Diverticulectomía laparoscópica: técnica sistematizada / Laparoscopic diverticulectomy: a systemised technique

Objetivos: Presentar una técnica original para la diverticulectomía vesical laparoscópica sin necesidad de disecar la pared diverticular, haciendo el procedimiento seguro y significativamente más simple. Material y métodos: Entre septiembe de 2014 a abril de 2016 se intervinieron 4 pacientes. El diagnóstico se realizó en todos los casos por ecografía, y el estudio incluyó un análisis de sangre y orina con urocultivo, citologías urinarias, TAC con contraste, cuestionario de síntomas prostáticos (IPSS), flujometría y cistoscopia. Un caso precisó resección transuretral de próstata en un primer tiempo. Resultados: La edad media de los pacientes fue de 64 años (rango: 56-71). El tamaño diverticular medio fue de 4 cm (rango: 3-6). La localización fue retrotrigonal en todos los casos, 2 de ellos en el lado izquierdo, uno retromeático derecho y un cuarto próximo a la línea media. El tiempo quirúrgico medio fue de 146 min (rango: 120-180), acortándose en cada nuevo caso. No hubo sangrado significativo, complicaciones o conversión a cirugía abierta en ningún caso. El postoperatorio cursó sin incidencias. La estancia hospitalaria fue de 3 días en 3 casos y 48h en el otro (media 3,5 días). La sonda se retiró ambulatoriamente a los 14 días. Conclusiones: La experiencia inicial con la técnica descrita demuestra ser segura y reproducible, con resultados similares a otras técnicas laparoscópicas actuales. Eludir la disección de la pared diverticular reduce la dificultad técnica del procedimiento de forma significativa

Objectives: To present an original technique for laparoscopic vesical diverticulectomy without the need for dissecting the diverticular wall, thereby making the procedure safe and significantly simpler. Material and methods: Four patients were operated on between September 2014 and April 2016. The diagnosis was made by ultrasonography in all cases, and the study included blood and urine analyses with urine cultures, urine cytology, contrast-enhanced CT scans, prostate symptom questionnaire (International Prostate Symptom Score), flowmetry and cystoscopy. One case required transurethral prostate resection in a first time. Results: The mean age of the patients was 64 years (range: 56-71). The mean diverticulum size was 4cm (range: 3-6). The location was retrotrigonal in all cases, on the left side in 2 cases, right retromeatic in 1 case and near the midline in 1 case. The mean surgical time was 146min (range, 120-180), shortening for each new case. There were no significant bleeding, complications or conversion to open surgery in any of the cases. The postoperative period had no incidences. The hospital stay was 3 days in 3 cases and 48h in the other case (mean, 3.5 days). The catheter was withdrawn in the outpatient clinic at 14 days. Conclusions: The initial experience with the technique described above shows it to be safe and reproducible, with results similar to other current laparoscopic techniques. Avoiding the dissection of the diverticular wall significantly reduces the technical difficulty of the procedure

Laparoscopic diverticulectomy: A systemised technique. / Diverticulectomía laparoscópica: técnica sistematizada.

OBJECTIVES: To present an original technique for laparoscopic vesical diverticulectomy without the need for dissecting the diverticular wall, thereby making the procedure safe and significantly simpler. MATERIAL AND METHODS: Four patients were operated on between September 2014 and April 2016. The diagnosis was made by ultrasonography in all cases, and the study included blood and urine analyses with urine cultures, urine cytology, contrast-enhanced CT scans, prostate symptom questionnaire (International Prostate Symptom Score), flowmetry and cystoscopy. One case required transurethral prostate resection in a first time. RESULTS: The mean age of the patients was 64 years (range: 56-71). The mean diverticulum size was 4cm (range: 3-6). The location was retrotrigonal in all cases, on the left side in 2 cases, right retromeatic in 1 case and near the midline in 1 case. The mean surgical time was 146min (range, 120-180), shortening for each new case. There were no significant bleeding, complications or conversion to open surgery in any of the cases. The postoperative period had no incidences. The hospital stay was 3 days in 3 cases and 48h in the other case (mean, 3.5 days). The catheter was withdrawn in the outpatient clinic at 14 days. CONCLUSIONS: The initial experience with the technique described above shows it to be safe and reproducible, with results similar to other current laparoscopic techniques. Avoiding the dissection of the diverticular wall significantly reduces the technical difficulty of the procedure.

Análisis de los factores que influyen en la pérdida hemática en la nefrolitotomía percutánea: registro de la Asociación Española de Urología sobre la posición supina / Analysis of the Factors Affecting Blood Loss in Percutaneous Nephrolithotomy: A Registry of the Spanish Association of Urology in the Supine Position

Objetivo: La nefrolitotomía percutánea (NLP) es la técnica mínimamente invasiva de elección para el tratamiento de la litiasis renal mayor de 2 cm. El objetivo de este estudio es analizar los diferentes factores que influyen en el descenso de hemoglobina durante el procedimiento, realizado en posición supina. Material y métodos: Realizamos un estudio prospectivo multicéntrico observacional de la nefrolitotomía percutánea en posición supina, basado en el registro de la AEU. Se estudian los diferentes factores que influyen en el descenso de hemoglobina: datos demográficos y antropométricos, comorbilidad asociada, localización y tamaño de la litiasis, variantes anatómicas y aspectos técnicos del procedimiento. Resultados: Desde septiembre de 2008 hasta diciembre de 2012 se han registrado 397 NLP en posición supina, realizadas en 15 centros españoles. El descenso medio de hemoglobina fue 2,3 ± 1,5 g/dl y la tasa de transfusión de 5,5%. No hubo diferencias significativas en el descenso de hemoglobina entre varones y mujeres, IMC ni por grupos de edad. Tampoco existen diferencias entre los pacientes con antecedentes cardiovasculares, diabetes, HTA o tratamiento anticoagulante. El tamaño y la localización de la litiasis no influyen de forma significativa en la pérdida hemática. La duración del procedimiento (> o < 120 min), técnica de punción (ecografía, fluoroscopia), el tipo de dilatación del trayecto percutáneo (Alken, balón o Amplatz) y la ausencia de catéter de nefrostomía final (tubeless) no afectaron al descenso de hemoglobina. Únicamente el número de trayectos percutáneos (≥ 2) y el acceso a través de un cáliz medio tuvieron repercusión estadísticamente significativa en la pérdida hemática (p = 0,03 y p = 0,01 respectivamente) (AU)

Conclusiones: La NLP en posición supina es un procedimiento mínimamente invasivo para el tratamiento de litiasis renales múltiples y de gran tamaño (> 2 cm), que implica escasa pérdida hemática, con mínima tasa de transfusión de hemoderivados. Los únicos factores relacionados con mayor descenso de hemoglobina fueron el número de accesos percutáneos y la localización del trayecto en el cáliz medio (AU)

Objective: Percutaneous nephrolithotomy (PCNL) is the minimally invasive procedure of choice for removing renal stones larger than 2 cm. This study has aimed to identify the different variables that might influence decrease of hemoglobin during the surgery performed in supine position. Material and methods: A prospective, multicenter, observational study of supine PCNL, based on the Spanish Association of Urology database, was analyzed. The different preoperative and postoperative factors that might affect the decrease of hemoglobin were assessed: demographics and anthropometric data, comorbidities, size and location of the stones, anatomical variants and technical aspects of the procedure. Results: From September 2008 to December 2012, 397 supine PCNL procedures performed in 15 Spanish centers were registered. Mean hemoglobin decrease was 2.3 ± 1.5 g/dl and overall blood transfusion rate was 5.5%. No statistically significant differences were found between genders, body mass index (BMI) and age in terms of blood loss. There were also no differences between patients with cardiovascular, hypertensive, diabetic and anticoagulant treatment background. Blood loss was not significantly influenced by stone size and location. Technical aspects of the procedure as operative time (> 120 min ≤), access to the pelvi-caliceal system (ultrasound, fluoroscopy), percutaneous tract dilation technique (Alken, balloon or Amplatz) or placement of nephrostomy (tube versus tubeless) were not associated with differences in pre-op/post-op hemoglobin. Only multiple percutaneous tracts (≥ 2) and middle calix access were statistically significantly (P = 0.03 and P = 0.01) related with less blood loss (AU)

Conclusions: PCNL in supine position is a minimally invasive procedure for removal of large (≥ 2 cm) and multiple renal stones, with a low incidence of blood loss and minimal transfusion rate. Multiple percutaneous tracts and middle calix puncture were the only statistically significant variables associated with decrease in hemoglobin levels (AU)

Analysis of the factors affecting blood loss in percutaneous nephrolithotomy: a registry of the Spanish Association of Urology in the supine position.

OBJECTIVE: Percutaneous nephrolithotomy (PCNL) is the minimally invasive procedure of choice for removing renal stones larger than 2 cm. This study has aimed to identify the different variables that might influence decrease of hemoglobin during the surgery performed in supine position. MATERIAL AND METHODS: A prospective, multicenter, observational study of supine PCNL, based on the Spanish Association of Urology database, was analyzed. The different preoperative and postoperative factors that might affect the decrease of hemoglobin were assessed: demographics and anthropometric data, comorbidities, size and location of the stones, anatomical variants and technical aspects of the procedure. RESULTS: From September 2008 to December 2012, 397 supine PCNL procedures performed in 15 Spanish centers were registered. Mean hemoglobin decrease was 2.3±1.5 g/dl and overall blood transfusion rate was 5.5%. No statistically significant differences were found between genders, body mass index (BMI) and age in terms of blood loss. There were also no differences between patients with cardiovascular, hypertensive, diabetic and anticoagulant treatment background. Blood loss was not significantly influenced by stone size and location. Technical aspects of the procedure as operative time (> 120 min ≤), access to the pelvi-caliceal system (ultrasound, fluoroscopy), percutaneous tract dilation technique (Alken, balloon or Amplatz) or placement of nephrostomy (tube versus tubeless) were not associated with differences in pre-op/post-op hemoglobin. Only multiple percutaneous tracts (≥2) and middle calix access were statistically significantly (P=.03 and P=.01) related with less blood loss. CONCLUSIONS: PCNL in supine position is a minimally invasive procedure for removal of large (≥2 cm) and multiple renal stones, with a low incidence of blood loss and minimal transfusion rate. Multiple percutaneous tracts and middle calix puncture were the only statistically significant variables associated with decrease in hemoglobin levels.

El aprendizaje de la nefrolitectomía percutánea en posición supina. Estudio observacional multicéntrico / Learning of percutaneous nephrolithotomy in supine position. An observational multicenter study

Objetivo: Estudiar prospectivamente los resultados operatorios y las complicaciones de la nefrolitectomía percutánea (NLP) en posición supina para valorar la dificultad de su aprendizaje y cómo afecta la experiencia a los resultados. Establecer una comparación relativa con los datos publicados en la literatura acerca de la posición en prono. Material y métodos: Estudio prospectivo observacional multicéntrico sobre NLP en posición de Valdivia o en su variante de Galdácano. Se recogen variables demográficas y variables específicas dependientes de la litiasis. Se valoran aspectos técnicos, tiempo quirúrgico, tasa de éxito y complicaciones según la clasificación de Clavien-Dindo. Resultados: Desde septiembre de 2008 a junio de 2011 se han registrado 335 NLP en posición supina realizadas en 13 centros españoles. La proporción hombre/mujer fue 1:1,28 y la edad media 51,3 + 14,5 años; 211 (63%) casos fueron realizados por urólogos con experiencia de > 50 casos y 124 (37%) por urólogos con menos experiencia. El tiempo operatorio medio fue 113,3±46,4min, 106,6±38,2 en experimentados vs. 124,9±56,2 en noveles (p<0,002). No se detectó diferencia en el tamaño medio de la litiasis, pero en el grupo con experiencia se trató una mayor proporción de casos coraliformes y de litiasis múltiples que en el grupo novel (p<0,001). La tasa de éxito evaluada como ausencia total de restos litiásicos fue 69,6%, sin diferencias entre grupos (68,2 vs. 71,8%). En 102 (30,6%) pacientes hubo litiasis residual, precisando tratamiento complementario 60 (17,9%). La tasa relativa de éxito global fue 82,1% y la tasa de complicaciones 25,4%, sin detectarse diferencias entre grupos. No obstante, el grupo novel presentó mayor número de complicaciones mayores (p>0,001). Conclusión: La NLP en supino está teniendo una rápida y consolidada difusión en nuestro entorno, y su efectividad y seguridad parece equivalente a la descrita en la literatura para la NLP en prono. Resulta posible conseguir buenos resultados con una modesta curva de aprendizaje. La tasa de complicaciones mayores asociadas al procedimiento disminuye con la experiencia (AU)

Objective: To prospectively study the post-operative results and complications of percutaneous nephrolithotomy (PNL) in supine position to assess difficulty of learning it and how experience affects the results. To establish a relative comparison with the data published in the literature on the prone position. Material and methods: A prospective observational multicenter study on PNL in Valdivia position or in its Galdakao variant was performed. Demographic variables and specific variables related to the lithiasis were collected. Technical aspects, surgery time, success rate and complications according to the Clavien-Dindo classifications were assessed. Results: A total of 335 PNL in supine position conducted in 13 Spanish centers were registered from September 2008 to June 2011. The man: woman ratio was 1:1.28 and mean age 51.3 + 14.5 years. 211 (63%) cases were performed by urologists with experience in > 50 cases and 124 (37%) by urologists with less experience. Mean operation time was 113.3±46.4min, 106.6±38.2 for the experienced ones vs. 124.9±56.2 in the novice ones (P<0.002). No difference was detected in the mean size of the lithiasis. However, in the experienced group, there was a greater proportion of coraliform cases and multiple lithiasis than in the novice group (P<0.001). Success rate evaluated as total absence of lithiasic residuals was 69.6%, without differences between groups (68.2 vs. 71.8%). In 102 (30.6%) patient had residual lithiasis and 60 (17,9%) required complementary treatment. Relative global success rate was 82.1% and complications rate 25.4%, without detecting differences between groups. However, the novel group had more major complications (P>0.001). Conclusion: The PNL in supine position is obtaining rapid and consolidated diffusion in our setting and its effectiveness and safety seems to be equivalent to that described in the literature for PNL in prone position. It is possible to obtain good results with a modest learning curve. The rate of greater complications associated to the procedure decreases with experience (AU)

[Learning of percutaneous nephrolithotomy in supine position. An observational multicenter study]. / El aprendizaje de la nefrolitectomía percutánea en posición supina. Estudio observacional multicéntrico.

OBJECTIVE: To prospectively study the post-operative results and complications of percutaneous nephrolithotomy (PNL) in supine position to assess difficulty of learning it and how experience affects the results. To establish a relative comparison with the data published in the literature on the prone position. MATERIAL AND METHODS: A prospective observational multicenter study on PNL in Valdivia position or in its Galdakao variant was performed. Demographic variables and specific variables related to the lithiasis were collected. Technical aspects, surgery time, success rate and complications according to the Clavien-Dindo classifications were assessed. RESULTS: A total of 335 PNL in supine position conducted in 13 Spanish centers were registered from September 2008 to June 2011. The man:woman ratio was 1:1.28 and mean age 51.3+14.5 years. 211 (63%) cases were performed by urologists with experience in >50 cases and 124 (37%) by urologists with less experience. Mean operation time was 113.3 ± 46.4 min, 106.6 ± 38.2 for the experienced ones vs. 124.9 ± 56.2 in the novice ones (P<.002). No difference was detected in the mean size of the lithiasis. However, in the experienced group, there was a greater proportion of coraliform cases and multiple lithiasis than in the novice group (P<.001). Success rate evaluated as total absence of lithiasic residuals was 69.6%, without differences between groups (68.2 vs. 71.8%). In 102 (30.6%) patient had residual lithiasis and 60 (17,9%) required complementary treatment. Relative global success rate was 82.1% and complications rate 25.4%, without detecting differences between groups. However, the novel group had more major complications (P>.001). CONCLUSION: The PNL in supine position is obtaining rapid and consolidated diffusion in our setting and its effectiveness and safety seems to be equivalent to that described in the literature for PNL in prone position. It is possible to obtain good results with a modest learning curve. The rate of greater complications associated to the procedure decreases with experience.