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 Scarpa's 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.

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.

Preliminary experience with extraperitoneal endoscopic radical prostatectomy through duplication of the open technique.

OBJECTIVE: To describe surgical and functional results with extraperitoneal laparoscopic radical prostatectomy with duplication of the open technique, from the experience obtained in the treatment of 28 initial cases. MATERIALS AND METHODS: In a 36-month period, we prospectively analyzed 28 patients diagnosed with localized prostate cancer undergoing extraperitoneal laparoscopic radical prostatectomy. RESULTS: Mean surgical time was 280 min, with mean blood loss of 320 mL. As intraoperative complications, there were 2 rectal lesions repaired with laparoscopic suture in 2 planes. There was no conversion to open surgery. Median hospital stay was 3 days, with return to oral diet in the first post-operative day in patients. As post-operative complications, there were 3 cases of extraperitoneal urinary fistula. Two of these cases were resolved by maintaining a Foley catheter for 21 days, and the other one by late endoscopic reintervention for repositioning the catheter. Five out of 18 previously potent patients evolved with erectile dysfunction. The diagnosis of prostate cancer was confirmed in all patients, with focal positive margin occurring in 3 cases. During a mean follow-up of 18 months, 2 patients presented increased PSA, with no clinical evidence of disease. CONCLUSION: Laparoscopic radical prostatectomy is a laborious and difficult procedure, with a long learning curve. Extraperitoneal access is feasible, and it is possible to practically duplicate the principles of open surgery. The present technique can possibly offer advantages in terms of decreased blood loss, preservation of erectile function and prevention of positive margins.

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.

Hand-assisted laparoscopic nephrectomy as a minimally invasive option in the treatment of large renal specimens.

INTRODUCTION: We describe our experience with hand-assisted laparoscopy (HAL) as an option for the treatment of large renal specimens. MATERIALS AND METHODS: Between March 2000 and August 2004, 13 patients candidate to nephrectomies due to benign renal conditions with kidneys larger than 20 cm were included in a prospective protocol. Unilateral nephrectomy was performed in cases of hydronephrosis (6 patients) or giant pyonephrosis (4 patients). Bilateral nephrectomy was performed in 3 patients with adult polycystic kidney disease (APKD) with low back pain refractory to clinical treatment previous to kidney transplant. The technique included the introduction of 2 to 3 10 mm ports, manual incision to allow enough space for the surgeon's wrist without a commercial device to keep the pneumoperitoneum. The kidney was empty, preferably extracorporeally, enough to be removed through manual incision. We have assessed operative times, transfusions, complications, conversions, hospital stay and convalescence. RESULTS: The patients mean age (9 women and 4 men) was 58 years. Mean operating time was 120 +/- 10 min (hydronephrosis), 160 +/- 28 min (pyonephrosis) and 190 +/- 13 min (bilateral surgery for APKD). There was a need for a conversion in 1 case and another patient needed a transfusion due to a lesion in the renal vein; 2 patients had minor complications. CONCLUSIONS: HAL surgery is a minimally invasive alternative in the treatment of large renal specimens, with or without significant inflammation.