Multicenter study on multidisciplinary committees in advanced prostate cancer.

INTRODUCTION AND OBJECTIVE: Although Multidisciplinary Teams (MDTs) are recommended in the management of Advanced Prostate Cancer (APC), their functioning in real practice has been poorly evaluated. We carried out a multicenter study with the objective of evaluating the functioning of uro-oncology MDTs in 6 hospitals. MATERIALS AND METHODS: A descriptive cross-sectional study was performed. The level of Compliance with the Fundamental Quality Requirements (CFQR) of the MDTs was evaluated by means of a questionnaire filled out by the coordinators of the MDTs in each hospital. The information on the perspective of the members of the MDTs was evaluated through an anonymous survey. RESULTS: A high level of CFQR in MDTs was evidenced (75%), showing deficiencies in terms of protocol update, agendas, audits, and scientific production. The survey was answered by 62.32% of the 69 physicians surveyed (urologists, oncologists, radiation therapists, radiologists, and pathologists). The 88.4% consider the duration of the meetings appropriate. There are disparate opinions concerning the protection of the MDT meeting time as well as protocol update. Of the patients with APC presented at the MDTs meeting, 62,8% require intervention from two specialties. Only 50% of respondents believe that all CRPC cases are discussed and that there is a prior agenda. The decisions made by the MDTs are reflected in the clinical history in 65.1% and are binding only in 60.5% of the cases. Half of the respondents have not been trained in MDTs. Most participants (90.7%) agree on the fact that MDTs. convey benefits. CONCLUSIONS: The evaluations of the MDTs identify rectifiable deficiencies by modifying hospital inertia and care planning.

The use of one-piece U-shaped mesh and barbed sutures in laparoscopic sacrocolpopexy. / Empleo de malla en U de una pieza y sutura barbada durante la colposacropexia laparoscópica.

INTRODUCTION: Laparoscopic sacrocolpopexy (LS) is considered a safe and effective surgery for the treatment of pelvic organ prolapse (POP), but it requires expertise in laparoscopic surgery. The complexity of the intervention is due to the requirements of intracorporeal sutures and the manipulation of the mesh inside the cavity, which may be cumbersome. The barbed sutures (BS) simplify intracorporeal suturing and do not require knotting. Additionally, one-piece U-mesh (OP-UM) may facilitate handling, stabilization and tension adjustment. We describe our LS surgical technique using both materials to assess its feasibility, safety and effectiveness in a prospective series of patients. MATERIALS AND METHODS: A total of 7 patients with symptomatic pelvic organ prolapse were included. Urogynecological history, classification of the pelvic organ prolapse according to Baden-Walker and the application of the Prolapse Quality of Life questionnaire were performed in all cases. The non-absorbable polypropylene OP-UM (Uplift ™) was used. The posterior side of the single sling is sutured to the elevator anus muscles with two non-absorbable stitches. Two strands of BS (V-Loc™), tied at their ends, were used to attach the mesh to the vagina in two lines of continuous sutures in opposite directions. Self-anchoring tackers were used for promontofixation and BS for peritoneal closure. RESULTS: The median age was 60 years, the median time of the anterior branch mesh BS fixation was 23minutes (range 21,30 - 26,40min), intraoperative bleeding was minimal, and the median hospital stay was 3 days. No intraoperative complications were recorded, and no mesh erosions or recurrences were observed at a median follow-up of 14 months (range 3-25 months). All patients presented clinical improvement of the prolapse and were satisfied with surgery. We observed that the OP-UM self-stabilizes when it extends longitudinally into the abdominal cavity, reducing the need of the surgical assistant. The independent promontofixation of each part of the mesh (posterior and anterior) allows a more anatomical tension adjustment. Fixing the mesh to the vagina is fast and simple with our BS technique. CONCLUSIONS: The use of OP-UM and BS during LS is feasible, safe, effective and could simplify this surgical technique.

Prospective study comparing laparoscopic and open adenomectomy: Surgical and functional results. / Estudio prospectivo comparativo entre adenomectomía laparoscópica y abierta: resultados operatorios y funcionales.

INTRODUCTION: Open adenomectomy (OA) is the surgery of choice for large volume benign prostatic hyperplasia, and laparoscopic adenomectomy (LA) represents a minimally invasive alternative. We present a long-term, prospective study comparing both techniques. PATIENTS AND METHODS: The study consecutively included 199 patients with benign prostatic hyperplasia and prostate volumes>80g who were followed for more than 12 months. The patients underwent OA (n=97) or LA (n=102). We recorded and compared demographic and perioperative data, functional results and complications using a descriptive statistical analysis. RESULTS: The mean age was 69.2±7.7 years (range 42-87), and the mean prostate volume (measured by TRUS) was 112.1±32.7mL (range 78-260). There were no baseline differences among the groups in terms of age, ASA scale, prostate volume, PSA levels, Qmax, IPSS, QoL or treatments prior to the surgery. The surgical time (P<.0001) and catheter time (P<.0002) were longer in the LA group. Operative bleeding (P<.0001), transfusion rate (P=.0015) and mean stay (P<.0001) were significantly lower in the LA group. The LA group had a lower rate of complications (P=.04), but there were no significant differences between the groups in terms of major complications (Clavien score≥3) (P=.13) or in the rate of late complications (at one year) (P=.66). There were also no differences between the groups in the functional postoperative results: IPSS (P=.17), QoL (P=.3) and Qmax (P=.17). CONCLUSIONS: LA is a reasonable, safe and effective alternative that results in less bleeding, fewer transfusions, shorter hospital stays and lower morbidity than OA. LA has similar functional results to OA, at the expense of longer surgical times and longer catheter times.

Micro-ureteroscopy: Initial experience in the endoscopic treatment of pelvic ureteral lithiasis.

OBJECTIVES: To present to report the first case of ureteral lithiasis resolved using a new endoscopic approach, which we call microureteroscopy (m-URS) and attempts to reduce the ureteral damage caused by conventional instrumentation. MATERIAL AND METHODS: We selected a 53-year-old patient with a 16-mm calculus in the right distal ureter. For endoscopic access, we used a 4.8 Fr sheath from the microperc set and fragmented the stone with a 230-micron laser fiber. RESULTS: Complete fragmentation of the stone was achieved. We placed a JJ catheter due to significant ureteral edema. The surgical time and postsurgical stay were 156minutes and 24hours, respectively. There were no complications, the requirements for analgesia were minimal, and the patient was free of residual stones. CONCLUSIONS: The m-URS technique is feasible, simple and effective for the treatment of pelvic ureteral lithiasis in women and optimizes minimal invasion, with results that can be comparable to conventional endoscopic techniques in terms of ease of access and quality of endoscopic vision without affecting the resolution capacity. Larger studies and greater technological development is needed to define the definitive role of this procedure. Currently, its major limitations lie in the treatment of proximal ureter lithiasis and in the treatment of men. This technique could also be a viable alternative for pediatric patients.

"Knotless" laparoscopic extraperitoneal adenomectomy.

INTRODUCTION: Laparoscopic adenomectomy is a feasible and effective surgical procedure. We have progressively simplified the procedure using barbed sutures and a technique we call "knotless" laparoscopic adenomectomy. We present a prospective, multicenter, descriptive study that reflects the efficacy and safety of this technique in an actual, reproducible clinical practice situation. METHODS: A total of 26 patients with benign prostatic hyperplasia of considerable size (>80cc) underwent "knotless" laparoscopic adenomectomy. This is an extraperitoneal laparoscopic technique with 4 trocars based on the controlled and hemostatic enucleation of the adenoma using ultrasonic scalpels, precise urethral sectioning under direct vision assisted by a urethral plug, trigonization using barbed suture covering the posterior wall of the fascia, capsulorrhaphy with barbed suture and extraction of the morcellated adenoma through the umbilical incision. RESULTS: The median patient age was 69 (54-83)years, the mean prostate volume was 127 (89-245)cc, the mean operative time was 136 (90-315)min, the mean estimated bleeding volume was 200 (120-500)cc and the hospital stay was 3 (2-6)days. All patients experienced improved function in terms of uroflowmetry and International Prostate Symptom Score and quality of life questionnaires. There were complications in 6 patients, 5 of which were minor. CONCLUSIONS: "Knotless" laparoscopic adenomectomy is a procedure with low complexity that combines the advantages of open surgery (lasting functional results and complete extraction of the adenoma) with laparoscopic procedures (reduced bleeding and need for transfusions, shorter hospital stays and reduced morbidity and complications related to the abdominal wall). The use of ultrasonic scalpels and barbed sutures simplifies the procedure and enables a safe and hemostatic technique.

[Ureterectomy in the treatment of urothelial carcinoma of the distal ureter]. / La ureterectomía distal laparoscópica en el tratamiento del carcinoma urotelial del uréter distal.

INTRODUCTION: Segmental ureterectomy with preservation of the kidney is a treatment option for the low grade urothelial carcinoma (LG-UC) in distal ureter that is not a candidate for endoscopic resection. Laparoscopic distal ureterectomy (LDU) with ureteral reimplantation is common in benign conditions (stenosis, iatrogenic lesion, endometriosis). However, it has been hardly described in malignant ureteral condition. The literature is reviewed in this regards and the surgical technique described. MATERIAL AND METHODS: The experience regarding two cases of LDU due to low grade urothelial carcinoma in distal ureter is presented. In both, previous bladder transurethral resection (RTU) was performed. The urinary cytology was negative and the imaging studies identified urinary obstruction and distal ureter filling defect. One of the patients had a background of T1G3 bladder cancer and suffered renal failure. In both, the ureter was ligated early. Segmental ureterectomy was performed using a combined endoscopic and laparoscopic procedure with ureteral desinsertion in one case. In the other, it was exclusively laparoscopic. Both were done with 4 trocars. Ureteral reimplantation was conducted with continuous hermetic suture and without tension. In one case with background of high grade bladder tumor, pelvic lymphadenectomy was also performed. RESULTS: Operating time was 180 and 240 min, respectively, with estimated bleeding of 100 and 250 ml. Hospitalization time was 6 and 4 days. The only post-operatory complication was paralytic ileum (Clavien I) in the first case. With a 20 and 12 month follow-up, there is no evidence of recurrence or dilatation. In the patient with renal failure, creatinine clearance improved. CONCLUSIONS: The LDU with ureteral reimplantation is a complex technique. However, it represents a feasible and effective alternative for the treatment of LG-UC in distal ureter, as long as the oncological and reconstructive principles are respected.

[Simplified renorrhaphy using self-retaining barbed suture during laparoscopic partial nephrectomy]. / Renorrafia simplificada empleando sutura barbada durante la nefrectomía parcial laparoscópica.

INTRODUCTION AND OBJECTIVES: Laparoscopic partial nephrectomy (LPN) is a challenging procedure that requires quick and effective intracorporeal suturing, that could limit widespread adoption. Refinements of surgery have improved warm ischemia times and facilitated renal reconstruction. We present a technique that makes renorrhaphy easier using Self-Retaining Barbed Suture (SRBS) weaving two threads. PATIENTS AND METHODS: Two patients with carcinoma of the kidney, 3.4 and 1.5 cm respectively, were subjected to the LPN. The SRBS is an absorbable polygluconate with small projections along its axis which are anchored in the tissue, distributing the tension of the suture line and eliminating the need for knots. Renorrhaphy was performed using the SRBS by two continuous suture lines without knots, setting the sutures with clips of Hem-o-lok(®) and adjusting it with the technique of «sliding clip¼, without placing «bolsters¼ inside the renal parenchymal defect. RESULTS: Operative time was 156 minutes and 163 minutes, intraoperative bleeding was 50 ml and 850 ml, the warm ischemia time was 14.3 minutes and 23 minutes and follow-up time was 7 months and 3 months in the first and second cases respectively. The hospital stay was 5 days and there were no postoperative complications. CONCLUSIONS: Simplified renorrhaphy using SRBS is effective, hemostatic, facilitates the renal reconstruction, and can help reduce the warn ischemia time.

[Nephroscopy with carbon dioxide in combination with laparoscopy in the treatment of urinary stones]. / Nefroscopia con uso de dióxido de carbono en combinación con laparoscopia para el manejo de la litiasis urinaria.

OBJECTIVE: Laparoscopy in combination with nephroscopy is rarely used for the treatment of complex urinary stones or anatomical abnormalities with difficult access stones. During the nephroscopy, in an opened renal pelvis, large amounts of fluid leaks and collects in the peritoneal cavity and can be a drawback. In these cases, the nephroscopy with use of carbon dioxide (CO2) can be an alternative. We present our experience in with this technique. MATERIAL AND METHOD: We performed surgeries using the 3-port transperitoneal technique. Five patients with urolithiasis were included. Three patients had concomitant ureteropelvic junction stenosis, one with stones in ectopic kidney, and the third had a large stone impacted in the proximal ureter. Patients were treated by pyelolithotomy or ureterolithotomy combined with flexible nephroscopy using CO2 and dismembered pyeloplasty was performed in appropriate cases. A flexible cystoscope was passed through a port and guided laparascopically through the opening in the renal pelvis. The gas cannula was connected to the irrigation channel of the endoscope to insufflate CO2 and calculi were extracted with a nitinol basket. RESULTS: Median age was 45 years (24-58). Mean operative time of nephroscopy was 22.4 minutes (range 15-48). Mean intra-operative blood loss was inestimable. There were no complications or conversion. Residual lithiasis requiring ureteroscopy was present in one patient. CONCLUSIONS: Flexible nephroscopy using CO2 in combination with laparoscopy is a feasible and effective technique for the treatment of urinary stones in selected cases to avoid accumulation of fluid in the peritoneal cavity.

[Comparative study between laparoscopic extraperitoneal and open adenomectomy]. / Estudio comparativo entre adenomectomía extraperitoneal laparoscópica y abierta.

OBJECTIVES: In spite of the development of endoscopic techniques, open adenomectomy continues to be the treatment of choice for large adenomas. Laparoscopic and robotic adenomectomy provides good results in specialized centers. The experience acquired with laparoscopic extraperitoneal adenomectomy (LEA) in a regional center is presented to evaluate its results and compare them prospectively with the results of open surgery. PATIENTS AND METHODS: 46 patients with benign prostatic hyperplasia (BPH) (prostate >80 g) and an indication for surgery were evaluated. The first 11 patients underwent LEA and were not included in the comparison. Thereafter, the cases were compared; 17 patients underwent LEA and 18, open surgery. In the extraperitoneal technique with 4 trocars, enucleation was performed with an ultrasonic scalpel. RESULTS: There were no significant differences between groups in age, prostate volume, uroflow (Qmax), International Prostate Symptom Score (IPSS), Quality of Life scale (QoLs). The operation time was significantly greater in the LEA group (135.2 vs. 101.2 minutes, p = 0.022). Intraoperative bleeding (250 vs. 493.3 ml, p = 0.004), irrigation time (22.2 vs. 39.1 hours, p = 0.038), catheter indwelling time (5.5 vs. 7.5 days, p = 0.030), hospital stay (3.7 vs. 6.6 days, p = 0.006) and transfusion rate (0 vs. 22.2%) were significantly less in the laparoscopy group. There was a greater incidence of hemorrhagic and surgical wound complications in the open surgery group. CONCLUSIONS: LEA is a relatively complex technique that requires laparoscopic skills, but it is a feasible and safe alternative to open surgery and has several advantages.

[Laparoscopic repair of vesico-vaginal fistula without intentional cystotomy and guided by vaginal transillumination]. / Reparación laparoscópica de fístula vésico-vaginal sin cistotomía intencional y guiada por transiluminación vaginal.

OBJECTIVES: Repair of vesico-vaginal fistula (VVF) by laparoscopy provides excellent exposure, which facilitates their implementation through small cystotomy. In some cases is difficult to locate the fistula without the prior opening of the bladder. We present a maneuver using vaginal transillumination to locate the fistula and to reduce the size of the opening bladder during laparoscopic repair without intentional cystotomy. MATERIAL AND METHODS: A total of 4 patients with supra-trigonal FVV produced post-hysterectomy received laparoscopic repair. All patients underwent physical examination, dye test, urethrocystoscopy and intravenous pyelography. Fistula was located using a cystoscope inserted through vagina and placed over the fistula. The emitted light guide laparoscopic dissection in to the plane between the vagina and the bladder just above the fistula, without previous intentional cystotomy. RESULTS: The mean age of patients was 42 (38-47) years. Bladder opening size did not reach 2cm. The mean operative time was 160 (120-186) minutes and catheterization time was 10 days. There were no recurrences. CONCLUSIONS: The laparoscopic repair of VVF without intentional cystotomy, by direct dissection of the fistulous tract guided by vaginal transillumination is effective; because it quickly locates the fistula in all cases, reduces the size of the bladder opening, shortens operative times and reduces irritative symptoms.

[Animal model for training in laparoscopic pyeloplasty]. / Modelo animal de entrenamiento en pieloplastia laparoscópica.

OBJECTIVE: With the coming of the laparoscopy, multiple surgical techniques have been developed that have revolutionized the urological practice. The laparoscopic pyeloplasty has been one of the techniques most developed. However, there are very few training models that permit the surgeon to decrease the learning curve. An animal model of training for the laparoscopic pyeloplasty technique is described. METHODS: Eight procedures of laparoscopic pyeloplasty were performed using the animal model (Gallus gallus) in the laparoscopic practice laboratory of the Urology Service of the University Hospital of Caracas. The preparation times of the model and the operation times of each surgeon were compared. The statistical analysis was made calculating the mean operation time, standard deviation, frequencies and percentages. A significant value was considered as p < 0.05. RESULTS: The laparoscopic pyeloplasty procedure was performed successfully in all of the cases by two surgeons. The preparation time ranged from a maximum of 14 minutes to a minimum of 6 minutes, this being the same for both surgeons in the fourth case. The operation time ranged from a maximum of 65 minutes to a minimum of 43 minutes, observing significant differences when comparing the times individually for each surgeon. Only one case had filtration when comparing the patency of the specimen. CONCLUSIONS: The animal model of training of laparoscopic pyeloplasty that is described is economical, reproducible, of easy availability and it makes it possible to develop laparoscopic surgical skills and competency necessary for reconstructive surgery and techniques that warrant intracorporeal suture.

Técnica de nefrectomía radical lumboscópica / Techniques of radical nephrectomy with 3-trocars lumboscopy

La Nefrectomia Radical sigue siendo el tratamniento de elección para Tumores Sólidos del Riñon, Actualmente existen diversas modalidades para efectuarla entre las que cuentan las técnicas endoscópicas, ya sea por Laparoscopia o por Lumboscopia. Describimos una Técnica de Nefrectomía Radical Lumboscóipica utilizando sólo 3 trocares, (diferente de la convencional con 4 trocares), interviniendo a 10 pacientes con Diagnóstico de Tumores sólidos renales. Se presentó una sola complicación intraoperatoria como fue sangramiento profuso de hilio renal que fue controlado con engrapadora endoscópica vascular. Ocho de los diez pacientes egresaron en menos de 60 horas de operados (2,5 días) y solo 2 pacientes egresaron a las 72 horas (3días) debido a inestabilidad hemodinámica que ameritó transfusión de 1-2 concentrados globulares. Los demás pacientes no presentaron complicaciones postoperatorias ni inmediatas ni tardías. Cuando esté indica Nefrectomía Radical por patología maligna, los procedimientos Endoscópicos (Laparoscipia o Lumboscopia) puede ahora considerarse como el estándar de atención en la mayoría de los casos. Los datos de eficacia intraoperatoria son comparables con los de la cirugía abierta convencional, con ventajas significativas en la morbilidad postoperatoria, convalescencia y estética. Al evadir la cavidad peritoneal, retroperitoneal proporciona ventajas adicionales que lo hacen el enfoque preferido en varios centros especializados. La técnica quirúrgica previamente detallada ha resultado un procedimiento confiable y reproducible con excelentes resultados en manos de los autores. Es importante la atención en la localización del trocar primario, la posición del balón adilatador, evitar el amontonamiento de los puertos y la familiarización con las ferencias anatómicas específicas para el abordaje retroperitoneal