[PET/CT and biochemical recurrence of prostate adenocarcinoma: Added value of 68Ga-PSMA-11 when 18F-fluorocholine is non-contributive]. / TEP/TDM et récidive biologique d'adénocarcinome prostatique : apport du 68Ga-PSMA-11 lorsque la 18F-fluorocholine n'est pas contributive.

INTRODUCTION: Since April 201, we have introduced PET/CT using a ligand of prostate-specific membrane antigen labeled with gallium-68 (PSMA-11). We aimed to evaluate its positivity rate and impact in patients presenting biochemical recurrence of prostate cancer whose 18F-fluorocholine (FCH) PET/CT was non-contributive. PATIENTS AND METHOD: Patients were prospectively included between April and December 2016. PET/CT was performed 60min after injection of 2MBq/kg of body mass of 68Ga-PSMA-11. Three anatomical areas were considered: prostatic lodge, pelvic lymph nodes and distant locations. The impact of PSMA-11 PET/CT was assessed by comparing changes in therapeutic strategy decided during multidisciplinary meeting. RESULTS: Thirty-three patients were included. The mean PSA serum level measured on the month of the PSMA-11 PET/CT was 2,8ng/mL. Twenty-five (76%) PSMA-11 PET/CT were positive, 7 (21%) negative and 1 (3%) equivocal. Of 11 patients whose FCH PET/CT showed equivocal foci, PSMA-11 PET/CT confirmed those foci in 5 cases. Follow-up was available for 18 patients (55%). PSMA-11 PET/CT results led to a change in management in 12 patients (67%). CONCLUSION: 68Ga-PSMA-11 PET/CT is useful in detecting recurrence of prostate cancer, by identifying residual disease which was not detected on other imaging modalities and by changing management of 2 patients out of 3. LEVEL OF EVIDENCE: 5.

[Neurological and vascular preservation during laparoscopic radical prostatectomy]. / Préservation neurologique et vasculaire au cours de la prostatectomie totale laparoscopique.

The objective of the cavernous nerve preservation is to avoid injury of the unmyelinated nerve fibers and arteries destined to the corpora cavernosa. Dissection anatomical plans could be inter or extra fascial allowing complete or partial neurovascular bundle preservation. The technique is chosen according to the carcinological evaluated risk and anatomical characteristics. Accessory pudendal arteries preservation must be performed when such an artery is identified in order to improve the chance of recovery of spontaneous erections.

[Teaching laparoscopic urologic oncology. The Memorial Sloan-Kettering Cancer Center experience]. / Formación en oncología urológica laparoscópica. La experiencia del Memorial Sloan-Kettering Cancer Center.

OBJECTIVE: We outline the structure of the clinical and training program of laparoscopic urologic oncology at Memorial Sloan-Kettering Cancer Center. We discuss the steps and key elements necessary in acquiring lapa roscopic proficiency. MATERIAL AND METHOD: The program lasts 2 years and trains fellows and faculty. For fellows, the program consists of a 6 months high volume laparoscopic oncology rotation, during which dry lab, animal lab, vide review and operating room experience are required. For faculty, the program consists of 1 accredited continuin medical education course, 20 hours of dry lab, 1 session animal lab, observation of laparoscopic cases, first assistant in a minimum of 15 laparoscopic cases, performing laparoscopic cases under mentoring. RESULTS: 8 fellows have completed the training, 4 of whom have completed their fellowship and are in academic centers, performing advanced laparoscopy. The laparoscopic approach represents on average 80% of their urologic practice. Three attendings are performing laparoscopic surgery with mentoring. CONCLUSION: The goals of a surgical education program should be the standardization of the acquisition o surgical skills and assessment of the performance in a uniform setting to ensure the maintenance of the acquisition of skills and to develop programs to teach new skills.

Laparoscopic radical prostatectomy: an evolution in surgery.

The late 1990s witnessed an unprecedented evolution in the surgical approaches to the prostate thru the eye of the laparoscope. Initially taken with doubt, laparoscopic radical prostatectomy (LRP) has gained tremendous popularity and widespread implementation at specialized centers worldwide becoming the standard in many of them. LRP represents a technically demanding laparoscopic procedure but it can be performed systematically with standard techniques. Obvious advantages are shorter convalescence and markedly lower operative blood loss without compromise of cancer control. Long-term functional and oncological results are maturing but early reports of positive surgical margin rates and freedom from prostate-specific antigen (PSA) recurrence rates after LRP are encouraging. Early quality of life results of postoperative urinary and sexual function appear similar to those in open surgical series. The real challenge for laparoscopic surgeons entails a paradigm swift, one that breaks off from the traditional and bias impetus, and tests the instruments, procedures, techniques differences and evaluates outcomes in a prospective controlled and randomized manner. If achieved, the laparoscopic movement may give rise to a generation of forward thinking surgeons generating a wealth of clinical evidence for their patients.

Laparoscopic [correction of laproscopic] management of rectal injury during laparoscopic [correction of laproscopic] radical prostatectomy.

PURPOSE: Rectal injury is a potential complication of radical prostatectomy. Because laparoscopic radical prostatectomy is still a challenging procedure, we review the incidence and management of rectal injury in 1,000 cases of consecutive laparoscopic radical prostatectomy performed at our institution. MATERIALS AND METHODS: Of the first 1,000 laparoscopic transperitoneal radical prostatectomies performed between January 1998 and April 2002, 13 (1.3%) were complicated by rectal injury. Mean patient age was 66.5 years (range 58 to 76) and mean prostate specific antigen was 12.9 ng./ml. (range 2.9 to 26). Clinical stage was T1c, T2a and T2b in 5, 7 and 1 patient, respectively. Mean preoperative Gleason score was 5.8 (range 3 to 8). Once recognized the rectal defect was closed laparoscopically in 2 layers and tested for the absence of leakage. Broad-spectrum intravenous antibiotics were given for 7 days. Oral liquids were started the day after surgery with a low residue diet, and a regular diet was started on postoperative day 5. Healing of the vesicourethral anastomosis was confirmed by voiding cystourethrogram on postoperative day 5. RESULTS: All patients underwent a non-nerve sparing procedure except 1 in whom unilateral neurovascular bundle preservation was done. Of 13 injuries 11 were diagnosed and repaired intraoperatively, and 2 were diagnosed postoperatively. Of the 11 cases of intraoperative diagnosis and repair 9 healed primarily without colostomy and peritonitis was diagnosed in the remaining 2 on days 3 and 4, respectively. Of the latter 2 patients 1 required repair of a small rectal defect without colostomy while the other required colostomy. Colostomy was performed in the 2 patients with delayed diagnosis on days 3 and 4 but even then a rectourethral fistula developed in 1, necessitating secondary repair. Average urethral catheterization time was 8.6 days for the 9 patients with an uneventful immediate postoperative course and mean hospital stay was 6.8 days. For the remaining 4 patients urethral catheterization duration was 12, 13, 15 and 120 days, and hospital stay was 7, 16, 21 and 27 days, respectively. There was no perioperative mortality. CONCLUSIONS: Rectal injury during laparoscopic radical prostatectomy requires meticulous intraoperative repair in 2 layers, which allows primary healing without diversion colostomy. For injury prevention scrupulous attention is required during non-nerve sparing radical prostatectomy, particularly at the posterior surface of the prostatic apex.

Laparoscopic radical prostatectomy: oncological evaluation after 1,000 cases a Montsouris Institute.

PURPOSE: We performed a prospective oncological evaluation of laparoscopic radical prostatectomy in regard to local tumor control and biochemical recurrence. MATERIALS AND METHODS: Between January 1998 and March 2002, 1,000 consecutive patients with a mean age +/- SD of 63 +/- 6.2 years and clinically localized prostate cancer underwent laparoscopic radical prostatectomy at 1 institution. Preoperative 1997 TNM clinical stage was T1a in 6 patients (0.6%), T1b in 3 (0.3%), T1c in 660 (66.5%), T2a in 304 (30.4%) and T2b in 27 (2.7%). Mean preoperative prostate specific antigen (PSA) +/- SD was 10 +/- 6.1 ng./ml. (range 1.5 to 55). Postoperatively, surgical specimens were assessed and positive surgical margins recorded. Factors that could influence the surgical margins status were evaluated. Irrespective of pathological stage or surgical margin status, no adjuvant treatment was proposed before an increasing PSA. PSA recurrence was defined as PSA greater than 0.1 ng./ml. and was confirmed by a second increase. Recurrence time was defined as the time of the first increase in PSA. RESULTS: Postoperative pathological stage was pT2aN0/Nx in 203 patients (20.3%), pT2bN0/Nx in 572 (57.2%), pT3aN0/Nx in 142 (14.2%), pT3bN0/Nx in 77 (7.7%) and pT1-3 N1 in 6 (0.6%). Positive surgical margin rate was 6.9%, 18.6%, 30% and 34% for pathological stages pT2a, pT2b, pT3a and pT3b, respectively (p <0.001). The main predictors of a positive surgical margin were preoperative PSA (p <0.001), clinical stage (p = 0.001), pathological stage (p <0.001) and Gleason score (p = 0.003). The overall actuarial biochemical progression-free survival rate was 90.5% at 3 years. According to the pathological stage, the progression-free survival rate was 91.8% for pT2aN0/Nx, 88% for pT2bN0/Nx, 77% for pT3aN0/Nx, 44% for pT3bN0/Nx and 50% for pT1-3N1 (p <0.001). Of the patients 94% with negative surgical margins and 80% with positive margins had progression-free survival (p <0.001). Preservation of the neurovascular bundles in patients with localized tumors had no significant effect on the subsequent risk of positive surgical margins or progression-free survival. CONCLUSIONS: Based on followup, our evaluation confirms that laparoscopic radical prostatectomy provides satisfactory results in regard to local tumor control and biochemical recurrence.

Laparoscopic partial nephrectomy for renal tumor: single center experience comparing clamping and no clamping techniques of the renal vasculature.

PURPOSE: We performed a nonrandomized retrospective comparison of 2 techniques for laparoscopic partial nephrectomy, that is without and with clamping the renal vessels. MATERIALS AND METHODS: Between December 1997 and February 2002, 28 consecutive patients underwent transperitoneal laparoscopic partial nephrectomy for renal tumor. In group 1 (12 patients) partial nephrectomy was performed with ultrasonic shears and bipolar cautery without clamping the renal vessels, while in group 2 (16 patients) the renal pedicle was clamped before tumor excision. In group 2 patients intracorporeal kidney cooling was achieved by a ureteral catheter connected to 4C solution. Intracorporeal freehand suturing techniques were used to close the collecting system when opened and approximate the renal parenchyma. RESULTS: All procedures were successfully completed laparoscopically. Mean renal ischemia time +/- SD was 27.3 +/- 7 minutes (range 15 to 47) in group 2 patients. Mean laparoscopic operating time was 179.1 +/- 86 minutes (range 90 to 390) in group 1 compared with 121.5 +/- 37 minutes (range 60 to 210) in group 2 (p = 0.004). Mean intraoperative blood loss was significantly higher in group 1 than in group 2 (708.3 +/- 569 versus 270.3 +/- 281 ml., p = 0.014). Three patients in group 1 and 2 in group 2 required blood transfusions. Immediately postoperatively mean creatinine was 1.26 +/- 0.36 and 1.45 +/- 0.61 mg./dl. in groups 1 and 2, respectively (p = 0.075). Surgical margins were negative in all specimens. Pathological examination revealed renal cell cancer in 18 cases (stages pT1 in 17 and pT3a in 1), oncocytoma in 4, angiomyolipoma in 5 and renal adenoma in 1. CONCLUSIONS: Laparoscopic partial nephrectomy represents a feasible option for patients with small renal masses. Clamping the renal vessels during tumor resection and suturing the kidney mimics the open technique and seems to be associated with less blood loss and shorter laparoscopic operative time.

Laparoscopic radical prostatectomy: a review of techniques and results worldwide.

Laparoscopic radical prostatectomy (LRP) is currently performed in multiple centers world-wide, with several different surgical approaches and techniques utilized. A comprehensive review of the published literature worldwide on laparoscopic radical prostatectomy was performed to outline the evolution of this technique, and to review the published surgical, oncological and functional results. A systematic review of peer reviewed articles concerning laparoscopic radical prostatectomy was obtained using Medline query. LRP is being performed in multiple centers worldwide, using a variety of surgical approaches and technologies. Analysis of perioperative parameters, including surgical blood loss, operative time, complications and convalescence, demonstrates a low morbidity and shows a clear trend in improvement with increased experience. The functional results, as recorded by postoperative urinary and sexual functions, appear encouraging. The reported positive surgical margin rates decrease with more recent series. Oncological results and cancer control rates as measured by PSA recurrence and disease-free intervals are difficult to ascertain in the immature series published to date. LRP has witnessed tremendous popularity and widespread implementation in specialized centers worldwide. LRP represents a technically demanding laparoscopic procedure with a difficult learning curve, but can be performed systematically with standard techniques. The advantages include shorter convalescence and markedly lower operative blood loss, with quicker removal of the urinary catheter. Long-term functional and oncologic results are not yet available.

Complications of transperitoneal laparoscopic surgery in urology: review of 1,311 procedures at a single center.

PURPOSE: The development of laparoscopic surgery in urology is increasing rapidly. We describe our experience with complications during and after transperitoneal laparoscopic surgery after 9 years of practice. MATERIALS AND METHODS: A total of 1,311 laparoscopic procedures were performed by 5 senior urologists in the same department since 1992, of which 72% were classified as difficult or very difficult (prostatectomy, nephrectomy for cancer, nephroureterectomy, partial nephrectomy, cystectomy, para-aortic lymph node dissection), 27.5% as moderately difficult (nephrectomy for benign disease, adrenalectomy, genitourinary prolapse, ureteropelvic junction, pelvic and ureteral stones, ureterovesical reimplantation, pelvic lymph node dissection) and 0.5% as easy (lymphocele, renal cyst and so forth). RESULTS: There was no mortality or anesthetic complications. The overall transfusion rate was 2.4%. Complications were serious in 0.7% of cases, all of which required reoperation, intermediate in 1.8% of which 1% required reoperation and minor in 1.1%. The main complications were bowel (1.2%), vascular (0.5%) and ureteral injuries (0.8%). The conversion rate was 1.2% and the reoperation rate was 2.4%. Of the patients 1.2% had to be admitted to the intensive care unit. Postoperative complications were observed in 19% of cases. Laparoscopic surgery is associated with essentially the same complications as open surgery, and they, particularly bowel injuries and bleeding, can be diagnosed and often treated with repeat laparoscopy. CONCLUSIONS: Complications during and after transperitoneal laparoscopy remain low and are not superior to those observed during and after open surgery. As laparoscopy becomes more widely used, urologists wishing to learn this technique must realize that the learning process is long but essential.

Laparoscopic surgery in urological pelvic cancer.

Laparoscopy has become more widely used in urological practice, both for upper and lower urinary tracts. Improvements in instrumentation, and in surgeons' skills and experience have broadened the applications of laparoscopy. In particular, indications for laparoscopy in urological pelvic oncology have emerged as possible but still theoretical alternatives to conventional surgery. The development of the laparoscopic approach is still under close evaluation. Beyond these 'conventional' forms of laparoscopy, potential technical applications of computer assistance provide a glimpse of what could become the surgery of tomorrow.

Proposal for a "European Scoring System for Laparoscopic Operations in Urology".

PURPOSE: To propose a scoring system of difficulties for the most currently performed laparoscopic procedures in urology. MATERIALS AND METHODS: Each current laparoscopic procedure has been evaluated according to three different criteria: technical difficulty, operative risk and the attention required. Each criterion is scored from 1 (minimal impact of the criteria) to 7 (maximal impact of the criteria). The sum of the 3 criteria is used to classify each operation according to an increasing level of global difficulty, classified into 6 levels: easy (E: sum of criteria between 3 and 5), slightly difficult (SD: sum of criteria between 6 and 8), fairly difficult (FD: sum of criteria between 9 and 11), difficult (D: sum of criteria between 12 and 14), very difficult (VD: sum of criteria between 15 and 17), extremely difficult (ED: sum of criteria greater than 18). RESULTS: Procedures currently performed by laparoscopy have been selected for evaluation according to the above criteria, and retrospectively validated by European experts in laparoscopic urology according to their experience and the international literature. CONCLUSION: This proposal of a scoring scale system is a basis for discussion, teaching and learning of urological laparoscopy. By necessity, this scale is evolving and will be regularly reconsidered and updated every 5 years.

Robotically assisted laparoscopic radical prostatectomy: feasibility study in men.

PURPOSE: We report our early experience of robotically assisted laparoscopic radical prostatectomy. MATERIAL AND METHODS: Five consecutive patients, with an average age of 58 years, PSA 12, 1.6 positive biopsies, Gleason score 6, were operated in our institution over a period of 1 week by the same surgeon. A robotically assisted laparoscopic nerve sparing radical prostatectomy was performed according to the Montsouris technique with the Da Vinci robot (Intuitive Inc., Mountain View, Calif., USA). RESULTS: The mean installation time was 93 min (range 76-149). The mean operating time (starting at the dissection of the seminal vesicles until the final stitch of the anastomosis) was 222 min (range 150-381 min). The average blood loss was 800 cm(3) (range 700-1,600 cm(3)). No postoperative complications were seen. Bladder catheter time: 6.5 days, hospital stay 5.5 days, urine leak 1/5, continence 4/5, positive margin 1/5. CONCLUSION: After this short experience, we conclude that: The use of a tele manipulation system accompanied by a three-dimensional view of the operating field provides a real benefit for the surgeon, and the urethro-anastomosis is easier to perform. The benefit for the patient is presently not very clear in terms of operating time, postoperative course and functional results, our initial results show that the robotically assisted procedure is at least as safe and effective as the conventional laparoscopic procedure.

Robot assisted laparoscopic nephrectomy.

PURPOSE: The feasibility and safety of remote laparoscopic surgery using a surgical telemanipulator have been demonstrated in laboratory experience and recently in clinical practice. To our knowledge we report the first robot assisted, laparoscopic nephrectomy in a human. MATERIALS AND METHODS: A 77-year-old woman was diagnosed with a nonfunctioning hydronephrotic right kidney due to ureteropelvic junction obstruction. Robot assisted, transperitoneal right laparoscopic nephrectomy was performed. RESULTS: Complete dissection was successfully performed with the robot. The renal pedicle was dissected without any problem, and the artery and vein were individually ligated. Operative time was 200 minutes, anesthesia time was 245 minutes and blood loss was less than 100 ml. Convalescence was uneventful. Histological examination confirmed the preoperative diagnosis. CONCLUSIONS: We report the technical feasibility of robot assisted laparoscopic nephrectomy in humans. Current technology needs further improvement and its actual usefulness for patient treatment must be established by large clinical trials. Technological improvements and future telecommunication networks should open new avenues in surgery, namely remote telesurgery.

Laparoscopic radical prostatectomy: the lessons learned.

PURPOSE: To evaluate the operative, oncologic, and functional results of laparoscopic radical prostatectomy based on an initial series of 350 patients. PATIENTS AND METHODS: Between January 1998 and May 2000, 350 consecutive patients underwent laparoscopic radical prostatectomy according to our technique. The study of operative morbidity was based on all intraoperative and postoperative complications. The oncologic assessment was based on clinical, laboratory, and intraoperative and postoperative pathological data. Postoperative functional results were assessed by the ICS-male self-administered questionnaire. RESULTS: No deaths were observed in this series. Conversion was required in seven cases, exclusively among the first 70 patients. The mean operating time was 217 +/- 59 minutes, including the lymphadenectomy phase that was considered necessary in 21.4% of patients, and 195 +/- 56 minutes for the most recent 200 patients. The mean intraoperative blood loss was 354 +/- 250 mL. The overall transfusion rate was 5.7% and 2.8% in the last 250 patients. Intraoperative complications were reported in 14 patients (4%), and the reoperation rate was 3.7%. The mean postoperative bladder catheterization time was 5.8 +/- 3.3 days, and the catheter could be removed before the 5th day in 41% of patients. The mean hospital stay was 6 +/- 3.9 postoperative days (range 2-33 days). By pathologic stage, the positive surgical margin rate was 3.6% for pT2a specimens (3 patients), 14% for pT2b specimens (29 patients), 33% for pT3a specimens (12 patients), and 43.5% for pT3b specimens (10 patients). In the first 75 patients with pT2N0/Nx negative-margin specimens and a follow-up of >12 months, the PSA concentrations was <0.2 ng/mL in 92% of patients. The continence rate (no protection necessary either during the day or at night) among the first 133 patients was 85.5% and the postoperative erection rate was 59% among 22 selected consecutive patients. CONCLUSIONS: This study confirms the value, in our experience, of the laparoscopic approach to radical prostatectomy, which allows satisfactory cancer control associated with low perioperative morbidity and encouraging functional results in terms both of continence and erectile function.

Laparoscopic partial nephrectomy in the pig: comparison of three hemostasis techniques.

BACKGROUND AND PURPOSE: Control of intraoperative bleeding is the main technical difficulty encountered during laparoscopic partial nephrectomy. The objective of this study was to compare the efficacy and morbidity of three renal parenchymal hemostasis techniques: high-frequency bipolar electrical current, high-frequency unipolar spray electrical current, and ultrasound during laparoscopic partial nephrectomy performed in pigs without vascular control. MATERIALS AND METHODS: A standardized laparoscopic transperitoneal right lower-pole partial nephrectomy was performed in 27 pigs with a mean weight of 65 +/- 5 kg. The pigs were divided into three groups according to the technology used: Group 1 = bipolar electrical current, Group 2 = unipolar spray electrical current, and Group 3 = ultrasound. Intravenous urography was performed on the 28th day. The kidneys were then removed for histologic examination, and the pigs were sacrificed. The criteria evaluated were intraoperative and postoperative complications, blood loss, renal function, and thickness of the parenchymal lesions induced. The Kruskal-Wallis nonparametric test for comparison of medians was used for statistical analysis of the data (P < 0.05). Data from pigs that died before the end of the study were excluded from the analysis. RESULTS: All partial nephrectomies were performed laparoscopically, and all pigs were alive at the end of the operation. The postoperative complication rate was 11% (N = 3): two pigs died before the end of the study, one from hemorrhage on Day 6 (Group 2), and the other from prolonged reflex ileus with sacrifice of the pig on Day 7 (Group 3). One pig developed an asymptomatic urinoma (Group 2). Blood loss was significantly lower when ultrasound was used (P = 0.026). Global renal function was not significantly altered in the various groups. The median thickness of tissue necrosis and fibrosis detected in the scar zone was 6 mm (range 4-10 mm) and was similar in the three groups. CONCLUSION: Partial nephrectomy can be performed by laparoscopy without vascular control in the pig. Coagulation by ultrasound appears to present an advantage in terms of limitation of blood loss compared with coagulation by bipolar or unipolar spray electrical currents without presenting any benefit in terms of preservation of the renal parenchyma.

Laparoscopic radical prostatectomy: assessment after 240 procedures.

Radical prostatectomy can be successfully performed by transperitoneal laparoscopy by a urologic team experienced in laparoscopy and radical prostatectomy. Operative and postoperative morbidity rates are low. Postoperative pain is minimal, allowing reduction of the length of hospital stay. The oncologic results seem satisfactory based on short-term follow-up. The improvement of the quality of intraoperative vision related to magnification of the image allows a more precise procedure. This subjective improvement of the quality of dissection should reduce the usual functional sequelae of conventional radical prostatectomy, such as incontinence and impotence. This finding needs to be confirmed by a larger series of patients with longer follow-up. Laparoscopic radical prostatectomy is now performed routinely and is proposed as a first-line surgical treatment for localized prostatic cancer at the authors' center.

Robotic assisted, laparoscopic pelvic lymph node dissection in humans.

PURPOSE: We evaluate the feasibility and efficacy of robotic assisted, laparoscopic pelvic lymph node dissection for locally advanced prostate cancer staging. MATERIALS AND METHODS: Robotic assisted, laparoscopic pelvic lymph node dissection was performed in 10 consecutive patients with mainly T3 M0 prostatic carcinoma (robotic group). Operative, postoperative and pathological parameters were compared with the results of the last 10 patients undergoing conventional, laparoscopic pelvic lymph node dissection performed with similar indications by the same operator (laparoscopy group). RESULTS: All operations were performed according to the established protocol with no specific intraoperative or postoperative complications. No conversion was required, and no technical incidents were observed in the robotic group. Mean operating time plus or minus standard deviation for the robotic group was 125 +/- 57 minutes (range 75 to 215), significantly longer than that for the laparoscopy group, which was 60 +/- 15 minutes (p = 0.0013). In the robotic group 2 patients presented with postoperative lymphoceles revealed in 1 by deep venous thrombosis and in the second by obturator pain. In the laparoscopy group 1 patient presented with acute urinary retention. The histological results concerning the number of lymph nodes removed were similar in both groups (p = 0.5). CONCLUSIONS: We show the technical feasibility of robotic assisted, laparoscopic pelvic lymph node dissection in humans. Although the benefit of this technique has not yet been established, predictable technological improvements would suggest the development of telesurgery and an improved precision of surgical procedure.

Laparoscopic ureterolithotomy for ureteral calculi.

BACKGROUND AND PURPOSE: Most patients with ureteral calculi that do not pass spontaneously can be treated by either extracorporeal shockwave lithotripsy (SWL) or ureteroscopy. In rare cases of large, hard and chronically impacted stones, or after failure of first-line treatments, surgical ureterolithotomy is still indicated. Laparoscopy allows performing this procedure in a minimally invasive manner. PATIENTS AND METHODS: Twenty-four patients (22 men and 2 women) underwent laparoscopic ureterolithotomy between 1994 and 1999. The procedure was indicated in 10 cases as a salvage treatment after failure of SWL (5 patients), ureteroscopy (2 patients), both (1 patient), laparoscopic ureterolithotomy (1 patient), or even open ureterolithotomy (1 patient), and in 14 patients as a primary treatment for large stones (median size 11.5, range 8-33 mm). The first 3 procedures were carried out via the retroperitoneal route and the following 21 via the transperitoneal approach. RESULTS: All but 1 stone were successfully removed in a mean operating time of 111 (range 45- 180) min. Postoperative pain was managed with first-line analgesics. Hospital stay ranged from 2 to 10 (mean 3.8) days. The 2 postoperative complications encountered were prolonged ileus (1 patient) and venous thrombosis (1 patient). CONCLUSIONS: Laparoscopic ureterolithotomy is a safe and effective procedure that enables the urologist to maintain a minimally invasive strategy when first-line treatment have failed or are unlikely to be effective.