Laparoscopic inguinal hernia repair: gold standard in bilateral hernia repair? Results of more than 2800 patients in comparison to literature.

BACKGROUND: Advantages and disadvantages of open and endoscopic hernia surgery are still being discussed. Until now there has been no study that evaluated the advantages and disadvantages of bilateral hernia repair in a large number of patients. METHODS: Our prospectively collected database was analyzed to compare the results of laparoscopic bilateral with laparoscopic unilateral hernia repair. We then compared these results with the results of a literature review regarding open and laparoscopic bilateral hernia repair. RESULTS: From April 1993 to December 2007 there were 7240 patients with unilateral primary hernia (PH) and 2880 patients with bilateral hernia (5760 hernias) who underwent laparoscopic transabdominal preperitoneal patch plastic (TAPP). Of the 10,120 patients, 28.5% had bilateral hernias. Adjusted for the number of patients operated on, the mean duration of surgery for unilateral hernia repair was shorter than that for bilateral repair (45 vs. 70 min), but period of disability (14 vs. 14 days) was the same. Adjusted for the number of hernias repaired, morbidity (1.9 vs. 1.4%), reoperation (0.5 vs. 0.43%), and recurrence rate (0.63 vs. 0.42%) were similar for unilateral versus bilateral repair, respectively. The review of the literature shows a significantly shorter time out of work after laparoscopic bilateral repair than after the bilateral open approach. CONCLUSIONS: Simultaneous laparoscopic repair of bilateral inguinal hernias does not increase the risk for the patient and has an equal length of down time compared with unilateral repair. According to literature, recovery after laparoscopic repair is faster than after open simultaneous repair. Laparoscopic/endoscopic inguinal hernia repair of bilateral hernias should be recommended as the gold standard.

Quantification of tumor cell burden by analysis of single cell lymph node disaggregates in metastatic prostate cancer.

BACKGROUND: The size of lymph node (LN) metastases in prostate cancer patients represents an important prognosticator, but histological work-up may not reflect the true extent of tumor invasion. We present a novel technique (1) to detect early tumor cell dissemination and (2) to quantify the true tumor burden. METHODS: Prospectively 232 LN of 20 consecutive patients with prostate cancer after lymph node dissection were longitudinally bisected, one half was subjected to single cell immunocytochemistry for pancytokeratine (CK), the other half underwent routine histopathological work-up and step section analysis. In immunocytochemistry, tumor cell density (TCD) was quantified by calculating the number of CK-positive cells/million leucocytes and compared to routine histopathology and step section analysis. RESULTS: Eight of 20 patients were positive in histopathology and step sectioning, but 14 of 20 patients were positive in single cell analysis. Twenty-five of 232 LN were positive in routine histopathology, whereas 52 of 232 LN were positive in single cell analysis. Median TCD in histopathologically positive LN was 3060.0 x 10(-6) and 9.9 x 10(-6) in histopathologically negative LN (P < 0.0001). Mean TCD of histopathologically negative LN of pN1 patients was significantly higher than the mean TCD of pN0 patients (P < 0.003). Mean TCD per patient correlated with serum-PSA (r(2) = 0.48, P < 0.006). CONCLUSIONS: Single cell analysis has an increased detection rate compared to routine histopathology and even to serial step section analysis. The method can detect early tumor dissemination and enables quantification of the tumor burden. The subgroup of histopathologically negative LN with CK-positive cells represents tumor cell dissemination not depicted histologically.

Modified concept for radioisotope-guided sentinel lymph node dissection in prostate cancer.

PURPOSE: To present a modified concept for sentinel lymph node (SLN)-guided pelvic lymph node dissection in prostate cancer. METHODS: A total of 463 patients with histologically proven prostate cancer underwent SLN-guided lymph node dissection. The day before surgery patients received intraprostatic injection of Tc-99 m-labeled nanocolloid (Tc-NC) under transrectal ultrasound guidance. At the time of surgery, the lymph nodes of the obturator fossa were dissected routinely in all patients. After meticulous testing with a handheld gamma probe, all lymphatic tissues in predefined anatomic regions (external iliac, internal iliac, common iliacal and presacral) with Tc-NC uptake were additionally resected. RESULTS: In 146 (12.8%) patients, SLN were located exclusively in the obturator fossa, but 317 patients (87.2%) underwent resection of additional sentinel regions. In 28 (6.1%) patients, 62 lymph node metastases were detected, and 32 (51.6%) of these were located outside the obturator fossa. Eight (28.6%) patients displayed lymph node metastases exclusively outside the obturator fossa and had been resected only because of positive SLN probing. CONCLUSIONS: The obturator fossa comprises the major landing site of lymph node metastases, but more than half of the metastases are located outside this anatomic region. Routine resection of the obturator fossa with additional resection of positive sentinel regions improves staging accuracy compared to resection of the obturator fossa only.