Radical laparoscopic cystectomy. Experience in 100 patients

Indexación: Web of Science; ScieloObjetivo: Presentar nuestra serie de cistectomía radical laparoscópica, su técnica, resultados y complicaciones. Material y Métodos: En un período de 10 años, se efectuaron un total de 100 cistectomías lapa-roscópicas en forma consecutiva por un solo cirujano, cuya indicación fue por cáncer vesical. Se realizaron 57 cistoprostatectomías radicales, 22 exanteraciones anteriores, 14 cistectomías con preservación prostática y 7 cistectomías radicales. La derivación urinaria fue efectuada por vía extracorpórea en el 92% de los casos. Se analizan los resultados peri operatorios y a largo plazo obtenidos con esta técnica. Resultados: Los 100 procedimientos se completaron por vía laparoscópica sin conversión. La relación hombre mujer fue de 3:1. La edad promedio fue de 63 años (29-83). El índice de masa corporal promedio (IMC) fue de 28 kg/m2 (20-47). La derivación urinaria empleada fue una Neovejiga ortotópica en 49 pacientes, Conducto ileal incontinente en 32, Reservorios urinario-continente tipo Indiana en 10 y Neovejiga recto-sigmoidea (Mainz II) intracorpórea en 9 pacientes. El tiempo operatorio promedio fue de 271 min (180-375) y el sangrado estimado promedio de 459 ml (50-1.500). Hubo 8 pacientes (11%) con complicaciones intra o peri operatorias. Hubo 7 complicaciones tardías (9%). El tiempo promedio de hospitalización fue de 8,8 días (4-28). Hubo un fallecido. El seguimiento promedio fue de 48 meses. Diez pacientes (13%) presentaron muerte por progresión de la enfermedad. Conclusión: Los resultados a mediano plazo son prometedores, se requiere de un seguimiento más prolongado para consolidar su validez oncológica.Background: Laparoscopic cystectomy is a less invasive alternative than traditional surgery. Aim: To report our experience with laparoscopic radical cystectomy, the technique, results and complications. Material and Methods: During a 10-year period, 100 consecutive laparoscopic cystectomies for bladder cancer were carried out. The procedures performed were 57 radical cystoprostatectomies, 27 pelvic exenterations, 14 cystectomies with prostate preservation and seven radical cystectomies. An extracorporeal urinary diversion was performed in 92% of cases. Results: The age of patients ranged from 29 to 83 years and the male/female ratio was 3:1. As urinary diversion, an orthotopic reservoir was used in 49 patients, and ileal conduit in 32, Indiana continent reservoir in 10 and intracorporeal Sigma-rectum pouch (Mainz pouch II) in 9 patients. All Mainz II pouches were constructed laparoscopically. Mean operative time and blood loss were 279 minutes (range 180 to 375) and 436 ml (range 50 to 1.500) respectively. Eight patients (11%) had perioperative complications: five had vascular lesions, two had eviscerations and two had septicemia. Delayed complications were observed in seven cases (9%). Three patients had a urinary sepsis, one had a ureteral stenosis, two had spontaneous ruptures of a continent reservoir and one had an intestinal fistula. Mean hospital stay was 8.8 days (range de 4 to 28). One patient died due to an intestinal fistula and secondary peritonitis. Mean follow-up was 18 months (range 2 to 68 months). Ten patients (13%) had disease progression and died in long-term follow up. Conclusions: Laparoscopic radical cystectomy is associated with a reduced operative bleeding, a short hospital stay and acceptable morbidity.http://ref.scielo.org/jh42v

Da Vinci robot-assisted radical prostatectomy: initial experience in 50 consecutive cases

Indexación: Web of Science; ScieloObjective: To report our initial experience in 50 cases submitted to a Robotic Radical Prostatectomy (RRP), evaluating results and the learning curve. Material and Methods: From january to october 2010 we performed 50 consecutives cases of RRP with the da Vinci S-HD Surgical System®. The database was performed prospectively, and was analyzed retrospectively. We evaluate demographic data (age, body mass index) and perioperative data such as clinical stage, preoperative PSA (Prostate Specific Antigen), Gleason Score, ASA, operative times, estimated blood loss, morbidity, hospital stay, time of bladder catheterization and positive margins. A statistical analysis of exponential regression was performed to estimate the learning curve. Results: The mean age was 62 years and the most frequent clinical stage was T1c (84%). The mean PSA was 6.36 ng/mL and in 50% of the patients the Gleason Score was 7. The median surgical time was 199 minutes. The mean blood loss was 666 mL (50-4.000 mL). The hospital stay and the average bladder catheterization time were 2 and 6 days, respectively. There were 2 conversions to a laparoscopic approach, none to open surgery, and 8% of postoperative complication (all Clavien 1). Inmediat urinary continence and potency rates were 88.3% and 33.3%, respectively. When comparing the 25 initial cases versus the last 25, there was a decrease in surgical time and estimated blood loss (254 minutes vs 189 minutes and 876 mL vs 467 mL, respectively). We also found a lower rate of positive margins (20% vs 12%). The learning curve statistically estimated is 40 procedures. Conclusion: The surgeon's experience determine a decrease in surgical time, intraoperative bleeding and especially in the rate of positive margins.Objetivo: Comunicar nuestra experiencia inicial en 50 casos de Prostatectomía Radical Robótica (PRR), evaluando resultados y curva de aprendizaje. Material y Métodos: Desde enero a octubre de 2010 se realizaron 50 PRR con el sistema da Vinci S-HD®. La base de datos fue confeccionada en forma prospectiva y se evaluaron en forma retrospectiva los datos demográficos (edad, índice de masa corporal), estadio clínico, valor de Antígeno Prostático Específico (APE), Score de Gleason, ASA, tiempos quirú;rgicos, sangrado estimado, complicaciones, estadía hospitalaria, tiempo de sonda vesical y tasa de márgenes positivos. Se realizó un análisis estadístico de regresión exponencial para estimar la curva de aprendizaje del método. Resultados: La edad media fue de 62 años y el estadio clínico más frecuente fue el T1c (84%). El valor medio de APE fue de 6,36 ng/mL. El score de Gleason en un 50% correspondió al 7 y la media del ASA a 2. La mediana del tiempo quirú;rgico fue de 199 minutos. El sangrado medio estimado fue de 666 mL (50-4.000 mL). La media de la estadía hospitalaria y el tiempo de sonda fueron de 2 y 6 días, respectivamente. Hubo 2 conversiones a cirugía laparoscópica, ninguna a cirugía abierta y un 8% de complicaciones postoperatorias (todas Clavien 1). La tasa de continencia y de potencia inmediata fue de 88,3% y 33,3%, respectivamente. Cuando comparamos los 25 casos iniciales versus los 25 finales hubo un descenso significativo en el tiempo quirú;rgico y sangrado estimado (254 minutos vs 189 minutos y 876 mL vs 467 mL, respectivamente). También encontramos una menor tasa de márgenes positivos en el grupo 2 (12% vs 20%). El análisis estadístico determinó la curva de aprendizaje en 40 procedimientos. Conclusión: Una mayor experiencia del cirujano, determina una disminución en los tiempos quirú;rgicos, sangrado intraoperatorio y sobre todo en la tasa de márgenes positivos.http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0718-40262011000600011&nrm=is

Laparoscopic radical cystectomy. The new gold standard for bladder carcinoma? ¿es la osteotomía radical laparoscópica el nuevo standard de oro para el cáncer de vejiga?

OBJECTIVES: The experience of a renowned Latin American laparoscopic center is reported and the differences with the open technique are thoroughly discussed. METHODS: During a 7 year period a total of 85 laparoscopic cystectomies were performed, in 92% urinary diversion was performed extracorporeally. This accounted for: 14 anterior exenterations, 50 radical cystoprostatectomies, 7 radical cystectomies and 14 simple cystectomies. Male to female ratio was 3:1. Mean patient age was 63 years (range 29 to 83). Mean Body Mass Index (BMI) was 28 kg/m2 (range 20 to 47). Operative data and long term results are analyzed. RESULTS: All 85 procedures were completed laparoscopically without the need for conversion to open surgery. Orthotopic neobladder, Santiago pouch, Studer, Fontana and Le Bag were performed in 42, 13, 16, 12 and 1 case respectively. Ileal conduit, Indiana pouch and Mainz II were employed in 24, 10 and 9 cases respectively. All Mainz II were performed intracorporeally Mean oper

Radical laparoscopic prostatectomy

Indexación: ScieloRadical laparosocpic prostatectomy (RLP) is an attractive therapeutic modality for localized prostate cancer. The results obtained with this technique are similar to those obtained with open radical prostatectomy, which continues to be the gold standard for the treatment of prostate cancer. The surgical access for RLP can be extra-peritoneal or trans-peritoneal. The advantages of laparoscopy are lower bleeding rates, less need for transfusion and shorter recuperation time and hospital stay. The oncological results of RLP are similar, but in any case better, that those obtained with open retropubic radical prostatectomy. Recent reports raised the concern that laparoscopic prostatectomy could have higher rates of relapse of cancer. However this opinion is questionable. RLP is a difficult technique and should be performed by experienced teams. Robot assistance facilitates the procedure and could improve functional and oncological results. Therefore RLP is nowadays an alternative to traditional retropubic prostatectomy.La Prostatectomia radical laparoscópica (PRL) se ha convertido en una técnica atractiva para el tratamiento quirúrgico del cáncer de próstata localizado. Si bien, los resultados actuales son inicialmente comparables a la prostatectomia radical abierta, es importante mencionar que la tendencia quirúrgica en cáncer de próstata, se ha modificado a pesar de que no hay estudios que confirmen la superioridad del método endoscópico y hoy, el estándar dorado sigue siendo la prostatectomia radical abierta. Dos rutas de acceso quirúrgico pueden ser utilizadas para la realización de PRL, la vía extraperitoneal y la transperitoneal. Un menor sangrado y menor tasa de transfusión, así como, tiempo de hospitalización y recuperación más cortos, son ventajas incuestionables para los procedimientos laparoscópicos. Los resultados oncológicos y funcionales de la prostatectomia laparoscópica son hoy en día comparables, pero en ningún caso mejores que la técnica retropúbica abierta estándar. Recientemente, Hu y colaboradores, en base a una revisión de cerca de 3.000 pacientes tratados en los Estados Unidos, plantean la posibilidad de que los pacientes tratados con prostatectomia laparoscópica (pura o asistida por robot), pudiesen tener mayor riesgo de recurrencia de la enfermedad. Esta es una posición discutible, ya que el análisis, a pesar de ser extenso es limitado para establecer conclusiones finales en el tema. Es importante recordar que la PRL sigue siendo una intervención técnicamente difícil y debiera ser realizada en centros seleccionados con equipos experimentados. La prostatectomía laparoscópica asistida por Robot, facilita el procedimiento y en suma, pareciera mejorar los resultados oncológicos y funcionales. La PRL es hoy en día una alternativa válida a la prostatectomía retropúbica tradicional, con ciertas ventajas adicionales.http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0718-40262011000200016&lng=es&nrm=is

Radical laparoscopic prostatectomy Prostatectomía radical laparoscópica

Radical laparosocpic prostatectomy (RLP) is an attractive therapeutic modality for localized prostate cancer. The results obtained with this technique are similar to those obtained with open radical prostatectomy, which continues to be the gold standard for the treatment of prostate cancer. The surgical access for RLP can be extra-peritoneal or trans-peritoneal. The advantages of laparoscopy are lower bleeding rates, less need for transfusion and shorter recuperation time and hospital stay. The oncological results of RLP are similar, but in any case better, that those obtained with open retropubic radical prostatectomy. Recent reports raised the concern that laparoscopic prostatectomy could have higher rates of relapse of cancer. However this opinion is questionable. RLP is a difficult technique and should be performed by experienced teams. Robot assistance facilitates the procedure and could improve functional and oncological results. Therefore RLP is nowadays an alternative to tradi

Modified urethrovesical anastomosis during robot-assisted simple prostatectomy: Technique and results

Background: Despite significant developments in transurethral surgery for benign prostatic hyperplasia, simple prostatectomy remains an excellent option for patients with severely enlarged glands. The objective is to describe our results of robot-assisted simple prostatectomy (RASP) with a modified urethrovesical anastomosis (UVA). Methods: From May 2011 to February 2014, RASP with UVA was performed in 34 patients by a single surgeon (O.C.) using the da Vinci S-HD surgical system. The UVA was performed between the bladder neck and urethral margin using the Van Velthoven technique. Demographic, perioperative, and outcome data were recorded. Complications were recorded with the Clavien–Dindo system. Results: The mean (standard deviation) age was 68 years (62–74 years). The median preoperative prostate volume (interquartile range) was 117 cc (99–146 cc). Operative time was 96 minutes (78–126 minutes), estimate blood loss was 200 mL (100–300 mL), and two (5.8%) patients required a blood transfusion. No conversion to open surgery was needed. The median specimen weight on pathological examination was 76 g (58–100 g). The average hospital stay was 2.2 days (1–4 days) and average Foley catheter time was 4.6 days (4–6 days). No intraoperative complications were recorded. There were seven (20.5%) postoperative complications, most of them Clavien less than or equal to Grade II. Conclusion: The results of our study show that RASP with UVA is a feasible, secure, and reproducible procedure with low morbidity. Additional series with larger patient cohorts are needed to validate this approach

Testosterone replacement therapy and prostate cancer: the downfall of a paradigm?

Resumen Por casi seis décadas ha sido parte de la cultura médica en general, que los niveles altos de testosterona incrementan el riesgo de padecer o agravar un cáncer de próstata. Esta creencia se ha derivado fundamentalmente de la bien documentada regresión del cáncer de próstata luego de la castración médica o quirúrgica. Sin embargo, no existe evidencia científica que apoye la idea de que niveles altos de testosterona están asociados con un incremento del riesgo de cáncer de próstata. Más aún, los hombres con hipogonadismo tienen una tasa substancialmente alta de cáncer de próstata detectado por biopsia, lo que sugiere que los niveles bajos de testosterona no tienen un efecto protector en el desarrollo de cáncer de próstata y, además, la tasa de cáncer de próstata es más alta en los pacientes de edades avanzadas cuando sus niveles hormonales son más bajos. Estos argumentos tienden a demostrar que no existiría un incremento del riesgo de padecer un cáncer de próstata asociado a la terapia de reemplazo con testosterona

Urologic Notes: Where are we and where are we going? Cirugía endoscópica transluminal por orificios naturales en urología: Donde estamos y hacia donde vamos

The natural orifice translumenal endoscopic Surgery (NOTES) approach has been successfully reported by several surgical teams in different specialties. Urologic teams have recently presented several experimental and clinical experiences with the technique. Our aim is to review the initial experience with NOTES in minimal access urological surgery

Bilateral simultaneous laparoscopic adrenalectomy for congenital adrenal hyperplasia: Initial experience

Objective: Congenital adrenal hyperplasia (CAH) is an uncommon syndrome which represents a therapeutic challenge. We analyzed the role of bilateral simultaneous laparoscopic adrenalectomy in the management of CAH. Material and methods:: Between October 2004 and September 2006, three female patients underwent bilateral simultaneous laparoscopic adrenalectomy for CAH. Data were retrospectively collected. Variables analyzed were persistence of CAH clinical signs, variations in 17 OH progesterone level and corticoid medication, operative time, median blood loss, postoperative pain, hospital stay, and body image perception after surgery. Results: Median age was 16.3 years. Complete regression of virilization signs, acne and hyperpigmentation was achieved in one case. The other two cases showed partial regression of signs. Levels of 17 OH progesterone reached normal parameters in all cases. Steroids doses were lowered and given only for replacement purposes. Mean operative time was 125, 65