Primary renal myxofibrosarcoma.

Kidney sarcomas are rare, representing only 1% of malignant renal tumors. We herein report the case of a 70-year-old woman that was admitted for an episode of confusion in relation to hypertensive encephalopathy. Imaging investigations revealed a large mass in the right kidney with extension to the renal hilum. The patient underwent right open radical nephrectomy. The histopathologic study disclosed a 15-cm, myxoid and cellular, pleomorphic tumor with elongated, curvilinear, thin-walled vessels, and focal necrosis that involved the upper and middle segments of the kidney. Immunohistochemically, the tumor cells showed strong positivity for vimentin, bcl2 protein (nuclear staining pattern), CD34, CD99, and alpha-methylacyl coenzyme A racemase. The tumor was diagnosed as myxofibrosarcoma (MFS) grade 2 according to the FNCLCC system. To the best of our knowledge, this is the first report of an MFS arising from the kidney. Thus, MFS is an uncommon soft tissue tumor that can exceptionally arise from the kidney. The differential diagnosis with other myxoid tumors is of vital importance because it includes lesions with subtle differences and extremely variable biological behavior. Radical surgery is the treatment of choice. Long-term follow-up is recommended because of the tumor's capability for local recurrence and distant metastasis.

Colpocleisis in vesico-vaginal radiation fistula.

OBJECTIVE: To assess Latzko's colpocleisis with bilateral Martius flap as a solution for vesico vaginal fistula secondary to radiotherapy. METHOD: 65 year old woman with past medical history of cervix adenocarcinoma treated with hysterectomy, pelvic radiotherapy and brachytherapy. She also had terminal colostomy for recto-vaginal fistula. She complained of a 2-year history of continuous urinary escape through vagina. On cistoscopy, the ureteral orifices were close to the loss of substance. Colpocleisis following Latzko's technique was performed. RESULTS: Complete resection of the fistulous tract and tension free closure is a surgical challenge not always achieved, and with a high recurrence rate. Latzko's colpocleisis is a simple and safe option in patients that have previously undergone a hysterectomy. Bilateral Martius flap increases vascular support of the affected tissues, which is of pivotal importance in patients subjected to radiotherapy. CONCLUSION: Latzko's colpocleisis is a valid therapeutic option in those histerectomised patients with vesico vaginal fistulas due to radiotherapy who are not eligible for fistulorraphy.

Colpocleisis en fístula vesicovaginal rádica / Colpocleisis in vesico-vaginal radiation fistula

OBJETIVO: Valorar la Colpocleísis de Latzko con Colgajo de Martius bilateral como solución a una fístula vésico-vaginal secundaria a tratamiento radioterápico.MÉTODO: Mujer de 65 años con antecedentes de Carcinoma epidermoide de Cérvix tratada mediante histerectomía, radioterapia pélvica y braquiterapia. Portadora de colostomía definitiva por fístula recto-vaginal. Consulta por fuga continua de orina por vagina de dos años de evolución. En la exploración genital se aprecia un extenso defecto de la pared anterior de la vagina. En la cistoscopia se observan los orificios ureterales próximos a la pérdida de sustancia. Se realizó colpocleisis según técnica de Latzko.RESULTADO: La resección completa del trayecto fistuloso y el cierre sin tensión es un reto quirúrgico no siempre factible y con una alta tasa de recidivas. La colpocleísis según la técnica de Latzko es una alternativa terapéutica sencilla y segura, en pacientes que hayan sido sometidas a histerectomía. El colgajo de Martius bilateral incrementa la vascularización de los tejidos intervenidos, factor de especial importancia en pacientes sometidas a radioterapia.CONCLUSIÓN: La Colpocleísis según la técnica de Latzko es una actitud terapéutica válida para aquellas pacientes histerectomizadas con fístulas vésico-vaginales actínicas no subsidiarias de fistulorrafia(AU)

OBJECTIVE: To assess Latzko´s colpocleisis with bilateral Martius flap as a solution for vesico vaginal fistula secondary to radiotherapy.METHOD: 65 year old woman with past medical history of cervix adenocarcinoma treated with hysterectomy, pelvic radiotherapy and brachytherapy. She also had terminal colostomy for recto-vaginal fistula. She complained of a 2-year history of continuous urinary escape through vagina. On cistoscopy, the ureteral orifices were close to the loss of substance. Colpocleisis following Latzko´s technique was performed.RESULTS: Complete resection of the fistulous tract and tension free closure is a surgical challenge not always achieved, and with a high recurrence rate. Latzko´s colpocleisis is a simple and safe option in patients that have previously undergone a hysterectomy. Bilateral Martius flap increases vascular support of the affected tissues, which is of pivotal importance in patients subjected to radiotherapy.CONCLUSION: Latzko´s colpocleisis is a valid therapeutic option in those histerectomised patients with vesico vaginal fistulas due to radiotherapy who are not eligible for fistulorraphy

Laparoscopic radical prostatectomy with the Heilbronn technique: oncological results in the first 500 patients.

PURPOSE: Laparoscopic radical prostatectomy has become an accepted alternative to open surgery. However, there is still a lack of data concerning the oncological outcome. MATERIALS AND METHODS: From March 1999 to July 2004, 1,078 patients underwent laparoscopic radical prostatectomy at our institution. Oncological results in the first 500 patients with a minimal followup of 23 months were analyzed, focusing on positive margins, prostate specific antigen (PSA) failure, clinical progression and survival. RESULTS: Median followup was 40 months (range 23 to 65). Of the patients 417 underwent pelvic lymph node dissection, which revealed positive nodes in 6 (1.2%). Positive margins were documented in 22 of 296 pT2 tumors (7.4%), 27 of 107 pT3a tumors (25.2%) and 29 of 69 pT3b tumors (42.0%). PSA recurrence was diagnosed in 55 patients (11.0%) at a mean of 20.8 months (range 6 to 36) that is stages pT2a, pT2b, pT3a and pT3b/4 in 3.2%, 6.5%, 15.9% and 23.9%, respectively. PSA progression-free rates were 83.0% at 3 years and 73.1% at 5 years. Two patients died of disease and 6 died of other causes (99.2% overall survival). The clinical progression rate was to 4.1% at 3 years and 9.8% at 5 years. No port site metastasis was observed. CONCLUSIONS: At centers of expertise laparoscopic radical prostatectomy may provide an oncological outcome similar to that of the open procedure. However, it offers the advantages of minimally invasive surgery.

The effect of previous transperitoneal laparoscopic inguinal herniorrhaphy on transperitoneal laparoscopic radical prostatectomy.

PURPOSE: Previous laparoscopic herniorrhaphy has been considered a contraindication to laparoscopic radical prostatectomy (LRP). In this study we analyzed the impact of previous laparoscopic or open inguinal hernia repair on the outcome of transperitoneal laparoscopic radical prostatectomy using the Heilbronn technique. MATERIALS AND METHODS: In our database of 1,089 patients with LRP we identified 20 who underwent transperitoneal LRP and had a history of transperitoneal laparoscopic inguinal herniorrhaphy using prosthetic mesh (group 1). The outcome in that group was compared to that of 20 matched pair patients of a total of 95 in whom LRP was performed following open inguinal herniorrhaphy (group 2) and 20 matched pair patients of a total of 771 without previous surgery (group 3). Perioperative parameters (operative time, blood donation and complications) and postoperative results (duration and amount of analgesic treatment, catheterization and the continence rate) were analyzed. RESULTS: According to the matched pair algorithm the 3 groups did not differ with respect to age (63.8, 66.2 and 63.0 years, p = 0.226), prostate volume (47.2, 43.3 and 47.7 gm, p = 0.501) or body mass index (26.1, 25.8 and 26.2 kg/m, respectively, p = 0.641). Ten pelvic lymphadenectomies and 8 nerve sparing (4 unilateral and 4 bilateral) procedures were performed per group. Ten and 12 patients in groups 1 and 2 had a history of bilateral herniorrhaphy, while previous unilateral herniorrhaphy was noted in the remaining 10 and 8, respectively. Mean operative time +/- SD (203.3 +/- 3.54, 196.7 +/- 43.7 and 214.7 +/- 37.7 minutes, p = 0.346) and mean catheterization time (8.1 +/- 2.8, 7.7 +/- 2.5 and 7.4 +/- 2.1 days, respectively, p = 0.684) did not differ significantly among the 3 groups. However, the mean amount of narcotic analgesic was significantly higher in group 1 compared with groups 2 and 3 (32.1 +/- 11.9, 21.8 +/- 11.9 and 19.5 +/- 10.1 mg, respectively, p = 0.002). Continence rates were similar in the groups at 88%, 87% and 92%, respectively, 1 year after surgery. CONCLUSIONS: Previous laparoscopic inguinal herniorrhaphy using prosthetic mesh does not adversively affect the operative outcomes or functional results of LRP, while the total amount of narcotic analgesics was significantly higher, reflecting increased postoperative morbidity.

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: is it better than open surgery?

OBJECTIVE: In 1991, laparoscopic nephroureterectomy has been introduced as a treatment option for upper tract transitional cell carcinoma. Based on the review of the current literature and personal experience we want to analyze the actual results of this technique in comparison to open surgery. MATERIALS AND METHODS: We performed a MEDLINE/PubMed search and reviewed the literature on laparoscopic and open nephroureterectomy between 1991 and 2004 (n = 1365 patients) including the results of 45 patients who underwent either laparoscopic (n = 23) or open nephroureterectomy (n = 21) during the same period of time at the Klinikum Heilbronn. Demographic, perioperative and follow-up data were compared. RESULTS: The analysis revealed a slightly longer OR-time (276.6 vs. 220.1 min), and significantly lower blood loss (240.9 vs. 462.9 ml) in the laparoscopic series. No differences of minor (12.9 vs. 14.1%) or major complication rate (5.6 vs. 8.3%) were observed. All nine comparative studies revealed a significant dose reduction of the morphine-equivalents after laparoscopy. In all ten comparative series the hospital stay was shorter after laparoscopy, but only in 6 series the difference was statistically significant. The frequency of bladder recurrence (24.0 vs. 24.7%), local recurrence (4.4 vs. 6.3%), and distant metastases (15.5% vs. 15.2) did not differ significantly in both groups. The actual disease-free two-year survival rates (75.2 vs. 76.2%) were similar. The five-year survival rates averaged 81.2% in the three laparoscopic (n = 113 pat.) and 61% in the ten open series (n = 681 pat.) Six port site metastases were reported in 377 (1.6%) analyzed patients occurring 3 to 12 months following laparoscopy. CONCLUSION: Open radical nephroureterectomy still represents the golden standard for the management of upper tract transitional cell carcinoma, however, laparoscopic radical nephroureterectomy offers the advantages of minimally invasive surgery without deteriorating the oncological outcome. In case of advanced tumors (pT3,N+) open surgery is still recommended.

Comparison of transperitoneal and extraperitoneal laparoscopic radical prostatectomy using match-pair analysis.

PURPOSE: Based on the experience of 1000 cases of laparoscopic radical prostatectomy, we compared the operative parameters of transperitoneal and extraperitoneal approaches in match-paired patient groups. PATIENTS AND METHODS: We reviewed the charts of 53 consecutive patients who underwent selectively extraperitoneal laparoscopic radical prostatectomy comparing it to 53 match-paired patients treated by transperitoneal laparoscopic radical prostatectomy. The patients were matched for age, PSA (ng/ml), prostate volume (g), pathologic stage, Gleason score, presence of pelvic lymph node dissection and type of nerve-sparing technique. Perioperative parameters (operating time, blood donation, complications) and postoperative results (duration and amount of analgesic treatment, catheterization time) as well as oncological (surgical margin status) and functional (continence rate) results were analyzed. RESULTS: Patients were 62.9 +/- 5.5 versus 62.9 +/- 5.4 years old, had 27.5 +/- 3.5 kg/m2 versus 26.7 +/- 2.8 kg/m2 body mass indices in the extraperitoneal and transperitoneal groups, respectively. Preoperative mean PSA and prostate volume were 7.4 +/- 4.6 ng/ml and 41.8 +/- 16.3 g in the extraperitoneal, 7.6 +/- 3.8 ng/ml and 42.0 +/- 14.8 g in the transperitoneal group. Pathologic stages were T2a in 12 vs. 13, T2b in 21 vs. 20, T2c in 7 vs. 8, T3a in 11 vs. 10 and T3b in 2 vs. 2 patients for both groups. Overall 211.8 vs. 197.1 minutes mean operative time (p = 0.328) and 21.9 +/- 15.4 mg vs. 26.3 +/- 15.8 mg narcotic analgesic requirements (p = 0.111) did not differ significantly in both groups. However, mean operating time was significantly longer in the extraperitoneal group when performing pelvic lymphadenectomy (244.5 vs. 209.6 minutes, p = 0.017). There was no statistical difference of complication rate (4% vs. 2%) and median catheter time (7 vs. 7 days), positive surgical margins (22.6% vs. 20.7%) and 12 months continence (86.7% vs. 84.9%). CONCLUSIONS: There was no significant difference between the extraperitoneal and transperitoneal approaches using the Heilbronn technique regarding all important parameters. In addition to the preference and experience of the individual surgeon, previous abdominal surgery, gross obesity and requirement of simultaneous inguinal hernia repair may be considered as selective indications for extraperitoneal laparoscopic radical prostatectomy.