Postchemotherapy laparoscopic retroperitoneal lymph node dissection for low-volume, stage II, nonseminomatous germ cell tumor: first 100 patients.

BACKGROUND: Retroperitoneal lymph node dissection (RPLND) is indicated after chemotherapy in case of radiologic incomplete remission or teratomatous elements in orchiectomy specimens. Open RPLND is associated with considerable morbidity, but technical difficulty of postchemotherapy laparoscopic RPLND (L-RPLND) can be significant; therefore, literature concerning pc L-RPLND is sparse. OBJECTIVE: To evaluate feasibility and long-term oncologic outcome of postchemotherapy L-RPLND for clinical stage II disease at a single institution. DESIGN, SETTING, AND PARTICIPANTS: Records of patients with nonseminomatous germ cell tumor who underwent postchemotherapy L-RPLND between 1993 and 2010 were retrospectively reviewed. Unilateral template resection was used until a bilateral nerve-sparing approach was introduced in 2004. Follow-up investigations were performed at 3-mo intervals for the first 3 yr, every 6 mo for the next 2 yr, and annually thereafter. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: This was a descriptive analysis. RESULTS AND LIMITATIONS: The study cohort comprised 100 patients with stage II retroperitoneal disease (stage IIC: n=16; IIB: n=68; IIA with persisting tumor marker: n=16). Mean diameter of retroperitoneal masses before and after chemotherapy was 3.5 cm and 1.4 cm, respectively. Unilateral and bilateral templates were resected in 71 and 29 patients, respectively. Surgery was successfully completed in all but one patient, whose procedure was converted to open surgery due to bleeding. Mean operation time for unilateral and bilateral resection was 241 and 343 min, respectively. Mean blood loss was 84 ml. Postoperative complications were a large lymphocele in one patient and chylous ascites in another. Mean postoperative hospital stay was 3.9 d. L-RPLND specimens showed teratoma in 38 patients and active tumor in 2 patients. During a mean follow-up of 74 mo, one patient recurred. No recurrence was observed inside the applied surgical field. No patient died of tumor progression. After bilateral nerve-sparing postchemotherapy L-RPLND, 95.2% of patients reported antegrade ejaculation. CONCLUSIONS: Postchemotherapy L-RPLND performed by experienced hands is feasible and associated with low morbidity and high oncologic efficacy.

Changes of renal blood flow after ESWL: assessment by ASL MR imaging, contrast enhanced MR imaging, and renal resistive index.

The annual incidence of stone formation is increased in the industrialised world. Extracorporeal shockwave lithotripsy is a non-invasive effective treatment of upper urinary tract stones. This study is aimed to evaluate changes of renal blood flow in patients undergoing extracorporeal shock wave lithotripsy (ESWL) by arterial spin labeling (ASL) MR imaging, contrast enhanced dynamic MR imaging, and renal resistive index (RI). Thirteen patients with nephrolithiasis were examined using MR imaging and Doppler ultrasound 12h before and 12h after ESWL. ASL sequence was done for both kidneys and followed by contrast enhanced MR imaging. In addition RI Doppler ultrasound measurements were performed. A significant increase in RI (p<0.001) was found in both treated and untreated kidneys. ASL MR imaging also showed significant changes in both kidneys (p<0.001). Contrast enhanced dynamic MR imaging did not show significant changes in the kidneys. ESWL causes changes in RI and ASL MR imaging, which seem to reflect changes in renal blood flow.

A possible case of primary renal lymphoma: a case report.

INTRODUCTION: The entity primary renal lymphoma is controversial and rare. CASE PRESENTATION: We report a case in a 60-year-old man. Computed tomography revealed a large, homogeneous, retroperitoneal mass with 14.8 x 11.5 cm size arising from the right kidney. An ultrasound guided percutaneous biopsy was performed and the tumour was diagnosed histopathological as non-Hodgkin lymphoma. The patient was treated by systemic chemotherapy and thereafter a nephrectomy was performed. CONCLUSION: Primary renal lymphoma is a controversial and infrequent disease. However, there is growing evidence that it does exist.

Ureteroiliac fistula: a case report review of the literature.

INTRODUCTION: Ureteroiliac fistulas are rare but potentially life-threatening. Risk factors to develop a fistula are chronic indwelling ureteral stents, previous pelvic surgery and radiotherapy. CASE PRESENTATION: We report a case of a patient with intermittent gross hematuria after previous abdominal surgery, radiotherapy and indwelling ureteric stents. After several diagnostic and therapeutic procedures an ureteroiliac fistula could be finally identified and treated by endovascular stenting. CONCLUSION: Ureteroiliac fistula should be considered in any patient with intermittent gross hematuria and any of the known risk factors.

Allen key completely in male urethra: a case report.

INTRODUCTION: Various cases of self-inflicted foreign bodies in the male urethra have been reported. Most of them are associated with autoerotic stimulation, psychiatric disorders or intoxication. CASE PRESENTATION: We report the first case of a patient who put an Allen key completely in his urethra. The patient presented with dysuria, haematuria and penile pain. CONCLUSION: A self-inflicted urethral foreign body is a rare situation. Endoscopic removal is the recommended first-line treatment and if unsuccessful, open procedures may be necessary.

Robotic-assisted laparoscopic partial nephrectomy: surgical technique and clinical outcomes at 1 year.

OBJECTIVE: To report our surgical technique of robotic-assisted laparoscopic partial nephrectomy (RLPN) for renal tumours of <7 cm and present their clinical outcomes, as minimally invasive PN is an increasingly viable option for small renal tumours. PATIENTS AND METHODS: From July 2005 to December 2006, 20 consecutive patients (mean age 58.2 years, sd 7.9) had RLPN and a follow-up of > or =1 year, all surgery being undertaken by one surgeon. All cases were elective except in one patient with a solitary kidney. We used the three-arm da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA) in a four-port, transperitoneal approach. Transient vascular occlusion was applied in all cases using a tourniquet technique. The tumour was excised with a 5-mm margin using cold-cut scissors, and the margins were assessed by frozen sections. The specimen was placed in an impervious bag for subsequent removal via the camera port. Under direct vision, we repaired all pelvicalyceal system entries with absorbable sutures. After the entire tumour bed surface was lined with Floseal (Baxter Healthcare, Deerfield, IL, ISA) the capsule/parenchyma was closed with running suture, reinforced by haemostatic clips. RESULTS: The mean (sd) operative and warm ischaemia times were 82.7 (17.0) and 21.7 (2.4) min, respectively, and the mean estimated blood loss was 189 (32) mL. There were no intraoperative complications or conversion to open surgery. There was also no bleeding after surgery, perinephric haematoma or urinary leakage. The mean (sd) tumour size was 30.2 (2.4) mm, while margins were negative in all cases of malignancy. At the 1-year follow-up there was no local recurrence, renal functional deterioration or late surgical complications. CONCLUSIONS: Our RLPN technique is a safe and feasible option for small renal tumours. Reproducible technique and good team co-ordination are pivotal for obtaining good oncological and surgical outcomes.

Haemostatic sealants in nephron-sparing surgery: what surgeons need to know.

Surgical haemostatic agents have been increasingly applied for the control of bleeding, and have excellent potential in laparoscopy. Several factors are important when evaluating the use of sealants. We present a brief overview of the history, composition and mechanism of action of sealants, together with a report on experimental studies and clinical experience with haemostatic sealants. We searched for reports on haemostatic agents and their use in renal parenchymal haemostasis; 15 animal models studies and 11 papers on clinical experience were included. The development of haemostatic agents and instruments is allowing the wider diffusion of challenging procedures. Several experimental animal studies have shown the efficacy and safety of sealants for haemostasis during nephron-sparing surgery. Clinical studies confirm the effectiveness of synthetic or fibrin glue, in particular during laparoscopic surgery. Sealants are effective and safe topical agents to control bleeding during nephron-sparing surgery. They should not be viewed as an alternative, but as complementary agents to be used to improve surgical outcomes. Further prospective studies are necessary to validate their role in relation to other haemostatic support techniques.

Results of bilateral nerve sparing laparoscopic retroperitoneal lymph node dissection for testicular cancer.

PURPOSE: We evaluated the feasibility and early oncological outcome of a laparoscopic nerve sparing bilateral retroperitoneal lymph node dissection. The surgical technique is described. MATERIALS AND METHODS: From July 2004 to December 2007 a total of 42 patients with nonseminomatous germ cell tumor (21 with stage I, 2 with stage IIA marker negative and 19 with post-chemotherapy stage IIB disease) underwent transperitoneal bilateral laparoscopic retroperitoneal lymph node dissection. The sympathetic trunk and postganglionic nerves were identified, and lymphatic tissue was dissected between the nerves. Patients with clinical stage I and IIA disease that was lymph node positive at laparoscopic retroperitoneal lymph node dissection did not receive additional chemotherapy. RESULTS: Surgery was successfully completed in all patients and no conversion to open surgery was necessary. Mean operative time was 323 minutes. No intraoperative complications occurred. Of patients with stage I and marker negative stage IIA disease active tumor was found in 5 retroperitoneal lymph node dissection specimens, and no patients had recurrence. Of 19 patients with post-chemotherapy stage IIB disease teratoma was found in the lymphatic tissue in 4 (21.0%). No retroperitoneal recurrence was observed. Pulmonary metastases developed 9 months after surgery in 1 patient with stage I disease and negative retroperitoneal histology, and were treated successfully. All patients are currently free of disease at a mean followup of 17.2 months. Antegrade ejaculation was preserved in 36 patients (85.7%). CONCLUSIONS: Bilateral nerve sparing laparoscopic retroperitoneal lymph node dissection is feasible and associated with low morbidity if performed by experienced hands. The oncological efficacy of this approach is promising and currently under evaluation.

Another novel application of Hem-o-Lok clips for transient vascular occlusion in robot-assisted laparoscopic partial nephrectomy: an alternative to laparoscopic bulldog and Satinsky clamps.

We describe our technique of achieving transient vascular occlusion utilizing Hem-o-Lok clips during robotassisted laparoscopic partial nephrectomy (RLPN) A once-folded vascular loop is threaded through a 2-cm feeding tube. After passing around the renal vessel, its tail goes through the U-loop, creating a tourniquet. Vascular occlusion begins when the tube slides towards the vessel and a Hem-o-Lok clip is applied on the vascular loop next to the exposed end of the tube. When no longer needed, it is released. Since July 2006, 25 patients underwent RLPN utilizing this technique, which required <15 seconds to deploy for any vessel size. There were eight patients with multiple vessels. The mean operative time was 82.6 minutes, and the mean warm ischemia time was 22 minutes (range 17-27 minutes). There were no cases of intraoperative or postoperative bleeding. The technique is simple, inexpensive, and applicable to multiple vessels. It is a viable alternative to standard vascular occlusion techniques, such as laparoscopic bulldog or Satinsky clamps.

Retroperitoneal lymph node dissection after chemotherapy for germ cell tumours: is a full bilateral template always necessary?

OBJECTIVE: To evaluate the long-term oncological outcome in selected patients treated for nonseminomatous germ cell tumours (NSGCT) with a retroperitoneal lymph node dissection after chemotherapy (pcRPLND) and not using the full bilateral template. PATIENTS AND METHODS: From 1988 to 2005, 102 patients with retroperitoneal stage II NSGCT, who at initial presentation had metastases in the primary retroperitoneal site only, had pcRPLND within a restricted template, whether computed tomography showed complete or incomplete remission. In all, 78 patients had a unilateral template dissection and 24 an open modified template dissection. RESULTS: Of the 102 patients, 30 had stage IIC, 63 IIB, and nine tumour marker-positive stage IIA disease. Active tumour was found in two RPLND specimens; mature teratoma in 46 of the 102 patients, and necrosis/fibrosis in 54. Antegrade ejaculation was preserved in all 78 patients who had unilateral RPLND and in 18 of 24 who had a modified RPLND (overall antegrade ejaculation rate 94%). During a median follow-up of 102 months there were only three recurrences, two outside the retroperitoneum and one in the retroperitoneum. Only the latter was retrocaval, above the level of the inferior mesenteric artery within the boundaries of a full bilateral RPLND. This patient had had left unilateral template dissection after chemotherapy for IIC disease which was restricted to the para-aortic nodes. CONCLUSION: In a selected group of patients with stage II NSGCT, pcRPLND within the modified template might be oncologically efficient and allow ejaculation to be preserved.

Real-time virtual ultrasonographic radiofrequency ablation of renal cell carcinoma.

OBJECTIVE: To evaluate the usefulness of real-time virtual ultrasonography (RVS) as a new navigational tool for percutaneous radiofrequency ablation (RFA) of solid renal cell carcinoma (RCC). PATIENTS AND METHODS: Ten patients with 13 RCCs were treated with percutaneous RFA using RVS, which displays ultrasonograms and corresponding multiplanar reconstruction images of computed tomography in parallel. RESULTS: RVS allowed excellent anatomical visualization and precise navigation of RFA for RCC. All patients were treated successfully in one session with percutaneous RVS RFA. There were no significant complications, and none of the patients had a local tumour recurrence during the follow-up. CONCLUSION: RVS for RFA of solid RCC is a new and promising alternative imaging method.

Multimodal evaluation of renal perfusional changes due to extracorporeal shock wave lithotripsy.

OBJECTIVES: To examine the effect of extracorporeal shock wave lithotripsy (ESWL) on renal perfusion before and after treatment, by assessing renal resistive index (RI) using colour Doppler ultrasonography (CDUS), magnetic resonance perfusion imaging (MRPI), radionuclide renography and big-endothelin-1 values (Big-ET-1). PATIENTS AND METHODS: In 69 normotensive patients the RI was measured before, 1, 3, 6 and 24 h after ESWL using CDUS. The RI values, measured in interlobar/arcuate arteries, were correlated with the findings on MRPI, done before and within 24 h after ESWL. In addition, renal plasma flow (RPF, assessed on radionuclide renography) and Big-ET-1 levels (a potent vasoconstrictor peptide), served as a control for evaluating renal perfusion. The patients were stratified in three age groups, i.e. or=60 years, with 23 patients in each group. RESULTS: The mean (sd) RI increased significantly in the treated kidneys, from 0.64 (0.05) before to 0.72 (0.08) after ESWL (P = 0.001). Only in patients aged >or=60 years did the RI continue to increase over the 24 h. MRPI showed a decrease of renal blood flow (RBF) in all age groups, but most significantly in those aged >or=60 years. The radionuclide renography and big-ET-1 levels changed significantly only in the oldest group. The best correlation was between RI and RBF changes detected by MRPI. CONCLUSIONS: ESWL obviously causes disturbances of renal perfusion, particularly in elderly patients (>or=60 years). Measurement of RI with Doppler techniques might provide useful information for the clinical diagnosis of renal damage.

Comparison of contrast-enhanced color Doppler imaging (CDI), computed tomography (CT), and magnetic resonance imaging (MRI) for the detection of crossing vessels in patients with ureteropelvic junction obstruction (UPJO).

OBJECTIVE: To assess the use of contrast-enhanced color Doppler imaging (CDI), computed tomography (CT), and magnetic resonance imaging (MRI) for the detection of crossing vessels at the ureteropelvic junction (UPJ) in patients with ureteropelvic junction obstruction (UPJO). MATERIALS AND METHODS: Forty-eight patients aged 18-69 yr (mean age, 52) who had been diagnosed with an UPJO on intravenous pyelography and diuretic renography were included. Contrast-enhanced CDI was performed by using both color Doppler frequency and color Doppler amplitude ("Power") modes. Spiral CT was performed by using a three-phase CT (arterial, venous, and excretory phases) allowing for CT angiography. MRI technique included dual-phase magnetic resonance angiography (arterial, venous) for the assessment of respective arteries and veins. The type (ie, arterial or venous) and position of the vessel relative to the UPJ (ie, anterior or posterior) were assessed. The CDI, CT, and MRI findings were correlated with the surgical findings at laparoscopic pyeloplasty. RESULTS: Forty-four of 48 patients (92%) demonstrated crossing vessels at subsequent laparoscopy. Altogether a total of 60 vessels were detected. Contrast-enhanced CDI and MRI correctly detected all crossing vessels (accuracy, 100%), whereas CT missed four posterior crossing veins (accuracy, 93%). CONCLUSION: Contrast-enhanced CDI is recommended as first-line imaging modality for the detection of crossing vessels in patients with UPJO.

Fenestration of the Gerota's fascia as symptomatic treatment of floating kidneys.

A 16-year-old man presented with severe nephrotic syndrome complicated by massive perirenal fluid. Percutaneous drainage of fluid was performed 3 times, followed by improvement in renal function and hypertension, but perirenal fluid recurred within days. Nephrotic syndrome was unresponsive to steroid therapy. A laparoscopic bilateral fenestration of Gerota's fascia and peritoneum allowed permanent drainage of fluid into the peritoneal cavity. During the same procedure, a renal wedge biopsy was performed. Histological examination showed advanced focal glomerular sclerosis of the tip lesion variant. The glomerular disease was refractory to further treatment with cyclophosphamide, mycophenolate, and rituximab. However, perirenal fluid did not recur despite persistent nephrotic syndrome, showing that fenestration of Gerota's fascia is a successful treatment of floating kidneys in such patients.

Case report: laparoscopic ureteropyelostomy and distal ureterectomy for management of duplication with ectopia.

PURPOSE: To evaluate the role of laparoscopic ureteropyelostomy and subtotal ureterectomy for management of an ectopic ureter to the prostatic urethra. CASE REPORT: A 54-year-old man presented with complaints of paravertebral pain and recurrent prostatitis with elevation of the serum prostate specific antigen concentration. Diagnostic evaluation revealed right renal duplication with an ectopic ureter to the prostatic urethra. Using a four-port transperitoneal laparoscopic technique, a laparoscopic ureteropyelostomy and subtotal ureterectomy were performed. Diagnostic follow-up documented successful treatment with the minimally invasive technique. CONCLUSIONS: Laparoscopic ureteropyelostomy and subtotal ureterectomy provide effective treatment for this rare condition. The minimally invasive technique may also have clinical applications in the pediatric population.

Robotic Anderson-Hynes pyeloplasty: 5-year experience of one centre.

OBJECTIVE: To present our 5-year experience with robotically assisted laparoscopic pyeloplasty (RALP), as LP has been shown to have similar success rates as open surgery, but standard LP requires high operative skills and a correspondingly long period of training, limiting its widespread availability, and RALP is easier and quicker to learn due to facilitated intracorporeal suturing. PATIENTS AND METHODS: In all, 92 patients had transperitoneal RALP for pelvi-ureteric junction obstruction (PUJO) using the daVinci system (Intuitive Surgical, Sunnyvale, CA, USA). A transperitoneal dismembered Anderson-Hynes procedure was used in all cases. Three robotic ports and one assistant port were used in all cases while a JJ stent was left indwelling for 6 weeks. Both primary PUJO (including horseshoe kidneys in 80 cases) and secondary (in 12 cases) were considered eligible. The follow-up included ultrasonography, excretory urography and renal scintigraphy. RESULTS: The mean follow-up was 39.1 months; PUJO was successfully resolved in 89 patients (96.7%) while three required additional procedures. Haemorrhage into the collecting system and urine extravasation occurring early after surgery were the causes of failure. The mean (range) operative duration, including the set-up of the robot, was 108.34 (72-215) min; the mean duration of docking and surgery significantly decreased with experience (P < 0.001). The mean hospital stay was 4.57 days. Split renal function improved from 37.6% to 41.9%. No cases of secondary PUJO were recorded during extended follow-up. CONCLUSIONS: RALP using the daVinci system is safe and effective, achieving similar long-term success rates to open surgery. The three-dimensional versatility of the robot enables the surgeon to recapitulate the open procedure. The results were durable with no cases of late complications, corroborating the accuracy of robot-assisted intracorporeal suturing and the subsequent quality of the pelvi-ureteric anastomosis. Moreover, the robotic approach was easy and quick to learn for both the surgical and the technical staff. Therefore, RALP is our preferred technique to treat PUJO.

Long-term results of laparoscopic retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testicular cancer.

PURPOSE: To report the long-term oncologic outcome and morbidity of laparoscopic retroperitoneal lymph-node dissection (L-RPLND) in clinical stage I nonseminomatous testicular germ-cell tumors (NSGCT) from a single institution. PATIENTS AND METHODS: From August 1992 to May 2005, 136 patients with clinical stage I disease underwent L-RPLND. The mean follow-up was 68 months (range 8-151 months). Patient selection was not based on histologic findings or the presence of risk factors. Lymphadenectomy was performed within the boundaries described by Weissbach and Boedefeld. RESULTS: The laparoscopic procedure could be completed in 129 patients (94.9%). Seven required conversion to open surgery. The median blood loss was 50 mL (range 20-3000 mL), and the mean operative time was 261 minutes (range 115-570 minutes). There were no perioperative deaths. The mean postoperative hospital stay was 4.1 days. Antegrade ejaculation was preserved in all patients. In the series, 25 patients (18.4%) had pathologic stage IIA disease and received adjuvant chemotherapy consisting of two cycles of cisplatin, etoposide, and bleomycin; none of these patients has relapsed. Eight patients (5.9%) suffered relapses, although L-RPLND had yielded negative lymph nodes in all of them. All eight patients were salvaged with cisplatin-based chemotherapy, with surgery also performed in two patients. All other patients (N = 128, 94.1%) remained relapse free. None of the patients died because of tumor progression. CONCLUSIONS: The L-RPLND has proved to be an excellent staging tool, which should be developed into a less-invasive alternative to primary open RPLND. The oncologic outcome of L-RPLND without adjuvant chemotherapy in pathologic stage II disease is being investigated.

The use of three-dimensional computed tomography for assessing patients before laparoscopic adrenal-sparing surgery.

OBJECTIVE: To evaluate the efficacy of three-dimensional computed tomography (3D-CT) in delineating the relationship of the adrenal mass to adjacent normal structures in preparation for laparoscopic partial adrenalectomy. PATIENTS AND METHODS: Multislice CT (1 mm slices, 0.5 s rotation time) was used to evaluate 12 patients before adrenal-sparing surgery for aldosterone-producing adenoma or phaeochromocytoma. The CT data were reconstructed using two rendering techniques; (i) volume rendering with the modified VOLREN software (Johns Hopkins Hospital, Baltimore, MD, USA) which allowed interactive 3D examination of the whole data volume within a few minutes; (ii) surface representations only of the interesting structures (kidney, adrenal tumour, vessels) represented in different colours and depicted together in a 3D scene using the software package 3DVIEWNIX. RESULTS: In all, 14 adrenal masses in 12 patients were evaluated with 3D-CT; the number and location of lesions was accurate in all cases with both rendering techniques. The coloured surface-rendered images showed a consistently better delineation of the adrenal tumour from the normal tissue than did the volume-rendering technique. From this information all laparoscopic partial adrenalectomies could be completed as planned. CONCLUSIONS: Interactive visualization of volume-rendered CT images was helpful for the planning and successful performance of the procedure, but coloured surface-rendered CT provided more convenient, immediate and accurate intraoperative information.

Laparoscopic varicocele ligation in children and adolescents using isosulphan blue: a prospective randomized trial.

OBJECTIVES: To evaluate, in a randomized prospective trial in children and adolescents, the feasibility of isosulphan blue-based lymphatic vessel preservation during laparoscopic varicocelectomy and its impact on the complication rate, as the operative management of varicoceles remains controversial. PATIENTS AND METHODS: In all, 50 consecutive patients were randomly assigned to two laparoscopic varicocelectomy groups. The indications for surgery included scrotal pain and a difference in testicular size, as well as severe cosmetic impairment. All the patients had a laparoscopic varicocelectomy using three ports. Patients in group A had standard laparoscopy, while those in group B had additional isosulphan blue administered. After surgery, the patients were assessed at 3, 6 and 12 months for varicocele recurrence, hydrocele formation, atrophy, pain or other complications. RESULTS: There were no intraoperative complications or conversions to open surgery. There were no adverse reactions, scrotal haematomas or atrophy. At 3 months after surgery, the incidence of hydrocele in group A was 20% whereas in group B no hydroceles were detected (P = 0.025); at 6 months the 20% still had hydroceles. One patient in each group had varicocele recurrence associated with persistent pain. In two patients in group B, blue pigmentation of the left hemiscrotum persisted at the 3-month follow-up but resolved by 6 months. CONCLUSIONS: Laparoscopic repair of varicoceles using isosulphan blue helps to identify and preserve the lymphatic drainage. It prevents secondary hydrocele formation, the most common complication, with no supplementary risk to the patient. Also, testicular oedema causing impaired spermatogenesis can be avoided.