Results of retroperitoneal laparoscopic radical nephrectomy.

PURPOSE: To analyze the retroperitoneal approach to laparoscopic radical nephrectomy in terms of feasibility, safety, morbidity, and cancer control. PATIENTS AND METHODS: We reviewed the records of 50 consecutive patients with renal cancer underwent radical nephrectomy via the retroperitoneal laparoscopic approach from 1995 through 1999. RESULTS: The mean operative time was 139 minutes (range 60-330 minutes) with a mean of 149.78-mL operative blood loss (0-1500 mL). The mean renal size was 100 mm (70-150 mm) with a mean tumor size of 38.6 mm (20-90 mm). The postoperative hospital was 6 days (2-13 days). Three open conversions were necessary: one for laparoscopically uncontrolled bleeding and two because obesity interfered with surgery. We noted two major complication and two minor complications. Two disease progression have been noted to date. One patient with a pT3 grade 2 renal-cell carcinoma had a local recurrence with liver metastasis 9 months after the procedure and died 19.7 months after radical nephrectomy. Another patient with a pT3aN+M+ cancer died 23.1 months after the procedure. CONCLUSION: Retroperitoneal laparoscopic nephrectomy for kidney cancer requires further assessment. It seems to have several advantages over open radical nephrectomy and to be effective and safe for small (<50-mm) renal tumors.

Experience with retroperitoneal laparoscopic adrenalectomy for pheochromocytoma.

PURPOSE: Although laparoscopic adrenalectomy has become the preferred surgical treatment of benign adrenal masses, for pheochromocytoma it is limited by concerns over hypertensive events related to early access to the adrenal vein. We report our experience with retroperitoneal laparoscopic adrenalectomy for pheochromocytoma. MATERIALS AND METHODS: From January 1995 to December 1999, 21 retroperitoneal laparoscopic adrenalectomies (left 12 and right 9) were performed for symptomatic pheochromocytoma in 11 men and 9 women 17 to 68 years old (mean age 46). To our knowledge pheochromocytoma was always diagnosed by increased urinary catecholamine, computerized tomography, magnetic resonance imaging and 131iodine iobenguane scintigraphy. RESULTS: There were no conversions to open surgery. The operating time ranged from 100 to 150 minutes (mean 116). Mean blood loss was 140 ml. (minimum 550), and none of the patients required transfusion. Hemorrhage due to adrenal vein injury occurred in 1 patient and was controlled intraoperatively. Average postoperative hospital stay was 3.4 days (range 1 to 12). The mean diameter of the excised masses was 38 mm. (range 15 to 70). Postoperative complications occurred in 4 cases, including hematoma in 1, trocar wound infections in 2 and eventration in 1 after 1 year. With a mean followup of 21.6 months (range 6 to 46), all patients had normal urinary catecholamine levels and 18 had normal blood pressure without treatment. CONCLUSIONS: Retroperitoneal laparoscopic adrenalectomy can be safely performed for small (less than 5 cm. diameter) pheochromocytoma. Retroperitoneal laparoscopy is a direct approach that allows the surgeon to control the adrenal vein first, thereby avoiding hypertensive events.

Carcinological risks and retroperitoneal laparoscopy.

PURPOSE: To determine the incidence of trocar site spillage, local recurrence, and metastatic disease associated with retroperitoneal laparoscopic tumor resection. METHODS: From 1994 to 1999, 228 retroperitoneal laparoscopic procedures were performed at our institution. Fifty-six procedures (24.6%) were for malignancies and comprised 41 radical nephrectomies and 8 partial nephrectomies for renal tumors, and 7 nephro-ureterectomies for renal pelvis tumors. The pathological stage and the status of surgical margins were noted according to the 1997 TNM classification. Postoperative follow-up data were obtained by means of physical and radiological examinations after 1 and 3 months, and then half-yearly. Trocar site seeding, local recurrence and metastatic disease were recorded. Kaplan-Meier actuarial analysis was used to determine the disease-free survival likelihood. RESULTS: The mean follow-up was 24.9+/-13.85 months. All the patients had tumor-free surgical margins. No laparoscopic trocar site recurrences were identified. For laparoscopic radical nephrectomy: one patient had a local recurrence with hepatic metastasis of a pT(3)G(2) tumor after 9 months and died 19.7 months after the procedure. One patient with a pT(3a)G(3)M+ tumor died 23.1 months after radical nephrectomy without any sign of local recurrence. For laparoscopic nephro-ureterectomy: one patient with a pT(3)G(3) tumor had a local recurrence 12.1 months after the procedure and died 26.6 months after surgery. One patient with a pT(1)G(2) renal pelvis tumor had bone metastasis at 9 months and died 29 months after the procedure. The Kaplan-Meier actuarial disease-free survival rate was 91% at 54 months for radical nephrectomy, 61% at 30 months for nephro-ureterectomy and 100% at 49 months for partial nephrectomy. CONCLUSION: Malignancies of the upper urinary tract can be managed by means of retroperitoneal laparoscopy. Short-term results suggest that this procedure is not associated with an increased risk of portsite or local recurrence, and that disease-free survival is equivalent to that obtained with open surgery.

Extraperitoneal laparoscopic repair of ureteropelvic junction obstruction: initial experience in 15 cases.

OBJECTIVES: To assess the feasibility and results of retroperitoneal laparoscopic pyeloplasty in the treatment of ureteropelvic junction obstruction. METHODS: From September 1996 to January 1999, 15 patients underwent extraperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction. Aberrant vessels were noted in 4 patients. Dismembered pyeloplasty was performed in 7 patients and nondismembered Fenger plasty in 7 patients. Pyeloplasty was not possible in 1 patient. RESULTS: Fourteen of the 15 procedures were successfully completed. The procedure was not possible in 1 patient who had already undergone endopyelotomy repair. The mean operating time was 178 minutes (range 100 to 250), and the mean postoperative hospital stay was 4.8 days (range 1 to 14). Postoperative complications occurred in 3 patients (two hematomas and one urinoma). Radiographic assessment by intravenous urography 3 months after the procedure showed good results. CONCLUSIONS: Retroperitoneoscopy, by providing easy and rapid access to the retroperitoneal space, seems to be a valuable alternative treatment for ureteropelvic junction obstruction.

Laparoscopic radical prostatectomy: preliminary results.

OBJECTIVES: To evaluate our preliminary experience with laparoscopic radical prostatectomy. The indications for laparoscopy are currently being extended to complex oncologic procedures. METHODS: Forty-three men underwent laparoscopic radical prostatectomy. We used five trocars. The surgical technique replicates the steps of traditional retropubic prostatectomy, except that the rectoprostatic cleavage plane is developed transperitoneally at the beginning of the procedure. In the first 10 patients, we performed the vesicourethral reconstruction with interrupted sutures; in the remaining 33 patients, we performed it with two hemicircumferential running sutures. The specimen was removed through the umbilical port site. RESULTS: Once the developmental phase with the first 10 patients was concluded, the median operating time was 4.3 hours without pelvic lymphadenectomy, and the median postoperative bladder catheterization was 4 days. Two (4.7%) of 43 patients underwent transfusion. Twelve patients (27.9%) had positive surgical margins; all patients had a postoperative prostate-specific antigen level of less than 0.1 ng/mL at 1 month. Rectal injury occurred in 1 patient, requiring colostomy, and 4 patients had urethrovesical anastomotic leakages requiring surgical repair. One month postoperatively, 36 patients (84%) were fully continent (no leakage). Six patients had had erections, and four stated they had had sexual intercourse. CONCLUSIONS: Laparoscopic radical prostatectomy has evolved to a fully standardized and reproducible procedure. The short-term oncologic and functional efficacy rates are equivalent to those for open surgery. The operating time is reasonable once the learning curve is over, and postoperative morbidity is diminished. Because of the improved visual accuracy, permitting more precise dissection, this technique has the potential to become an important advancement in urologic surgery.

[Mechanisms of action of BCG: towards a new individualized therapeutic approach?]. / Mécanismes d'action du BCG: vers une approche thérapeutique individualisée (ATI)?

A better knowledge of antitumour immunity and the mechanisms allowing the tumour to overcome the host's immune surveillance has led to progress in the understanding of the mechanisms of action of Bacille Calmette-Guérin (BCG), as the local intravesical immune response is intimately related to the interaction of three systems: the host (the patient), the BCG (mycobacteria) and the tumour. This interaction gives rise to a cascade of immunological events, some of which are essential to the protective action of BCG against relapse and tumour progression. The immune response to BCG is currently considered to comprise three phases. First of all, the BCG adheres to the urothelium and is then phagocytosed by antigen-presenting cells. This phase corresponds to early release of so-called inflammatory cytokines (IL1, IL6, IL8). These cytokines could be responsible for certain adverse effects, but could also participate in cytotoxic phenomena. The second phase consists of recognition of bacterial antigens by helper CD4 lymphocytes, which mainly release IL2 and IFNg (Th1 response). This cellular activation leads to the third phase: amplification of cytotoxic populations capable of killing tumour cells: CD8, gd lymphocytes, macrophages, NK, LAK, BAK cells. All these cells also produce cytokines, which participate in regulation of the immune response. The understanding of these mechanisms of action, urinary cytokine assays, a better definition of cytotoxic cells and their role, molecular analysis of the tumour and probably certain genetic characteristics of the host will allow the elaboration of more effective immunization protocols by defining an individualized therapeutic approach.