Laparoendoscopic single-site radical nephrectomy for renal cancer: technique and surgical outcomes.

BACKGROUND: Laparoendoscopic single-site (LESS) surgery has been developed in attempt to further reduce the morbidity and scarring associated with surgical intervention. OBJECTIVE: To describe the technique and report the surgical outcomes of LESS radical nephrectomy (RN) in the treatment of renal cell carcinoma. DESIGN, SETTING, AND PARTICIPANTS: LESS-RN was performed in 33 patients with renal tumours. The indications to perform a LESS-RN were represented by renal tumours not greater than T2 and without evidence of lymphadenopathy or renal vein involvement. SURGICAL PROCEDURE: The Endocone (Karl Storz, Tuttlingen, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and bent grasper and scissors was used. The sequence of steps of LESS-RN was comparable to standard laparoscopic RN. MEASUREMENTS: Demographic data and perioperative and postoperative variables were recorded and analysed. RESULTS AND LIMITATIONS: The mean operative time was 143.7±24.3 min, with a mean estimated blood loss of 122.3±34.1 ml and a mean hospital stay of 3.8±0.8 d. The mean length of skin incision was 4.1±0.6 cm and all patients were discharged from hospital with minimal discomfort, as demonstrated by their pain assessment scores (visual analogue scale: 1.9±0.8). The definitive pathologic results revealed a renal cell carcinoma in all cases and a stage distribution of four T1a, 27 T1b, and 2 T2 tumours. All patients were very satisfied with the appearance of the scars, and at a median follow-up period of 13.2±3.9 mo, all patients were alive without evidence of tumour recurrence or port-site metastasis. CONCLUSIONS: LESS is a safe and feasible surgical procedure for RN in the treatment of renal cell carcinoma and has excellent cosmetic results.

Is intensive multimodality therapy the best treatment for fournier gangrene? Evaluation of clinical outcome and survival rate of 41 patients.

BACKGROUND: To evaluate the effect of surgical wound debridement, antibiotics, and hyperbaric oxygen (HBO) in the treatment of Fournier gangrene (FG). METHODS: Forty-one patients with a mean age of 54.3±14.6 years were referred to our department with a diagnosis of FG. To calculate a Fourier Gangrene Severity Index (FGSI), nine factors were assessed (temperature; heart rate; ventilatory rate; serum sodium, potassium, creatinine, and bicarbonate concentrations; hematocrit; and leukocyte count). After clinical stabilization, extensive debridement of the necrotic tissue was performed, and a surgical vacuum-assisted closure (V.A.C.®) device was applied. Hyperbaric oxygen was administered; medical therapy consisted of intravenous antibiotics, electrolyte replacement, and parenteral nutrition. RESULTS: Intraoperative cultures revealed Escherichia coli in 27 patients (66%), Pseudomonas aeruginosa in 28 (68%), gram-positive cocci in 24 (59%), and mixed flora (aerobic and anaerobic bacteria) in 39 (95%). One month after primary debridement, wound granulation was sufficient for plastic surgical reconstruction in all patients. CONCLUSION: Because of the rapid worsening of FG, early diagnosis and immediate, aggressive multi-modality therapy with surgical debridement and broad-spectrum empiric antibiotics is crucial. The utility of HBO remains unproved.

Laparoscopic adrenalectomy in urological centres - the experience of the German Laparoscopic Working Group.

OBJECTIVE: To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain. PATIENTS AND METHODS: The data of 363 patients who underwent a LA were prospectively collected in 23 centres. All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10-20 LAs/year) and group C (>20 LAs/year). In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed. RESULTS: The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively. CONCLUSION: LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year.

Prospective follow-up of female sexual function after vaginal surgery for pelvic organ prolapse using transobturator mesh implants.

INTRODUCTION: Although the use of transobturator mesh implants for pelvic organ prolapse repair has been shown to be safe and effective, concern exists that the presence of prosthetic material in the vagina may adversely affect sexual function. AIM: To evaluate the impact of transobturator mesh implantation on sexual function using validated questionnaire. MAIN OUTCOME MEASURES: Female Sexual Function Index (FSFI), a validated 19-item questionnaire that assesses six domains of sexual function (desire, arousal, lubrication, orgasm, satisfaction, and pain), was used. The questionnaire was administered preoperatively, and at 3, 6, 12, and 24 months postoperatively. Clinical data were also recorded at each time point. METHODS: Prospective nonrandomized study including 96 women with pelvic organ prolapse (cystocele, rectocele, vault prolapse). Transvaginal anterior or posterior wall repair using transobturator mesh implants with or without concomitant transobturator sling procedure. RESULTS: Mean age was 51.4 ± 5.2 years. Mean operating time was 47.6 ± 23.4 minutes, and the mean hospitalization period was 3.8 ± 1.6 days. After initial decrease during the first 3 months, patients experienced a steady improvement in their sexual function. At 24 months postoperatively, the total mean FSFI score reached significantly higher values compared to the baseline (P = 0.023). Furthermore, pain-free intercourse improved during the follow-up reaching mean score of 4.27 ± 0.79 (P < 0.05) after 2 years. Pelvic floor examination at 2 years follow-up showed excellent surgical results with only 3.1% of the patients presenting with stage II vaginal wall prolapse. CONCLUSIONS: Surgical repair of symptomatic pelvic organ prolapse using mesh implants results in improvement of major parameters of sexual function. A worsening in pain with intercourse during the initial months postoperatively lessens after 3 months as healing is completed.

Single-portal access laparoscopic radical nephrectomy for renal cell carcinoma in transplant patients: the first experience.

We present the details of the first three single-portal access laparoscopic radical nephrectomies (S-Portal-RN) performed in patients with a malignant renal tumour that developed after a renal transplant. The mean operative time was 171.6 ± 37.5 min, with a mean blood loss of 126.6 ± 25.1 ml. A single small skin incision (5 cm) was performed to remove the kidney. No significant difference in glomerular filtration rate was observed postoperatively. The postoperative recovery was uneventful with favourable short-term outcomes and high patient satisfaction at the 2-mo follow-up. We believe that S-Portal-RN for renal cancer after a renal transplant can be performed without increased risks for the patients or for the transplanted kidney.

Bilateral vs unilateral laparoscopic intrafascial nerve-sparing radical prostatectomy: evaluation of surgical and functional outcomes in 457 patients.

UNLABELLED: Study Type - Therapy (case series). LEVEL OF EVIDENCE: 4. What's known on the subject? and What does the study add? Bilateral nerve-sparing radical prostatectomy still represents an issue for urologists as the indications to perform it depend oft from the personal clinical experience. Moreover, until now data concerning bilateral and unilateral laparoscopic nerve-sparing radical prostatectomy have been limited. This study states that bilateral laparoscopic intrafascial nerve-sparing technique results in superior functional outcomes when compared with unilateral nsLRP and it suggests to prefer a bilateral nerve-sparing technique in younger patients with low-risk, organ-confined prostate cancer. OBJECTIVE: To evaluate the surgical and functional outcomes in bilateral and unilateral nerve-sparing laparoscopic radical prostatectomy (nsLRP). PATIENTS AND METHODS: Between January 2005 and May 2009, 457 nsLRP were performed at our clinic. In all, 250 patients underwent a bilateral nsLRP and 207 patients underwent an unilateral nsLRP. One surgeon performed all the operations. All patients presented at biopsy a localized prostate cancer. Demographic data and perioperative and postoperative measurements and outcomes were compared. RESULTS: The operative times for bilateral nsLRP and unilateral nsLRP were 165 ± 45 min and 130 ± 25 min, respectively. The mean intra-operative blood loss was 450 ± 300 mL and 270 ± 160 mL in the bilateral and unilateral nsLRP groups with a transfusion rate of 3% and 1%, respectively (P = 0.013). Conversion to open surgery was never deemed necessary. Postoperatively, the mean Gleason Score after nsLRP and distribution of tumour stages was similar in the two groups, and the frequency of positive margins in both groups did not present any statistically significant difference. At 12 months, a complete continence was reported in 97% of patients who underwent a bilateral nsLRP and in 88% of patients of the unilateral nsLRP group. At that time, 69% in the bilateral nsLRP and 43% in the unilateral nsLRP groups reported the ability to engage in sexual intercourse. CONCLUSION: The bilateral laparoscopic intrafascial nerve-sparing technique results in superior functional outcomes with regard to urinary continence and sexual potency, when compared with unilateral nsLRP, reporting similar oncological outcomes.

Adipocytokine: a new family of inflammatory and immunologic markers of invasiveness in major urologic surgery.

BACKGROUND: Laparoscopic surgery has been proposed to reduce surgical trauma and diminish patients' stress response. OBJECTIVE: To investigate the role of the adipocytokine, in combination with changes in other known inflammatory markers, in patients undergoing radical prostatectomy. DESIGN, SETTING, AND PARTICIPANTS: A total of 580 patients were enrolled in this prospective study. Laparoscopic extraperitoneal radical prostatectomy (LRP) was performed in 286 patients, and open retropubic radical prostatectomy (RRP) in 294 patients. INTERVENTION: Blood samples were collected preoperatively and up to 5 d postoperatively. MEASUREMENTS: Serum concentrations of acute phase markers, interleukins (IL), and the adipocytokine leptin were measured at each time point by means of enzyme-linked immunosorbent assay. Clinical data were collected and analysed. RESULTS AND LIMITATIONS: Patients undergoing LRP had significantly lower IL-6 and adipocytokine levels at all measurement time points. However, biphasic kinetics of adipocytokine serum levels were observed during the postoperative course in all patients. LRP was associated with less adipocytokine and IL-6 release, indicating a smaller degree of surgical insult and the minimal invasive nature of this procedure. The limitation of this study was its nonrandomised design. CONCLUSIONS: Adipocytokines might serve as additional immunologic markers of invasiveness in major urologic surgery.

Pelvic organ prolapse management in female kidney transplant recipients.

PURPOSE: Pelvic organ prolapse in female postmenopausal kidney transplant recipients may be complicated by adverse events affecting graft function. We describe our experience with pelvic reconstructive surgery in renal transplant recipients. MATERIALS AND METHODS: Pelvic reconstructive surgery was done in 16 female renal transplant recipients with pelvic organ prolapse with or without stress urinary incontinence. Intraoperative and postoperative data were recorded prospectively, including medical and surgical history, pelvic organ prolapse quantification measurement, 24-hour pad count, quality of life measurements and graft outcome. Patients were followed up to 12 months. RESULTS: Mean +/- SD age at surgery was 58.3 +/- 7.7 years (range 50 to 66). Mean time to renal transplantation was 54.2 +/- 15.1 months (range 38 to 123). A total of 12 anterior and 4 combined anterior/posterior colporrhaphies were done. A concomitant suburethral single incision transobturator sling procedure was performed in 8 women. We noted no bladder or rectal injury, bleeding necessitating transfusion or infection. Pelvic floor testing at 12-month followup showed stage I vaginal wall prolapse in only 4 patients (25%). No patient had evidence of de novo incontinence, synthetic sling infection, erosion or rejection. All women reported improved quality of life on the SF-36 questionnaire. Renal graft function remained stable in all patients. CONCLUSIONS: Pelvic reconstructive surgery is feasible for pelvic organ prolapse in patients with a kidney allograft on immunosuppression. However, concern about impaired graft function, infection and wound healing remains important.

Male-to-female transsexualism: technique, results and 3-year follow-up in 50 patients.

AIM: To evaluate the functional and cosmetic results of male-to-female gender-transforming surgery. PATIENTS AND METHODS: Between May 2001 and April 2008 we performed 50 male-to-female gender-transforming surgeries. All patients had been cross-dressing, living as women, and receiving estrogen and progesterone for at least 12 months, which was sufficient for breast development and atrophy of the testes and prostate to occur. This hormonal therapy was suspended 1 month before the operation. RESULTS: The mean operative time was 190 min and the mean depth of the vagina was 10 cm. On follow-up, the most common complication (10%) was shrinkage of the neovagina, which could be corrected by a second surgical intervention. Of the 50 patients, 45 (90%) were satisfied with the esthetic results; 42 patients (84%) reported having regular sexual intercourse, 2 of whom had pain during intercourse. Of the 50 patients, 35 (70%) reported achieving clitoral orgasm. CONCLUSION: Male-to-female gender-transforming surgery can assure satisfactory cosmetic and functional results, with a reduced intra- and postoperative morbidity. Nevertheless the experience of the surgeon and the center remains central to obtaining optimal results.

Management of localized prostate cancer by retropubic radical prostatectomy in patients after renal transplantation.

BACKGROUND: The study aimed to report our experience with retropubic radical prostatectomy (RRP) for treatment of localized prostate cancer in renal transplant recipients (RTR). METHODS: Data of 16 RTR who had an RRP between 2001 and 2007 were retrospectively analysed and compared to the data of 294 non-transplanted patients who were operated for RRP during the same period. Diagnostic work-up consisted of digital rectal examination, serum prostate specific antigene levels, as well as Transrectal Ultrasonography (TRUS)-guided prostate biopsy. Follow-up was obtained in all patients with a mean follow-up time of 2.1 years in RTR. RESULTS: Mean time distance to the renal transplantation at the time of RRP was 81.2 ± 19.1 months. RRP was successfully performed and tolerated in all RTR without pelvic lymph node dissection. No major complications occurred during or after the operation. There were two minor complications in transplant group (prolonged haematuria and urinary leakage). Mean operative time was 108.3 ± 3.9 min in transplant group, which was significantly longer as in non-transplanted group (89.1 ± 4.1, P < 0.05). Mean estimated intra-operative blood loss was significantly lower in transplant group (P < 0.05). In RTR, one case of positive surgical margins was present (R(1): 6.2 vs. 12.3% in non-transplanted group, P < 0.05). None of the RTR had impairment of graft function. At follow-up, no case of biochemical recurrence was observed in RTR. CONCLUSIONS: RRP is safe and feasible for management of localized prostate cancer in patients with kidney allograft being under immunosuppression. However, concern about impairment of graft function, infection and wound healing remains important.

Laparoscopic vs open retropubic intrafascial nerve-sparing radical prostatectomy: surgical and functional outcomes in 300 patients.

OBJECTIVE: To evaluate the surgical and functional outcomes in nerve-sparing laparoscopic radical prostatectomy (nsLRP) and retropubic nsRP (nsRRP). PATIENTS AND METHODS: Between January 2005 and November 2007, 150 nsLRP and 150 nsRRP were performed at our clinic. Demographic data, variables before and after surgery, and outcomes, were compared. RESULTS: The operative duration was 165 min for nsLRP and 120 min for nsRRP. Although the nsLRP group had a lower frequency of positive margins, the difference was not statistically significant. At 1 year after surgery, complete continence was reported in 97% of patients who had nsLRP and in 91% who had nsRRP (P= 0.03). At that time, 66% of patients in the nsLRP and 51% in the nsRRP group reported being able to engage in sexual intercourse (P < 0.05). There were no statistical differences in surgical trauma in both groups. CONCLUSION: Our study showed that nsLRP performed by expert surgeons results in better functional outcomes for continence and potency than for nsRRP. There was no significant difference between the surgical techniques in surgical trauma.

Laparoscopic dismembered pyeloplasty: technique and results in 105 patients.

PURPOSE: To evaluate the postoperative and functional results of the laparoscopic dismembered pyeloplasty (LDP). PATIENTS AND METHODS: Between May 2000 and April 2008, we performed in our department 105 LDP. All patients presented an ureteropelvic junction obstruction with dilatation of renal calyx system with an enlarged renal pelvis. Demographic data (age, gender), perioperative and postoperative parameters, including operating time, estimated blood loss, complications, length of hospital stay, functional outcome were collected and evaluated. RESULTS: The mean operative time for LDP was 150 min (range 120-180 min) and the mean estimated blood loss was negligible in all patients. The mean hospital stay was 4 days (4-8). No conversion to open surgery occurred. In the follow-up, we noted a successful rate in 96.2% of the patients. CONCLUSION: Laparoscopic dismembered pyeloplasty, if performed by expert surgeons in high-volume centres, presents results that are comparable with open surgery, with a lower surgical trauma for the patients.

Laparoscopic vs open radical nephroureterectomy for upper urinary tract urothelial cancer: oncological outcomes and 5-year follow-up.

OBJECTIVE: To compare the oncological outcomes of laparoscopic radical nephroureterectomy (LNU) vs open NU (ONU) for upper urinary tract transitional cell carcinoma (TCC). PATIENTS AND METHODS: Between July 1999 and January 2003, we performed 70 LNUs and 70 ONUs for TCC of the upper urinary tract. ONU was reserved for patients with previous abdominal surgery or with severe cardiac and/or pulmonary problems. Demographic data, tumour staging and histological grading and rates of metastasis were recorded and compared. RESULTS: For LNU and ONU the mean operative durations were 240 min and 190 min, respectively. The definitive pathology showed a high incidence of tumour stage pT2 G2 in both LNU and ONU groups. The median follow-up was 60 months. In the LNU group, the 5-year disease-free survival (DFS) was 75%: 100% for pTa, 88% for pT1, 78% for pT2, and 35% for pT3 (P < 0.001). In the ONU group, the 5-year DFS was 73% (LNU vs ONU, P = 0.037): 100% for pTa, 89% for pT1, 75% for pT2 and 31% for pT3 (P < 0.001). CONCLUSION: The results of our long-term controlled study support the use of LNU as an effective alternative to ONU in the therapy of upper urinary tract urothelial cancer.

Huge isolated port-site recurrence after laparoscopic partial nephrectomy: a case report.

A 66-yr-old man with pain and swelling in the right flank was referred to our clinic for diagnosis. In 2005, the patient underwent a laparoscopic partial nephrectomy for renal cancer of the lower pole of the right kidney. A computed tomography scan revealed a 20-cm tumor in the right abdominal wall, resulting in a suspected diagnosis of port-site metastasis from the first laparoscopic operation. The patient underwent open surgery, which confirmed the diagnosis. After the operation, the patient recovered rapidly.

Retroperitoneal malignant solitary fibrous tumor of the small pelvis causing recurrent hypoglycemia by secretion of insulin-like growth factor 2.

A 28-yr-old man presented with recurrent reduced consciousness, generalized seizures of unknown etiology, recurrent hypoglycemia, psychomotor retardation, and grade 2 ectasia of the left kidney. Abdominal computed tomography (CT) and positron emission tomography (PET) scans demonstrated a well-circumscribed suprapubic pelvic mass, measuring 18 x 15 x 11 cm, with involvement of para-aortic lymph nodes and dilatation of the left ureter suggestive of an extragonadal testicular tumor. We excised the tumor by laparotomy, and it was confirmed to be a solitary fibrous tumor (SFT). After surgery and R0 tumor resection, the patient had no further evidence of hypoglycemia or of recurrence.

Prospective non-randomized evaluation of four mediators of the systemic response after extraperitoneal laparoscopic and open retropubic radical prostatectomy.

OBJECTIVE: To report a prospective, controlled, non-randomized patient study to determine the systemic response to extraperitoneal laparoscopic (eLRP) and open retropubic radical prostatectomy (RRP). PATIENTS AND METHODS: In all, 403 patients who had eLRP (163) or open RRP (240) were recruited; patients in both groups had similar preoperative staging. In addition to peri-operative variables (operative duration, complications, blood loss, transfusion rate, hospitalization, catheterization), oncological data (Gleason score, pathological stage, positive margins) were also compared. The extent of the systemic response to surgery-induced tissue trauma was measured in all patients, by assessing the levels of acute-phase markers C-reactive protein (CRP), serum amyloid A (SAA), interleukin-6 (IL-6) and IL-10 before, during and after RP. RESULTS: The duration of surgery, transfusion rate, hospital stay and duration of catheterization were comparable with those in previous studies. There was an increase in IL-6, CRP and SAA but no change in IL-10, and no differences between eLRP and RRP over the entire period assessed. CONCLUSION: The invasiveness of eLRP could not be substantiated objectively based on the variables measured in this study. The surgical trauma and associated invasiveness of both methods were equivalent.

Improved detection and treatment of bladder cancer using hexaminolevulinate imaging: a prospective, phase III multicenter study.

PURPOSE: We determined if improved tumor detection using hexaminolevulinate (HAL) fluorescence cystoscopy could lead to improved treatment in patients with bladder cancer. MATERIALS AND METHODS: A total of 146 patients with known or suspected bladder cancer were assessed in this open, comparative, within patient, controlled phase III study. Patients received intravesical HAL for 1 hour and were assessed with standard white light cystoscopy and blue light fluorescence cystoscopy. All lesions were mapped onto a bladder chart and biopsies were taken from suspicious areas for assessment by an independent pathologist. An independent urologist blinded to the detection method used recommended treatment plans based on biopsy results and medical history according to European Association of Urology bladder cancer guidelines. Any differences in recommended treatment plans arising from the 2 cystoscopy methods were recorded. RESULTS: HAL imaging improved overall tumor detection. Of all tumors 96% were detected with HAL imaging compared with 77% using standard cystoscopy. This difference was particularly noticeable for dysplasia (93% vs 48%), carcinoma in situ (95% vs 68%) and superficial papillary tumors (96% vs 85%). As a result of improved detection, additional postoperative procedures were recommended in 15 patients (10%) and more extensive treatment was done intraoperatively in a further 10. Overall 17% of patients received more appropriate treatment at the time of the study following blue light fluorescence cystoscopy, that is 22% or 1 of 5 if patients without tumors were excluded. CONCLUSIONS: HAL imaging is more effective than standard white light cystoscopy for detecting bladder tumors and lesions. This leads to improved treatment in a significant number of patients (p <0.0001).