Robotic pelvic exenteration in males: systematization of the technique.

Male pelvic exenteration is a challenging procedure with high morbidity. In very selected cases, the robotic approach could make dissection easier and decrease morbidity due to the better vision provided and higher range of movements. In this paper, we describe port placement, instruments, minilaparotomy location, and the stepwise sequence of these procedures. We address 3 different situations: total pelvic exenteration with abdominoperineal resection, colostomy and urostomy; pelvic exenteration with colorectal/anal anastomosis and urostomy; and pelvic exenteration with abdominoperineal resection, colostomy and urinary tract reconstruction.

Outcomes of laparoscopic salvage radical prostatectomy after primary treatment of prostate cancer.

Introduction: Treatment of radio-recurrent prostate cancer (PC) is managed mainly by androgen deprivation therapy. Nonetheless, selected patients could benefit from local salvage treatment options.In this study we present our series of recurrent PC cases submitted to laparoscopic salvage radical prostatectomy (sRP) at our institution. Material and methods: A total of 29 patients with recurrent PC after primary non-surgical treatment were submitted to laparoscopic sRP at our institution, with a mean follow-up time of 7 years. Results: There were 7 post-operative complications Clavien-Dindo grade ≥2. At the end of the follow-up, 58.6% patients presented biochemical recurrence and five-year recurrence-free survival (RFS) was 50%.Positive lymph nodes, high preoperative prostate-specific antigen (PSA) and TNM stage were correlated with worse RFS. Cox regression analysis demonstrated that stage pT3b was independently associated with worse RFS in comparison with stage pT3a or less.At 12 months, pad-free continence or mild incontinence was observed in 62% of the patients. Conclusions: sRP is a technically challenging surgery, and in our series, we were able to perform this procedure with acceptable operative time and limited blood loss.Post-operative complications, functional results and oncological outcomes were similar to other published studies, being our series, to the best of our knowledge, the one with the longest follow-up, of 7 years.sRP is a feasible local treatment with curative intent for radio-recurrent prostate cancer, with good oncological outcomes and reasonable continence rates in selected patients.

Metachronous Signet Ring Cell Bladder Metastasis as First Sing of Cancer Recurrence.

We describe the case of a 74-year-old woman with previous history of gastric signet cell carcinoma who develops bladder metastasis as first sign of recurrence 6 years later. Bladder metastasis due to signet cell carcinoma is extremely rare with only 19 cases reported. Treatment includes radical cystectomy or chemotherapy.

Results of simplified urethropexy in the recovery of continence after radical laparoscopic prostatectomy.

PURPOSE: To analyze the effectiveness of simplified urethropexy in the evolution of urinary incontinence after radical laparoscopic prostatectomy. PATIENTS AND METHODS: Between January 2007 and December 2008, 104 patients were included in a randomized trial to assess the effectiveness of simplified urethropexy. The simplified urethropexy technique was performed on conclusion of a urethrovesical anastomosis with running suture and, before cutting the suture material, a suture was applied using the same material with a needle through the pubic tubercle, tightening it and securing it with a Hem-o-lok. Fifty-one patients qualified for the trial in the simplified urethropexy group (group 1) and another 51 in the control group without urethropexy (group 2). Incontinence was defined as the lack of the need for protection for normal life, and the degree of continence was compared at 3, 6, and 12 months after surgery. RESULTS: Surgery lasted 141 minutes in group 1 and 139 in group 2 (NS). There were no secondary complications such as urine retention, osteitis pubis, or bladder perforation. After 3 months, 47.1% of patients in each group declared continence (NS). After 6 months, 72.6% of patients in group 1 and 66.7% in group 2 (P<0.05) declared continence. After 12 months, 92.2% of patients in group 1 and 84.3% in group 2 declared continence. CONCLUSIONS: In our experience, simplified urethropexy is a simple, nontime-consuming technique that shows a slight clinical improvement in continence within 6 and 12 months, without reaching significant differences with the Fisher Test. It would be necessary to perform a trial with a greater number of patients to confirm these data.

[Laparoscopic extraperitoneal prostatic adenomectomy: description of the surgical technique]. / Adenomectomía extraperitoneal laparoscópica: descripción de la técnica quirúrgica.

Historically, the surgical treatment of benign prostatic hyperplasia (BPH)in glands with volumes over 75-80 grams was performed using the conventional surgical approaches described by Terence Millin and Peter Freyer. Due to technological advancement over the past three decades, at present, minimally invasive techniques are being used with good results in the treatment of BPH. The incorporation of the laparoscopic approach to urologic surgery has allowed the technical development of adenomectomy using the same guidelines followed by conventional approaches. The aim of this paper is to describe in detail, step by step, the surgical technique of laparoscopic prostatectomy to treat BPH in glands larger than 60 cc., and to perform a retrospective analysis of preliminary results obtained in the immediate postoperative period of our initial series.

Feasibility of lymphadenectomy in laparoscopic radical cystectomy.

OBJECTIVES: The number of lymph nodes obtained through lymphadenectomy during radical cystectomy has prognostic and therapeutic value. We analyzed the number of nodes obtained during laparoscopic radical cystectomy to assess whether this approach allows satisfactory lymphadenectomy. METHODS: A total of 80 consecutive laparoscopic radical cystectomies with lymphadenectomy were performed by the same surgical team from 2005 to 2008. The male/female ratio was 5.7:1, the mean age was 65.3 years (range 47-87), and average body mass index was 26.7 kg/m(2) (range 20.6-40.1). Iliac-obturator lymphadenectomy up to the aortic bifurcation was performed after excising and pocketing the bladder. We analyzed the total number of lymph nodes identified by the pathologist and investigated a possible correlation with the variables presumably related to anatomic characteristics and other circumstances. RESULTS: The mean operative time of this step was 32 minutes (range 17-70). Minor vascular morbidity was present in 5 cases (6.25%). The average number of lymph nodes obtained was 22.3 (range 7-74, median 21). In 75 cases (93.8%), ≥10 nodes were obtained, and in 33 cases (41.2%), lymph node metastasis was diagnosed. No association or correlation was found in the number of nodes extracted regarding age, body mass index, or number of positive nodes. Also, no differences were found in association with gender, use of induction therapy, or the indication for cystectomy. CONCLUSIONS: Laparoscopic lymphadenectomy performed at radical cystectomy achieved an adequate number of lymph nodes. This technique did not entail an important increase in the duration of surgery. The complication rate was low. In experienced hands, laparoscopic lymphadenectomy is feasible and seems a secure oncologically correct procedure.

Surgical approach to a large left adrenocortical mass with associated tumour thrombosis of the left renal vein: preservation of the ipsilateral kidney.

A sixty-years-old male with diagnosis of a left adrenal mass (146 x 99 x 126 mm) with associated tumour thrombosis of the left renal vein with no clear signs of thrombosis of the inferior vena cava was admitted for elective surgery Finally an adrenalectomy and excision of tumour thrombus preserving the ipsilateral kidney was made. Despite of the complex vascular management, this kind of approaches allow to preserve normal renal function in patients with future nephrotoxic treatment like cisplatin.

Radical laparoscopic salvage prostatectomy: medium-term functional and oncological results.

AIM: To analyze the surgical, functional, and oncological results of radical laparoscopic salvage prostatectomy in local postradiotherapy recurrence. PATIENTS AND METHODS: Between May 2005 and April 2007, we treated nine patients with radical laparoscopic salvage prostatectomy. Five patients had received prior treatment with brachytherapy and the other four with external radiotherapy. The average age of the patients was 59.3 years (range 51-68). The average preoperative prostate-specific antigen was 9.1 ng/mL (range 2.6-30). The average follow-up period was 26.8 months (range 15-39). RESULTS: The average duration of surgery was 170 minutes (from 120 to 240). There was no need to resort to open surgery or transfusions. There were no cases of rectal injuries. Four cases were pT2c, 1 pT3a, 3 pT3b, and 1 pT4a. The Gleason score was 7 in three cases, 8 in two cases, and 9 in another four. Two patients had nodal metastasis. Postoperative prostate-specific antigen was undetectable in seven of the nine patients. Two patients experienced biochemical recurrence 16 and 13 months after the surgery. After a minimum follow-up period of 15 months, they were free from recurrence. There were no cases of urethrovesical anastomotic stenosis. Three patients manifested severe incontinence (more than two diapers per day), which was corrected in two cases by implanting an artificial sphincter. The other six patients required 0 to 1 pads/day. Before the surgery, only one of the five potential patients maintained his erectile function. CONCLUSIONS: Radical laparoscopic salvage prostatectomy is a complex technique that seems to allow attaining high and long-lasting rates of biochemical remission in patients with local postradiotherapy recurrence. Although there is less morbidity in our series in comparison with the anastomotic stenosis and rectal injuries rate published in radical retropubic salvage prostatectomy, more extensive comparative studies are required to confirm this fact.

[Da Vinci robot assisted radical prostatectomy: one year experience at the Hospital Clínico San Carlos]. / Prostatectomía radical asistida por robot Da Vinci: un año de experiencia en el Hospital Clínico San Carlos.

OBJECTIVES: Hospital Clínico San Carlos in Madrid is the first Spanish public centre using the latest surgical technology: the Da Vinci robot. First operation was carried out in our department in October 9th 2006. Since then, numerous changes have happened which enabled us to overcome difficulties, to complete the learning curve. METHODS: Between October 9th 2006 and November 30th 2007 we performed 30 radical prostatectomies with the Da Vinci robot. Mean patient age was 63 years (47-70 years) with an ASA (American society of anesthesia) risk below III in all cases, a Gleason score between 2 and 8 and a PSA < or = 15 (3.5-15). Mean prostatic volume measured by transrectal ultrasound was 36 cc (16-90 cc). RESULTS/CONCLUSIONS: Six trocars and a 15 mm Hg pneumoperitoneum were employed. Mean operative room occupation time was 5.9 hours (4-14 hours). Two cases were converted to open surgery and one to laparoscopy. No major intraoperative complications have happened. In the immediate post-operative period, 2 patients presented plexopathy and arthralgia, 1 infection at the site of one trocar, and 2 haematomas at the site of trocar insertion. Sixteen patients required transfusion (mean 1 red blood cells unit (0-4)). Bladder catheter was retrieved between 5th and 21st post-operative days (mean 11 days). Regarding continence: 10 patients were completely continent or present mild incontinence (0-1 pad) and 5 had moderate incontinence (2-5 pads). Three patients preserve sexual potency, the rest show different grades of dysfunction.

[Robotic assisted laparoscopic colposacropexy in the treatment of pelvic organ prolapse]. / Colposacropexia laparoscópica asistida por robot como tratamiento del prolapso urogenital.

Laparoscopic colposacropexy has become a substitute for open surgery in the treatment of pelvic organ prolapse. In the same way, robotic assisted surgery is a new step in the evolution of the procedure. In this paper we intend to show our surgical technique and preliminary results. From November 2006 to date, 10 patients have undergone this procedure at the Hospital Clinico San Carlos. The main indication for the operation was existence of symptomatic pelvic prolapse. Both patients with or without hysterectomy have been operated, without making significant differences between them. Preoperative evaluation workout included: cystogram, urinary tract ultrasound and urodynamics in all cases; urinary tract MRI was performed only in selected cases. All patients underwent surgery under general anesthesia, with at least three robotic trocars (8 mm) and one conventional trocar for the assistant; 2 accessory trocars were necessary in some cases, mainly at the beginning of the series. Most procedures in our series were associated with a transobturator suburethral sling for the treatment of stress urinary incontinence or prevention of its appearance after prolapse repair. Our results are comparable to those reported in other larger series in terms of operative time, hospital stay and early or late complications. Pending an evaluation on the long term with larger series, we can include robot assisted colposacropexy among the therapeutic options for symptomatic pelvic floor prolapse repair.

[Chemoprophylaxis and endoscopical treatment of upper urinary tract tumors recurrences]. / Quimioprofilaxis y tratamiento endoscópico de las recidivas de los tumores del tracto urinario superior.

OBJECTIVES: Upper urinary tract tumors are a rare condition. We review our experience in the diagnosis of upper urinary tract tumors and their recurrences, emphasizing the management of recurrences. METHODS: From January 1980 to June 2002 139 endourological procedures were carried out in 94 patients with the working diagnosis of upper urinary tract tumor. RESULTS: The overall treatment failure rate was 18.7 with ureteroscopy being the least efficient technique. CONCLUSIONS: In our experience, there is an indication for conservative endourological treatment in superficial low grade G1-2 tumors smaller than 2 cm.

[Early-onset sarcomatoid renal carcinoma. Report of a new case and comparison of the same case with another appearing at a mature age]. / Carcinoma renal sarcomatoide de temprana aparición. Aportación de un nuevo caso y comparación del mismo con otro de aparición en edad madura.

OBJECTIVE AND METHODS: We report two new cases of this rare and aggressive tumour; one case appeared in the earliest age reported in the literature (case #2). We also review etiological, diagnostic and therapeutic features. RESULTS: Despite aggressive surgery and adjuvant chemotherapy it has a very poor prognosis, with disease progression within 6 months in both cases. CONCLUSIONS: Sarcomatoid renal cell carcinoma is an infrequent entity, extremely aggressive and requires radical surgery at the time of diagnosis due to its advanced stage, although results are poor. It can also appear in young people with the same aggressiveness than in adult age.

[Mesothelial cysts in urology: a diagnostic and therapeutic problem]. / Quistes mesoteliales en urología; un problema diagnóstico y terapéutico.

OBJECTIVE: To present our experience with mesothelial cysts with excretory system involvement. METHODS: 3 cases of mesothelial cyst are presented; two of them caused obstructive uropathy. RESULTS: Cases 1 and 2 were treated by surgery, while case 3 was managed conservatively. All cases are currently asymptomatic. CONCLUSIONS: Mesothelial cysts are an uncommon cause of obstructive uropathy. Treatment is by surgery for the symptomatic cases and conservative management is a valid alternative for the asymptomatic cases.