had bladder perforation during an infusion of 400 mls of Capsaicin (1mMol in 30% alcohol) for treatment of detrusor hyperreflexia. Under spinal anesthesia during the procedure he was restless and complained of chest discomfort. The operation was therefore terminated and a cystogram was carried out. Cystography showed extraperitoneal leakage of contrast media. He was treated conservatively and had an uneventful post-operative period. To prevent this complication, we therefore recommend an infusion volume of Capsaicin of between half to two-thirds of the patients bladder capacity together with pressure monitoring during the procedure.

The pattern of lymph node metastasis of penile cancer in Thais.

The prognosis of penile cancer is dependent on ilioinguinal lymph node metastasis. However, some controversy still exists concerning the management of those lymph nodes because the pattern of lymph node metastasis, especially in Thai males, is questionable e. Hence a prospective study of the pattern of lymph node metastasis was undertaken in 26 penile cancer patients from 1992 to 1995. All patients had the same pattern of lymph node metastasis. From primary lesion, tumour metastasized first to the inguinal lymph node, and then to the ipsilateral pelvic lymph node. There was no skip pattern. There was no correlation between Jackson staging, degree of cell differentiation, extension of primary lesion, palpability of clinical inguinal lymph node and pathological staging of lymph node metastasis after bilateral ilioinguinal lymphadenectomy. The primary lesion with poor differentiation was highly related to lymph node metastasis at the initial diagnosis. In patients with a clinically negative inguinal lymph node, 50 percent had inguinal lymph node metastasis and 12.5 percent had inguinal lymph node metastasis. In patients with a clinically positive inguinal lymph nod, 83.3 percent had inguinal lymph node metastasis and 38.8 percent had pelvic lymph node metastasis. In conclusion, lymph node metastasis in penile cancer is unpredictable by clinical evidence. Therefore prophylactic bilateral inguinal lymphadenectomy is recommended in all patients, and especially in cases with poor differentiation of the primary lesion, low education or low compliance with follow up. If there is inguinal lymph node metastasis, ipsilateral pelvic lymphadenectomy is recommended.