Posterior reconstruction of the rhabdosphincter allows a rapid recovery of continence after transperitoneal videolaparoscopic radical prostatectomy.

OBJECTIVES: Urinary incontinence is one of the major drawbacks of radical retropubic prostatectomy (RRP). One of the possible reasons for this urinary incontinence is a postoperative deficiency of the rhabdosphincter (RS). It has been recently demonstrated that reconstruction of the posterior aspects of the RS allows a rapid recovery of continence after RRP. This study evaluated the application of this technique in videolaparoscopic radical prostatectomy (VLRP), assessing the percentage of continent patients at 3, 30, and 90 d after catheter removal. METHODS: A two-arm prospective comparative trial was carried out with 31 patients recruited for each arm. Group A underwent standard VLRP and group B underwent VLRP with RS reconstruction (VLRP-R). Continence was defined as no pads or one diaper/24h and was assessed 3, 30, and 90 d after the procedure. RESULTS: At catheter removal, 74.2% versus 25% (p=0.0004) of patients were continent with the VLRP-R technique versus VLRP, respectively. A statistically significant difference was present at 30 d (83.8% vs. 32.3%; p=0.0001) At 90 d the difference, although still present, was not statistically significant (92.3% vs. 76.9%; p=0.25). CONCLUSIONS: In this preliminary report, the posterior reconstruction of the RS appears to be an easy and feasible technique even in a laparoscopic setting. Time to continence recovery was significantly shortened.

Renal artery embolization for kidney trauma.

Kidney trauma occurs in approximately 1-5% of all traumas with the male to female ratio being 3:1. In this paper we reported two cases of male patients with kidney trauma treated by renal artery embolization. Endo-vascular embolization is an efficient method for the treatment of patient with severe renal haemorrhage preserving loss of renal parenchyma and renal function.

Oncologic outcome and continence recovery after laparoscopic radical prostatectomy: 3 years' follow-up in a "second generation center".

OBJECTIVES: Laparoscopic radical prostatectomy in major centers guarantees oncologic and functional results equal to open procedures. In our institution this operation was introduced in 2001 after an adequate training in laparoscopic surgery. We report the oncologic and functional results after 3 years of experience. METHODS: We considered our first 150 patients that had undergone transperitoneal laparoscopic radical prostatectomy. The following parameters were prospectively collected and analyzed: pathological findings, surgical margins, surgical time, blood loss, hospital stay, catheterization, complications, oncologic follow-up and continence. RESULTS: Single positive surgical margins were observed in 26 patients (17.3%) and multiple positive margins in 15 patients (10%). The rates of positive margins in organ confined tumors (pT2a/b) were 11.3%. Preoperative PSA>10 ng/ml (Chi-square p<0.01), pathological stage>pT2 (Chi-square p<0.001) and Gleason score>6 (Chi-square p<0.01) were significantly correlated with positive margins. Major complications occurred in 16 patients (10.7%). The total recurrence rate is 11.7%. The continence rate at 12 months is 91.7%.with 44.3% of patients completely continent at the moment of catheter removal. CONCLUSIONS: Laparoscopic radical prostatectomy in now a well codified operation that, after an adequate training, could be learned and reproduced safely. Actually this is our first choice surgical approach in patients with localized prostate cancer.

Laparoscopic radical cystoprostatectomy: our experience in a consecutive series of 10 patients with a 3 years follow-up.

OBJECTIVE: Laparoscopic radical cystectomy is a feasible procedure but there is still controversy if laparoscopic treatment of transitional cell carcinoma (TCC) of the bladder is oncologically safe. We report our experience with laparoscopic radical cystectomy in a consecutive series of 10 male patients with a 3 years follow-up. METHODS: Between June 2001 and July 2002, 10 men age 63 to 74 years (mean 68.8) underwent laparoscopic cystoprostatectomy with urinary diversion for muscle-invasive TCC or pT1 G3 TCC plus carcinoma in situ (Cis) after 2 cycles of intravesical bacille Calmette-Guerin therapy and three or more transurethral resections (delayed cystectomy). RESULTS: Histopathology revealed 2 stage pT1N0 TCC G3 plus Cis, 1 stage pT2aN0 TCC G3 plus Cis, 1 stage pT2bN0 TCC G2, 4 stage pT2bN0 TCC G2-3, 1 stage pT2bN0 TCC G3, 1 stage pT3aN0 TCC G3. The mean follow-up is 30.4 months (range 23-36). No local recurrences, peritoneal carcinosis or trocar-site metastases occurred. Metastases presented in 4 of 10 cases (2 patients with a stage pT1N0 plus Cis and 2 patients with a stage pT2bN0 TCC) respectively after 7, 14, 16 and 28 months. These patients died respectively at 20, 18, 22 and 31 months later. One patient died for unrelated causes. Five patients are alive, free from disease. CONCLUSIONS: Laparoscopic radical cystectomy is feasible and accomplished with low morbidity. Up to now publishing data do not support a verified negative oncological effect of the laparoscopy in the treatment of bladder TCC, but our initial results seem worst than those achieved with open surgery. The experience of other Institutions will help to provide objective evaluation of this new and controvers technique because it is not clearly demonstrated that laparoscopic radical cystectomy is an oncologically safe procedure in the management of bladder TCC. Thus in our opinion it should be still considered experimental.

Another route for retrieval of a Foley catheter when balloon does not deflate.

Failure of a Foley balloon to deflate is a rare complication that can be initially managed with various noninvasive procedures. If the balloon remains inflated, direct puncture of the balloon may be required. We describe a minimally invasive percutaneous transperineal transprostatic balloon puncture.

Laparoscopic radical prostatectomy: perioperative complications in an initial and consecutive series of 80 cases.

OBJECTIVES: We retrospectively evaluated the intraoperative and early postoperative complications of the initial experience with the first 80 laparoscopic radical prostatectomies performed at our institution. METHODS: Between January 17, 2001 and July 24, 2002, 80 patients between 53 and 78 years old (mean age 63.8) with clinically localized prostate cancer underwent laparoscopic radical prostatectomy with the Montsouris technique. A total of 24 (30%) staging pelvic lymphadenectomy were performed. The inpatient and outpatient medical records as well as all complications were reviewed. RESULTS: The pathological tumor stage revealed 18 pT2a (22.5%), 29 pT2b (36.25%), 21 pT3a (26.25%), 10 pT3b (12.5%), 1 pT4 (1.25%), 1 pT4 N1 (1.25%). No conversion was necessary in all cases. Mean operative time was 218 minutes (range 150-420) overall, mean blood loss was 376 ml (range 50-1000) and the mean postoperative hospital stay was 4.5 days (range 3-9). The mean and the median duration of bladder catheterization were respectively 11 and 10 days (range 7-23). Injury to the epigastric vessels was detected intraoperatively in 5 cases (6.25%) with immediate hemostasis achieved. There was 1 death (1.25%) 35 days after a cerebrovascular accident occurred on postoperative day 3. We observed 1 (1.25%) postoperative ileus, hemoperitoneum in 5 cases (6.25%), 2 (2.5%) acute urinary retentions, 6 (7.5%) anastomotic leakages, 1 (1.25%) anastomotic stricture, 1 (1.25%) hydrocele and 2 (2.5%) urinary tract infections. CONCLUSIONS: In our initial experience laparoscopic radical prostatectomy was performed with no complications in 77.5% of patients. We observed major and minor complications respectively in 16.25% and 6.25% of the patients. Our series provides evidence that the laparoscopic approach is feasible and associated with acceptable perioperative morbidity.

Laparoscopic radical cystoprostatectomy: a technique illustrated step by step.

OBJECTIVES: Laparoscopic surgery is expanding among urologists as a minimally invasive treatment and may now be applied to treat neoplasms of the pelvic organs. Laparoscopic cystoprostatectomy has still not been well codified and illustrated. We describe a technique of laparoscopic radical cystoprostatectomy that we have developed in 10 patients after practicing in laparoscopic radical prostatectomy. METHODS: Between June 2001 and July 2002, 10 men with bladder cancer underwent laparoscopic cystoprostatectomy with urinary diversion. This report details step by step our 5-port transperitoneal technique with primary access to the seminal vesicles and Denonvillier's fascia, ureters detection after umbilical arteries incision, endopelvic fascia incision and dorsal vein complex control before division of the vesical and prostatic fibrovascular pedicles with a harmonic scalpel. RESULTS: We performed 6 orthotopic ileal neobladders, 2 sigmoid ureterostomies and 2 cutaneous ureterostomies. In all cases no conversion to open surgery was necessary. The mean time to perform the laparoscopic radical cystoprostatectomy, including the lymph node dissection, was 166 minutes (range 150-180). Mean estimated blood loss was 310 ml (range 220-440). Mean hospital stay was 8.1 days (range 7-9) for ileal orthotopic neobladder, 8 days (range 7-9) for sigmoid ureterostomy and 5 days for cutaneous ureterostomy. The mean follow up is 12.3 months (range 5-18). Two patients respectively with stage T2bN0 G2-3 and stage pT1N0 (plus carcinoma in situ) G3 transitional cell carcinoma and surgical margins tumor free had diffusive metastatic disease after 6 months. The other 8 patients are free from disease. CONCLUSIONS: Laparoscopic radical cystectomy is still an operation for pioneers but this procedure may be not strictly relegated to a few academic centers. In our opinion laparoscopic cystoprostatectomy is a feasible, fast, safe and easy procedure and urinary diversion may be performed with a laparoscopic, open or combined approach without reducing the advantages of laparoscopy.