Complications and adverse events in lymphadenectomy of the inguinal area: worldwide expert consensus.

BACKGROUND: Inguinal lymph node dissection plays an important role in the management of melanoma, penile and vulval cancer. Inguinal lymph node dissection is associated with various intraoperative and postoperative complications with significant heterogeneity in classification and reporting. This lack of standardization challenges efforts to study and report inguinal lymph node dissection outcomes. The aim of this study was to devise a system to standardize the classification and reporting of inguinal lymph node dissection perioperative complications by creating a worldwide collaborative, the complications and adverse events in lymphadenectomy of the inguinal area (CALI) group. METHODS: A modified 3-round Delphi consensus approach surveyed a worldwide group of experts in inguinal lymph node dissection for melanoma, penile and vulval cancer. The group of experts included general surgeons, urologists and oncologists (gynaecological and surgical). The survey assessed expert agreement on inguinal lymph node dissection perioperative complications. Panel interrater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α. RESULTS: Forty-seven experienced consultants were enrolled: 26 (55.3%) urologists, 11 (23.4%) surgical oncologists, 6 (12.8%) general surgeons and 4 (8.5%) gynaecology oncologists. Based on their expertise, 31 (66%), 10 (21.3%) and 22 (46.8%) of the participants treat penile cancer, vulval cancer and melanoma using inguinal lymph node dissection respectively; 89.4% (42 of 47) agreed with the definitions and inclusion as part of the inguinal lymph node dissection intraoperative complication group, while 93.6% (44 of 47) agreed that postoperative complications should be subclassified into five macrocategories. Unanimous agreement (100%, 37 of 37) was achieved with the final standardized classification system for reporting inguinal lymph node dissection complications in melanoma, vulval cancer and penile cancer. CONCLUSION: The complications and adverse events in lymphadenectomy of the inguinal area classification system has been developed as a tool to standardize the assessment and reporting of complications during inguinal lymph node dissection for the treatment of melanoma, vulval and penile cancer.

Breast cancer in northern Peru: molecular subtypes and HER2 low. / Cáncer de mama en el norte del Perú: subtipos moleculares y HER2 low.

This study aimed to understand the immunohistochemical profile of breast cancer and to identify the HER2 low subgroup in the northern macro-region of Peru. A cross-sectional study was conducted in 1176 patients from the Regional Institute of Neoplastic Diseases Northern Peru, from January 2016 to December 2023. We analyzed the data (age, histological type, grade and complementary results), with frequencies and percentages. The profile corresponded to: luminal B (45.6%); luminal A (24.7%); triple negative (18.2%); and HER2 positive non luminal (11.5%). In addition, 215 patients presented HER2 low (25.1% of those previously considered negative). This study provides evidence that the subtyping of breast cancer has changed, being luminal B the most frequent. It is essential to involve health policies to acquire targeted therapies considering HER2 low patients. Motivation for the study. Molecular classification of breast cancer allows the use of targeted treatments. Information on this profile in the northern macroregion of Peru is unknown. In addition, new therapies have appeared for a subgroup of patients. Main findings. In this study, the most frequent molecular subtypes were: luminal B, luminal A, triple negative and non-luminal HER2. Also, 18.3% of patients had low HER2 expression. Implications. Health policies should be aligned with scientific advances, to guarantee targeted therapies and to update the information in health manuals or protocols.

El objetivo del estudio fue conocer el perfil inmunohistoquímico del cáncer de mama e identificar el subgrupo HER2 low en la macrorregión norte del Perú. Se realizó un estudio transversal con una muestra de 1176 pacientes atendidos en el Instituto Regional de Enfermedades Neoplásicas Norte del Perú desde enero de 2016 a diciembre de 2023. Los datos recolectados (edad, tipo histológico, grado y resultados complementarios), se analizaron con frecuencias y porcentajes. El perfil correspondió a: luminal B (45,6%); luminal A (24,7%); triple negativo (18,2%); y HER2 positivo no luminal (11,5%). Además, HER2 low fueron 215 pacientes (25,1% de los considerados previamente negativos). Este estudio proporciona evidencia que la subtipificación de cáncer de mama ha cambiado, siendo luminal B más frecuente, y es esencial involucrar a políticas de salud para adquirir terapias dirigidas considerando a pacientes HER2 low. Motivación para realizar el estudio. La clasificación molecular del cáncer de mama permite utilizar tratamientos dirigidos. La información de este perfil en la macrorregión norte del Perú es desconocida. Además, han aparecido nuevas terapias para un subgrupo de pacientes. Principales hallazgos. En este estudio, los subtipos moleculares por orden de frecuencia fueron: luminal B, luminal A, triple negativo y HER2 no luminal. Asimismo, 18,3% de pacientes tuvieron expresión HER2 low. Implicancias. Las políticas de salud deben corresponderse con los avances científicos, para garantizar terapias dirigidas y actualizar la información de los manuales o protocolos de salud.

Primary signet ring cell carcinoma of the cervix: case report and literature review.

Objective: To report an infrequent case of primary signet ring cell carcinoma of the cervix (PSRCC), review the literature and evaluate the clinicopathological characteristics. Material and methods: A 51-year-old female patient, with 3 years of disease characterised by gynaecologic bleeding and pelvic pain. On examination, cervix replaced by tumour and infiltrated parametria; with cytology and histology of adenocarcinoma with cells in a signet ring pattern. Disease extension studies were negative. Classified as PSRCC stage IIIB, chemotherapy and radiotherapy were indicated, but the patient died a month later. The bibliographic search included publications up to July 2023. Results: 32 cases with a mean age of 47.6 years were identified. The most frequent symptoms were uterine bleeding and abdominal and pelvic pain. The initial stages were treated surgically, some with adjuvant chemotherapy and/or radiotherapy, with favourable responses; a difference from advanced cases. The average survival was 17.6 months. Conclusion: PSRCC is rare, with 32 cases reported according to the review. The expression with immunohistochemical and molecular techniques for the human papilloma virus can help confirm the gynaecological primary, but its diagnosis is one of exclusion, since its morphological pattern is related to other primaries, mainly digestive.

Cáncer de mama en el norte del Perú: subtipos moleculares y HER2 low / Breast cancer in northern Peru: molecular subtypes and HER2 low

RESUMEN El objetivo del estudio fue conocer el perfil inmunohistoquímico del cáncer de mama e identificar el subgrupo HER2 low en la macrorregión norte del Perú. Se realizó un estudio transversal con una muestra de 1176 pacientes atendidos en el Instituto Regional de Enfermedades Neoplásicas Norte del Perú desde enero de 2016 a diciembre de 2023. Los datos recolectados (edad, tipo histológico, grado y resultados complementarios), se analizaron con frecuencias y porcentajes. El perfil correspondió a: luminal B (45,6%); luminal A (24,7%); triple negativo (18,2%); y HER2 positivo no luminal (11,5%). Además, HER2 low fueron 215 pacientes (25,1% de los considerados previamente negativos). Este estudio proporciona evidencia que la subtipificación de cáncer de mama ha cambiado, siendo luminal B más frecuente, y es esencial involucrar a políticas de salud para adquirir terapias dirigidas considerando a pacientes HER2 low.

ABSTRACT This study aimed to understand the immunohistochemical profile of breast cancer and to identify the HER2 low subgroup in the northern macro-region of Peru. A cross-sectional study was conducted in 1176 patients from the Regional Institute of Neoplastic Diseases Northern Peru, from January 2016 to December 2023. We analyzed the data (age, histological type, grade and complementary results), with frequencies and percentages. The profile corresponded to: luminal B (45.6%); luminal A (24.7%); triple negative (18.2%); and HER2 positive non luminal (11.5%). In addition, 215 patients presented HER2 low (25.1% of those previously considered negative). This study provides evidence that the subtyping of breast cancer has changed, being luminal B the most frequent. It is essential to involve health policies to acquire targeted therapies considering HER2 low patients.

Long-term oncological and surgical outcomes after Video Endoscopic Inguinal Lymphadenectomy (VEIL) in patients with penile cancer

ABSTRACT Objective: To report outcomes from the largest multicenter series of penile cancer patients undergoing video endoscopic inguinal lymphadenectomy (VEIL). Materials and Methods: Retrospective multicenter analysis. Authors of 21 centers from the Penile Cancer Collaborative Coalition-Latin America (PeC-LA) were included. All centers performed the procedure following the same previously described standardized technique. Inclusion criteria included penile cancer patients with no palpable lymph nodes and intermediate/high-risk disease and those with non-fixed palpable lymph nodes less than 4 cm in diameter. Categorical variables are shown as percentages and frequencies whereas continuous variables as mean and range. Results: From 2006 to 2020, 210 VEIL procedures were performed in 105 patients. Mean age was 58 (45-68) years old. Mean operative time was 90 minutes (60-120). Mean lymph node yield was 10 nodes (6-16). Complication rate was 15.7%, including severe complications in 1.9% of procedures. Lymphatic and skin complications were noted in 8.6 and 4.8% of patients, respectively. Histopathological analysis revealed lymph node involvement in 26.7% of patients with non-palpable nodes. Inguinal recurrence was observed in 2.8% of patients. 10y- overall survival was 74.2% and 10-y cancer specific survival was 84.8%. CSS for pN0, pN1, pN2 and pN3 were 100%, 82.4%, 72.7% and 9.1%, respectively. Conclusion: VEIL seems to offer appropriate long term oncological control with minimal morbidity. In the absence of non-invasive stratification measures such as dynamic sentinel node biopsy, VEIL emerged as the alternative for the management of non-bulky lymph nodes in penile cancer.

Long-term oncological and surgical outcomes after Video Endoscopic Inguinal Lymphadenectomy (VEIL) in patients with penile cancer.

OBJECTIVE: To report outcomes from the largest multicenter series of penile cancer patients undergoing video endoscopic inguinal lymphadenectomy (VEIL). MATERIALS AND METHODS: Retrospective multicenter analysis. Authors of 21 centers from the Penile Cancer Collaborative Coalition-Latin America (PeC-LA) were included. All centers performed the procedure following the same previously described standardized technique. Inclusion criteria included penile cancer patients with no palpable lymph nodes and intermediate/high-risk disease and those with non-fixed palpable lymph nodes less than 4 cm in diameter. Categorical variables are shown as percentages and frequencies whereas continuous variables as mean and range. RESULTS: From 2006 to 2020, 210 VEIL procedures were performed in 105 patients. Mean age was 58 (45-68) years old. Mean operative time was 90 minutes (60-120). Mean lymph node yield was 10 nodes (6-16). Complication rate was 15.7%, including severe complications in 1.9% of procedures. Lymphatic and skin complications were noted in 8.6 and 4.8% of patients, respectively. Histopathological analysis revealed lymph node involvement in 26.7% of patients with non-palpable nodes. Inguinal recurrence was observed in 2.8% of patients. 10y- overall survival was 74.2% and 10-y cancer specific survival was 84.8%. CSS for pN0, pN1, pN2 and pN3 were 100%, 82.4%, 72.7% and 9.1%, respectively. CONCLUSION: VEIL seems to offer appropriate long term oncological control with minimal morbidity. In the absence of non-invasive stratification measures such as dynamic sentinel node biopsy, VEIL emerged as the alternative for the management of non-bulky lymph nodes in penile cancer.

Intraoperative cytology when cryostat is not available. A 7-year experience in a Peruvian cancer center.

BACKGROUND: Intraoperative cytology (IC) is an alternative to frozen-section (FS) diagnosis. We present our experience with and the diagnostic value of IC during a 7-year period when FS was not available in a Peruvian Cancer Center. MATERIAL AND METHODS: This 7-year retrospective single-arm review study includes IC procedures performed by three pathologists between 2012 and 2018. These IC reports were reviewed independently by one pathologist and were correlated with the histologic diagnoses, which were used as the gold standard. All IC preparations (imprint, scrape, and crush smears) were stained with hematoxylin and eosin. IC interpretations were categorized as: malignant, benign, atypical, and "deferred to permanent sections." Sensitivity, specificity, and positive and negative predictive values were calculated by use of standard methods. RESULTS: A total of 1814 IC cases prepared from various organs obtained from 887 patients were reviewed. Malignant, benign, atypical, and "deferred to permanent sections" IC diagnoses were 26.3%, 68.9%, 3.7%, and 1.9%, respectively. Atypical and deferred cases were excluded from the statistical analysis; thus 1712 cases were found to be eligible. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall diagnostic accuracy were 91.6%, 97.7%, 94.1%, 96.7%, and 96%, respectively. CONCLUSION: In experienced hands, IC is a rapid, cost-effective, and accurate alternative diagnostic modality for intraoperative diagnosis when FS is not available.

Carcinoma primario peritoneal sincrónico con tumor de músculo liso de potencial maligno incierto: reporte de caso

El carcinoma seroso primario peritoneal (CSP) es una neoplasia maligna, agresiva e infrecuente que suele diagnosticarse de manera incidental, luego de haber excluido un primario ovárico. Otra rara entidad es el tumor del músculo liso uterino de potencial maligno incierto (STUMP), que es una patología límite entre leiomiomas y leiomiosarcomas. Su sincronismo no ha sido reportado en la literatura. Presentamos el caso de una mujer de 50 años, con tiempo de enfermedad de doce meses, caracterizado por distensión abdominal progresiva, dolor, pérdida de peso y edema en miembros inferiores. La paciente fue intervenida quirúrgicamente por tumor uterino, a descartar sarcoma, encontrándose además de la neoplasia ginecológica lesiones sólidas peritoneales. El diagnóstico histológico fue STUMP sincrónico con CSP. La evolución fue desfavorable, falleciendo tres semanas después de la cirugía. En la literatura no encontramos casos de coexistencia de estas patologías, por lo que nuestro hallazgo representa un aporte en la oncología ginecológica.

Interventional cytopathology and cancer in Peru: how to act during COVID-19?

The worldwide health crisis due to SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) has affected all healthcare systems. Low- and middle-income countries have needed to establish health strategies to combat the pandemic, many of which have collaterally affected the diagnosis and treatment of other illnesses. One of these other illnesses is cancer, which in Peru represents the primary cause of mortality. In recent decades, interventional cytopathology with fine-needle biopsy techniques has emerged as a minimally invasive, rapid, economical and effective procedure for diagnosing and staging cancer. However, in the current health context, it is confronted by the challenge of continuing to function in spite of the pandemic. This article reviews the existing literature on interventional cytopathology, the risk of infection from SARS-CoV-2 and biosafety and provides recommendations for carrying out said procedures for the benefit of the patient and the safety of healthcare staff.

Perfil molecular y características clínico-patológicas del carcinoma mamario, con énfasis en la expresión del Ki 67: Experiencia inicial en instituto oncológico del norte del Perú / Molecular profile and clinical-pathological characteristics of the mammary carcinoma, with emphasis on the expression of Ki 67: Initial experience at the oncological institute of the north of Peru

Objetivo: Identificar el perfil molecular y las características clínicas y patológicas del carcinoma de mama de acuerdo a la variabilidad en la expresión del Ki 67. Material y métodos. Serie de casos, en el que se evaluaron 157 pacientes con diagnóstico anatomopatológico e inmunohistoquímico de cáncer de mama atendidas en el IREN Norte (Perú) durante el período 2008 ­ 2015. Se clasificaron los tumores en Luminal A, Luminal B, HER2 y Triple negativo. Se utilizo dos puntos de corte para evaluar el Ki 67:> 14% y > 20%, de acuerdo a lo sugerido en St. Gallen 2011 y 2013 respectivamente. Resultados. En el grupo de pacientes con Ki 67 > 20%, el subtipo molecular que predominó fue el Luminal B (n = 54; 34%). El tamaño tumoral más frecuente se ubicó en el grupo de > 2 a < 5 cm. (T2), representando 56% en el subtipo Luminal B, 28% en Luminal A, 69% en HER2 y 41% en el Triple negativo. En los pacientes con Ki 67 > 14%, el subtipo molecular y el tamaño tumoral predominante también fue el Luminal B (n = 73, 46%) y el T2. El tipo histológico más común fue el carcinoma ductal independientemente del punto de corte del valor de Ki 67. Conclusiones. La utilidad del valor porcentual del Ki 67 evaluado en dos puntos de corte es controversial; en nuestro estudio el perfil molecular y las características clínico-patológicas de cáncer de mama fueron relativamente similares en relación a Luminal A y Luminal B.

Objetive: Identify the molecular profile and the clinical and pathological characteristics of breast carcinoma according to the variability in Ki 67 expression. Material and methods. Case series, in which 157 patients with an anatomopathological and immunohistochemical diagnosis of breast cancer treated at IREN Norte (Peru) were evaluated during the period 2008-2015. The tumors were classified into Luminal A, Luminal B, HER2 and Triple Negative. Two cut-off points were used to evaluate Ki 67: > 14% and > 20%, according to what was suggested in St. Gallen 2011 and 2013 respectively. Results. In the group of patients with Ki 67 > 20%, the mol ecul ar subtype that predominated was Luminal B (n = 54, 34%). The most frequent tumor size was in the group of > 2 to < 5 cm. (T2), representing 56% in the Luminal B subtype, 28% in Luminal A, 69% in HER2 and 41% in the Triple negative. In patients with Ki 67 > 14%, the molecular subtype and the predominant tumor size was also Luminal B (n = 73, 46%) and T2. The most common histological type was ductal carcinoma regardless of the cut-off point of the Ki 67 value Conclusions. The utility of the percentage value of Ki 67 evaluated at two cut points is controversial; in our study, the molecular profile and clinical-pathological characteristics of breast cancer were relatively similar in relation to Luminal A and Luminal B.

Diagnostic validity of fine-needle capillary cytology in palpable tumours at the Oncology Institute of Peru.

OBJECTIVE: To evaluate the diagnostic validity of fine-needle capillary cytology (FNCC) in palpable tumours. MATERIAL AND METHODS: A retrospective, single-tray, cross-sectional diagnostic test study was carried out. We reviewed the cytological reports of the case files of the Cytology Unit of the Northern Regional Institute of Neoplastic Diseases (IREN) from January 2012 to December 2016. RESULTS: A total of 332 patients were selected, with an average age of 54.77 years (range 13-90 years); 61.4% of patients were female. The most frequent anatomical sites were lymph nodes (49.7%), thyroid (13.3%), breast (12.3%) and soft tissues (11.4%). Twenty-five cytologies did not have a histological correlation and six showed an atypical result. In the lymph node study, the most frequent pathology was metastatic carcinoma (49.7%), followed by lymphoma (13.3%). The FNCC had a sensitivity of 99.55%, a specificity of 98.77%, a positive predictive value of 99.55% and a negative predictive value of 98.77%. The positive likelihood ratio was 80.63%. CONCLUSIONS: FNCC is a useful, safe, reliable and economical ambulatory technique with minimal complications and high diagnostic accuracy.

Spontaneous testicular tumor regression: case report and historical review.

Spontaneous regression of a primary testicular germ-cell tumour (GCT), over time known as 'Burned out', 'Shrinking Seminoma', 'pT0', 'Burnout' or 'Spontaneous Regression', is an uncommon, generally metastatic phenomenon, which may present elevated tumour markers and a suspicious testicular ultrasound image. The histological study of the testicle demonstrated morphological changes of complete or partial tumour regression and found fibrous scarring and other characteristic changes of this phenomenon, which in some cases include vestiges of GCT. There are few publications on testicular GCT tumour regression and those that exist present limited data on the biology of the disease and its etiopathogenesis. This entity was recently recognised in the latest edition of the World Health Organization's (WHO) Classification of Tumours. We present our clinical, imaging, laboratory, cytohistological and management experience, as well as a historical review of the literature.

[Paratesticular sarcoma with synchronous renal carcinoma.] / Sarcoma indiferenciado pleomorfico paratesticular sincrónico con carcinoma renal.

OBJETIVE: Primary undifferentiated pleomorphic sarcoma (UPS) of the testicular tunics is rare, and synchronism with other malignancies of the urinary tract is uncommon, and may complicate the staging and therapeutic approach. We report the case of a patient diagnosed with primary paratesticular UPS with synchronous Renal Carcinoma. METHODS: Patient presenting with intrascrotal tumor who underwent left radical orchiectomy. In staging work up studies a second urologic neoplasia was found in the kidney. Histological diagnosis using immunohistochemical techniques for adequate characterization was performed. Adjuvant treatment options were evaluated. We review the literature and discuss the case. RESULTS: The UPS diagnosis was performed with immunohistochemistry. Paratesticular origin from testicular tunics was evident in the macroscopic evaluation. After finding the synchronic ipsilateral renal tumor, he underwent conventional left radical nephrectomy, ipsilateral adrenalectomy, excision of remnant left cord and para-aortic and pelvic lymphadenectomy. He received chemotherapy and adjuvant radiotherapy. Currently, after twelve months of follow-up there is no evidence of disease. CONCLUSIONS: The UPS is a heterogeneous group with an exclusion immunohistochemical diagnosis. Its management requires a multidisciplinary approach; the initial surgical treatment is accepted for the paratesticular mass with high section radical orchiectomy. Although there is insufficient evidence of the efficacy of adjunctive lymphadenectomy, chemotherapy and/or radiotherapy.

Ureterocele urothelial carcinoma: managing a rare presentation.

It is very uncommon for urothelial carcinoma to develop in an ureterocele. It is generally discovered in an imaging study or in connection with haematuria. We found very few reports in the literature. Here, we report on the case of a 71-year-old male who initially presented with haematuria and low back pain and who then underwent transurethral resection for an intraureterocele tumour. Pathology confirmed urothelial carcinoma.

Endoscopic inguinal lymphadenectomy in penile cancer: case report and literature review.

OBJECTIVES: The objective was to submit our first experience in endoscopic inguinal lymphadenectomy (EIL), evaluate the feasibility of the procedure and carry out a review of the literature. MATERIAL AND METHODS: A 41-year-old patient was diagnosed with penile cancer with squamous cell carcinoma pT2G1 pathology, with no palpable inguinal lymph nodes. A bilateral inguinal lymphadenectomy was performed with preservation of the saphenous vein, conventional left and endoscopic right procedures. The perioperative data is presented and that obtained is discussed in the literature. RESULTS: The total time was 270 minutes, 180 for endoscopic and 90 for conventional procedures. Blood loss was minimal in both cases. Fifteen lymph nodes were dissected on the endoscopic side, and 17 in the conventional side, the latter with more pain and devitalised skin flap. CONCLUSIONS: EIL for penile cancer is feasible and there is less morbidity with an early recovery. The literature is not conclusive on the indication of EIL.

Testicular plasmacytoma as presentation of multiple myeloma: case report and review of the literature.

OBJECTIVE: We present the case of a patient with testicular plasmacytoma as initial presentation of multiple myeloma, and we carry out a literature review of this uncommon pathology. METHODS: 63 year-old male who consulted for a testicular mass for three months. After clinical and diagnostic studies he underwent radical orchiectomy. RESULTS: Pathologic study of the specimen revealed the presence of round cells, some with plasmocytic aspect. Immunohistochemical studies gave the final diagnosis of plasmacytoma. Studies on disease extension showed rounded lytic lesions spread over the vault of the skull bones. Bone marrow studies, as well as bone biopsy showed infiltration by plasma cell neoplasia in more than 90%, consistent with the diagnosis of multiple myeloma. The patient received treatment, developing disease progression and subsequently died from the disease. CONCLUSIONS: Solitary plasmacytoma represents only 6% of all plasma cell neoplasms. Testicular presentation is an unusual event, representing 2% of cases. Although this is usually an autopsy finding, it may constitute the first manifestation of multiple myeloma or exceptionally be the unique location of a plasma cell neoplasm. To date there are few reports published in the literature. This case constitutes a contribution for the knowledge of testicular plasmacytoma.

Single-port transvesical enucleation of the prostate: a clinical report of 34 cases.

OBJECTIVE: To present our experience with single-port transvesical enucleation of the prostate (STEP) in 34 patients with large-volume benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: We performed STEP in 34 patients with large volume (>60 g) BPH (mean age 69 years, body mass index 26 kg/m(2), and American Society of Anesthesiology class 2). The mean prostate volume estimated by transrectal ultrasonography was 102.5 mL and the mean baseline prostate-specific antigen level was 6.7 ng/mL. A novel single-port device was inserted percutaneously into the bladder through a 2-3 cm incision in the suprapubic skin crease. After establishing pneumovesicum, the prostate adenoma was enucleated transvesically using standard laparoscopic instruments, and the adenoma was extracted in pieces through the port. Digital assistance expedited enucleation of the apical adenoma in 19 (55%) cases. RESULTS: Transvesical enucleation was completed in all 34 cases; the mean operative duration was 116 min, and the estimated blood loss was 460 mL. There was one death from postoperative bleeding from uncontrolled coagulopathy in a Jehovah's Witness who refused a transfusion of blood and blood products. There were three complications during STEP (one death, one bowel injury and one haemorrhage) and five afterwards (four bleeding, one epididymo-orchitis). Open conversion was necessary in two patients for complications, and extension of the skin incision by 1-2 cm was necessary in two to expedite apical digital enucleation. The mean hospital stay was 3 days and mean analogue pain score at discharge was 2. All 33 patients (excluding the patient who died) were voiding spontaneously at a maximum follow-up of 8 months, with a mean American Urologic Association symptom score of 3, a maximum urinary flow rate of 44 mL/s, and a postvoid residual of 30 mL at the latest follow-up. No patient developed urinary incontinence. CONCLUSIONS: STEP is an effective treatment option for selected patients with large-volume obstructive BPH. Under pneumovesicum using laparoscopic visualization, the entire adenoma can be effectively enucleated and expeditiously extracted through the novel single port. Comparison of the STEP procedure with other open and transurethral techniques will determine its place in the surgical treatment of large-volume BPH.

Robotic extended pyelolithotomy for complete staghorn calculus.

Staghorn stones represent a therapeutic challenge to urologists. We present our experience with laparoscopic extended pyelolithotomy for treatment of staghorn and complex renal calculi in highly selected cases. This approach provides the principles of open surgery with the advantages of minimally invasive surgery. We describe our experience with robot-assisted extended pyelolithotomy for complex coralliform calculi. Since January 2007, robotic extended pyelolithotomy has been performed by transperitoneal approach in two patients with complete coralliform lithiasis (calculi average size 8 cm). One patient had history of percutaneous nephrolithotomy. Demographic and operative data were collected. All procedures were technically successful without need for open conversion. Mean estimated blood loss was 175 ml (range 50-300 ml), and mean operative time was 150 min (range 120-150 min). A perinephric drain was employed in one patient with duration of 5 days. Postoperative imaging confirmed complete stone clearance. Robotic extended pyelolithotomy is a feasible and reproducible procedure for removal of complete and partial staghorn calculi in selected patients with complex nephrolithiasis. This approach might limit the role of open surgery for these calculi, but further publications with more cases are necessary to further define its utility.

Epithelioid angiomyolipoma: a rare variant of renal angiomyolipoma.

OBJECTIVE: We present a case of primary renal epithelioid angiomyolipoma, its association with tuberous sclerosis and review the literature. METHODS: We present the case of a 12 year-old male with past medical history of tuberous sclerosis, characterized by developmental delay, tonic and clonic seizures, and cutaneous abnormalities. He presented with macroscopic hematuria and abdominal pain. CT scan of the abdomen showed the presence of a left renal tumor. He underwent left radical nephrectomy. Pathologic study of the specimen showed primary renal epithelioid angiomyolipoma, corroborated by immunohistochemistry staining. Review of the literature was performed for this rare variant and its malignant potential. RESULTS: The presence of this epithelial variant is rare and must be taken into account because of its malignant potential and, thus, with different prognosis and follow up, compared to classical angiomyolipoma. CONCLUSIONS: Renal angiomyolipoma is an uncommon benign tumor, representing a challenge for clinical and pathological diagnosis. Despite the big size they can reach, as well as bilaterality, multiplicity of lesions and/or lymphatic regional involvement, its malignant potential has not been established. Nevertheless, the epithelioid variant has been described recently, a rare entity with aggressive behavior, difficult histological characterization and poor prognosis.

Laparoendoscopic single-site surgery simple prostatectomy: initial report.

OBJECTIVES: To report the first case and detailed technique of laparoendoscopic single-site (LESS) surgery simple prostatectomy for benign hypertrophy. METHODS: A 67-year-old man presented with acute urinary retention requiring catheterization. Serum prostate-specific antigen level was 5 ng/mL, and a biopsy revealed benign hypertrophy with a transrectal ultrasound volume estimation of 110 mL. LESS simple prostatectomy was performed using a single multilumen port inserted through a solitary 2.5-cm intraumbilical incision. Standard laparoscopic ultrasonic shears and needle drivers, articulating scissors, and specifically designed bent grasping instruments facilitated dissection and suturing. RESULTS: An R-port was placed intraperitoneally through a 2.5-cm intraumbilical incision. No extraumbilical skin incisions were made. Total operative time was 120 minutes and estimated blood loss was 200 mL. A closed suction drain was externalized through the umbilical incision. No intraoperative or postoperative complications occurred. Hospital stay was 2 days, the retropubic drain was removed at 3 days, and the catheter removed at 1 week. Specimen weight was 95 g and final pathology revealed benign prostatic hyperplasia. At 3 months follow-up, the patient was completely continent and voiding spontaneously with a Q(max.) of 85 mL/s. CONCLUSIONS: We demonstrate technical feasibility and describe the detailed surgical technique of LESS simple prostatectomy. Our initial experience suggests that this technique may be an alternative for large-volume benign prostatic hyperplasia in lieu of open surgery. Comparative studies with other surgical techniques will determine its place in the surgical armamentarium of benign prostatic hyperplasia.