Robot-assisted laparoscopic sacrocolpopexy as management for pelvic organ prolapse.

BACKGROUND AND PURPOSE: Robot-assisted laparoscopic sacrocolpopexy (RALS) is a new surgical management option for pelvic organ prolapse that secures the apex of the vagina to the sacral promontory. Limited literature exists on outcomes of this procedure. We present our initial experience with RALS. PATIENTS AND METHODS: Women with vaginal vault prolapse and significant apical defects as defined by a Baden-Walker score of 3 or greater were offered RALS without any other procedure. Chart review was performed to analyze operative and perioperative data, including urodynamics (UDS) and Baden-Walker classification before and after surgery. Data were analyzed with comparison of presurgical and postsurgical data. RESULTS: From July 2005 through July 2007, 21 patients underwent RALS. Blood loss was negligible. Average operative time, including robot docking, was 3 hours, 14 minutes. Nineteen patients were discharged on postoperative day 1. UDS were not changed significantly. One patient had an apical recurrence. There were no operative complications or conversions; however, one patient had a small bowel obstruction 5 days after surgery necessitating laparotomy. Of the 21 patients, 12 have undergone anterior and posterior repair, 5 await repair, and 4 patients have opted for conservative management. CONCLUSIONS: RALS is effective to repair apical vaginal defects in patients with significant pelvic organ prolapse. Operative time is manageable and complications are few. Cystocele, rectocele, and UDS remain essentially unchanged by RALS. Most, if not all, patients with cystocele and rectocele will need further vaginal reconstruction after RALS, if desired. Greater follow-up and numbers are needed to further establish the role of this procedure.

Pure laparoscopic radical nephrectomy for stage T(3b) renal-cell carcinoma: more than 2-year follow-up.

BACKGROUND AND PURPOSE: Renal-vein tumor thrombus associated with renal malignancy has traditionally been approached with open surgery, and preoperative diagnosis of stage T(3b) renal tumors often mandates open surgery. However, early arterial division and "milking" of the thrombus away from the inferior vena cava may facilitate laparoscopic surgery. We describe our single-surgeon experience with laparoscopic nephrectomy in patients with tumor extension into the renal vein. PATIENTS AND METHODS: Among 240 laparoscopic nephrectomies performed by a single surgeon from 2002 to 2005, six patients (2.6%) were found to have renal-vein tumor thrombus. These patients included three men and three women with a mean age of 55.8 years (range 43-78 years). Data collected prospectively were evaluated to characterize this cohort. RESULTS: All six tumors were right-sided, stage T(3b), and all were managed laparoscopically without major complications. Three tumors were suspected to have renal-vein thrombus on preoperative imaging; the other three tumor thrombi were discovered on pathologic examination. The mean tumor size was 9.5 cm (range 7.5-11.5 cm). Two tumors were grade 2, three were grade 3, and one patient had a grade 4 rhabdoid cell-type tumor. At a mean follow-up of 27 months, all patients were without evidence of disease with the exception of the patient with grade 4 disease, who developed recurrence in the chest. CONCLUSION: Laparoscopic nephrectomy for tumor with renal-vein thrombus can be accomplished safely with adherence to proper oncologic techniques.

Management of nonpalpable incidental testicular masses.

PURPOSE: We report on 4 patients who presented with nonpalpable testicular masses discovered on scrotal ultrasound, and offer treatment recommendations based on our experience and a review of the literature. MATERIALS AND METHODS: Four patients underwent intraoperative ultrasound guided localization and excisional biopsy of nonpalpable testicular parenchymal masses. Radical orchiectomy was performed in 2 patients because of testicular cancer. Patient age, clinical presentation, ultrasound results, frozen section and permanent pathology results are reported. RESULTS: During a 3-year period 1,040 scrotal ultrasounds were performed for indications other than retroperitoneal mass at a single institution, and nonpalpable testicular parenchymal masses were discovered in 4 patients with an age range of 22 to 31 years. Testis mass size ranged from 5 to 6 mm in maximum diameter and serum tumor markers were negative in all patients. Frozen section pathology indicated benign lesions in all patients and permanent pathology revealed seminoma in 2 of the patients who underwent delayed radical orchiectomy. Permanent pathology of orchiectomy specimens did not reveal residual invasive tumor. CONCLUSIONS: Intraoperative ultrasound guided localization and excisional biopsy is a reasonable treatment option for patients with nonpalpable incidental testicular masses. Excisional biopsy with margins that show normal testicular tissue is essential in testis sparing surgery and patients must be cautioned that final pathology may indicate the need for delayed radical orchiectomy.