Suicide in patients with genitourinary malignancies.

Genitourinary cancers are significant causes of morbidity and mortality around the world. The present review summarises the current literature on suicide and its risk factors among patients with genitourinary cancers. The review was based on relevant articles published in MEDLINE, ProQuest, PsycINFO, Science Direct and Scopus databases. Patients with prostate cancer represented the most important risk group for suicide, among patients with urogenital cancers. Other risk factors are male gender, older age, white race, advanced disease, living alone and co-existing psychological comorbidities. Findings from the review call for a greater caregiver awareness on psychosocial morbidity and suicidality among genitourinary cancer patients pre- and post-treatment and their early identification, adoption of risk-reduction strategies and prompt referral for expert mental health care.

Video endoscopic inguinal lymphadenectomy: surgical and oncological results.

INTRODUCTION: We evaluated the reproducibility of video endoscopic inguinal lymphadenectomy (VEIL) and we report our initial experience in the treatment of penile cancer with palpable inguinal lymph nodes. MATERIAL AND METHODS: From July 2006 to November 2010 were conducted 33 VEIL in 20 patients as complementary treatment for penile cancer in two referral hospitals in Latin America. We analyzed the epidemiological and clinical characteristics of patients and surgical and oncologic outcomes. RESULTS: Fifty-five percent of the patients included were clinical stage N0 and 45% were N +. Thirteen patients underwent bilateral VEIL and the remaining seven underwent VEIL unilateral and conventional open surgery in the contralateral limb. The average operative time for VEIL was 119 minutes and mean resected lymph nodes was 8 per lymphadenectomy. The overall complication rate was 33.2%. No patient had skin necrosis. The lymphatic complication rate was 27.2%. Of the 6 cases in which the saphenous vein was preserved (18.2%) there were no lymphatic complications (P=,2). The overall survival rate was 80% and cancer-specific survival was 90%. Mean follow-up was 20 months. CONCLUSIONS: VEIL in the adjunctive treatment of penile cancer is safe, reproducible and may be an alternative to conventional lymphadenectomy. Patients with palpable lymphadenopathy also may benefit from this technique. Oncological results seem to be adequate however require longer follow-up to be confirmed.

[Prostate cancer: promising biomarkers related to aggressive disease]. / Cáncer de próstata: biomarcadores prometedores relacionados con la enfermedad agresiva.

BACKGROUND: Although a rapidly growing number of candidate biological markers of prognosis and/or response to specific treatments in prostate cancer, none have to date showed ability to completely prognosticate prostate cancer on evidence based urology. OBJECTIVE: To review the pertinent literature on the issue. ACQUISITION OF EVIDENCE: A comprehensive review of the current literature was done focusing on promising biomarkers related to aggressive prostate cancer. SUMMARY OF EVIDENCE: Combined with the heterogeneous nature of the disease, mixed case series are the most common study design, impeding robust results and the development of an effective therapeutic strategy. Improvement in prostate cancer patient survival requires not only the identification of new therapeutic target based on detailed understanding of the biological mechanisms involved in metastatic dissemination and tumor growth but strong clinical studies as well. CONCLUSION: Better study design involving potential markers and including well-classified and staged patients with robust methodology and adequate outcomes (mainly survival) are necessary to the field evolution.

Bisphosphonate therapy in patients under androgen deprivation therapy for prostate cancer: a systematic review and meta-analysis.

The objective of this study was to clarify the role of bisphosphonates in the treatment of osteoporosis in patients with prostate adenocarcinoma under androgen deprivation therapy (ADT). The Medline, EMBASE, Cancerlit and the American Society of Clinical Oncology abstract databases were searched for published randomized, placebo-controlled trials evaluating the usage of bisphosphonates in patients with prostate cancer (PC) under ADT. The outcomes assessed were fracture, osteoporosis, incidence of adverse events and changes in bone mineral density (BMD) during treatment. A total of 15 articles (2634 participants) were included in the meta-analysis. Treatment with bisphosphonates showed a substantial effect in preventing fractures (risk ratio (RR), 0.80; P = 0.005) and osteoporosis (RR, 0.39; P <0.00001). Zoledronic acid showed the best number needed to treat (NTT), compared with placebo, in relation to fractures and osteoporosis (NNT = 14.9 and NNT = 2.68, respectively). The between-group difference (bisphosphonates vs placebo) in the lumbar spine and femoral neck BMD were 5.18 ± 3.38% and 2.35 ± 1.16%, respectively. This benefit of bone loss prevention could be reached without major side effects (cardiovascular or gastrointestinal events). Bisphosphonates are effective in preventing bone loss in patients with PC who are under ADT.

[Androgen deprivation therapy and morbid obesity: do they share cardiovascular risk through metabolic syndrome?]. / Terapia de privación de andrógenos y obesidad mórbida: ¿tienenen común el riesgo cardiovascular por síndrome metabólico?

BACKGROUND: Although the use of androgen deprivation therapy (ADT) has resulted in improved survival in men with advanced prostate cancer, the resulting hypogonadism is associated with profound adverse effects comparable to those found in morbid obesity, being cardiovascular risk among the most lethal. OBJECTIVES: Evaluate metabolic syndrome, metabolic abnormalities and cardiovascular risk in patients with prostate cancer under ADT, not under ADT and morbid obese men. METHODS: This is a cross-sectional study that involves 79 men presenting prostate cancer, of whom 54 under ADT and 25 not under ADT and 91 morbidly obese patients paired by sex and age. To define metabolic syndrome, we used the International Diabetes Federation (IDF) criteria. Metabolic abnormalities, metabolic markers and Framingham score to predict the ten year coronary heart disease risk were compared among patients under ADT, not under ADT and morbid obese. RESULTS: Patients under ADT presented significantly greater occurrence of diabetes and central obesity and higher levels of total cholesterol and low density lipoprotein (LDL) compared to eugonadal men. The mean cardiovascular risk was significantly higher in patients under ADT (39.97±12.53% vs. 26.09±14.80%; p=0.021). Morbidly obese subjects had increased ten year coronary heart disease risk; comparable to patients under ADT (p=0.054). CONCLUSION: This study suggests that patients under ADT show higher prevalence of metabolic abnormalities and cardiovascular risk similar to those found in morbidly obese subjects. It is possible that both processes share cardiovascular risk through metabolic syndrome.

[Extraperitoneal endoscopic radical prostatectomy: How steep is the learning curve? Overheads on the personal evolution technique in 5-years experience]. / Prostatectomía radical endoscópica extraperitoneal: ¿cuál es la pendiente de la curva de aprendizaje? Efectos en la técnica de evolución personal en una experiencia de 5 años.

OBJECTIVE: Prospectively investigate endoscopic extra peritoneal radical prostatectomy (EERP) learning curve impact on outcomes. MATERIALS AND METHODS: In a 5 year period (2004-2008) 270 patients underwent 5-6 ports laparoscopic radical prostatectomy at a referral center in Brazil. The initial 70 cases learning curve protocol included low body mass index patients with low volume, low grade prostate cancer. After that there were no criteria to exclude laparoscopic surgery. The patients were analyzed in two groups: Group 1, first 70 patients (30 transperitoneal and 40 extra peritoneal)-learning curve and Group 2, last 200 patients - EERP only. Surgical and outcome parameters were compared through Student's t test and Fisher's Exact Test. RESULTS: The mean age was 65 years (+/-8.2) and comparing Groups 1 and 2, mean operative time was 300 (+/-190) versus 180 (+/-100) minutes, blood loss 330 (+/-210) versus 210 (+/-180) mL, hospital stay 3 (2 to 5) versus 2 (1 to 3) days, positive surgical margins 15% versus 10%, erection sufficient to penetration in previous potent patients 73.3% versus 75%, respectively with no difference between groups. Overall, 78% of patients referred no previous impotence with groups' equivalence. Severe urinary incontinence, transfusion and complications rates were higher in group 1 (p<0.05): 10% versus 2%, 12% versus 2.25% and 30% versus 12.5%, respectively. Peritoneum perforation occurred in 40% and conversion to open surgery was not required. Nerve sparing procedure was applied in 85%. In 3.5-years mean follow-up 90% of patients were free of PSA recurrence with no difference between groups. CONCLUSION: Severe urinary incontinence, transfusion and complications rates are related to learning curve which is continuous, although a significant improvement is pragmatic after 70 cases. An intensive mentored training program should be considered to minimize the learning outlays.

Laparoscopic left radical nephrectomy and hand-assisted isthmectomy of a horseshoe kidney with renal cell carcinoma.

A 64-year-old woman presented with recurrent gross hematuria and intermittent left-sided pain. A CT scan revealed an 8-cm mass in the left moiety of a horseshoe kidney. A laparoscopic transperitoneal approach was employed to control the vessels and release the left moiety of the kidney and a hand-assisted approach was performed for isthmectomy using compression of normal parenchyma and monopolar electrocautery. Additional sutures were applied externally in isthmus through hand-assisted incision to enhance hemostasis. The patient was discharged on postoperative day 4 with no complications and no relapse after a 1-year follow-up. We conclude that our technique is safe, cheap and effective for this complex clinical entity.

Video endoscopic inguinal lymphadenectomy (VEIL): minimally invasive resection of inguinal lymph nodes.

OBJECTIVES: Describe and illustrate a new minimally invasive approach for the radical resection of inguinal lymph nodes. SURGICAL TECHNIQUE: From the experience acquired in 7 operated cases, the video endoscopic inguinal lymphadenectomy (VEIL) technique was standardized in the following surgical steps: 1) Positioning of the inferior member extended in abduction, 2) Introduction of 3 work ports distal to the femoral triangle, 3) Expansion of the working space with gas, 4) Retrograde separation of the skin flap with a harmonic scalpel, 5) Identification and dissection of the long saphenous vein until the oval fossa, 6) Identification of the femoral artery, 7) Distal ligature of the lymph node block at the femoral triangle vertex, 8) Liberation of the lymph node tissue up to the great vessels above the femoral floor, 9) Distal ligature of the long saphenous vein, 10) Control of the saphenofemoral junction, 11) Final liberation of the surgical specimen and endoscopic view showing that all the tissue of the region was resected, 12) Removal of the surgical specimen through the initial orifice, 13) Vacuum drainage and synthesis of the incisions. COMMENTS: The VEIL technique is feasible and allows the radical removal of inguinal lymph nodes in the same limits of conventional surgery dissection. The main anatomic repairs of open surgery can be identified by the endoscopic view, confirming the complete removal of the lymphatic tissue within the pre-established limits. Preliminary results suggest that this technique can potentially reduce surgical morbidity. Oncologic follow-up is yet premature to demonstrate equivalence on the oncologic point of view.

Video endoscopic inguinal lymphadenectomy (VEIL): minimally invasive resection of inguinal lymph nodes

OBJECTIVES: Describe and illustrate a new minimally invasive approach for the radical resection of inguinal lymph nodes. SURGICAL TECHNIQUE: From the experience acquired in 7 operated cases, the video endoscopic inguinal lymphadenectomy (VEIL) technique was standardized in the following surgical steps: 1) Positioning of the inferior member extended in abduction, 2) Introduction of 3 work ports distal to the femoral triangle, 3) Expansion of the working space with gas, 4) Retrograde separation of the skin flap with a harmonic scalpel, 5) Identification and dissection of the long saphenous vein until the oval fossa, 6) Identification of the femoral artery, 7) Distal ligature of the lymph node block at the femoral triangle vertex, 8) Liberation of the lymph node tissue up to the great vessels above the femoral floor, 9) Distal ligature of the long saphenous vein, 10) Control of the saphenofemoral junction, 11) Final liberation of the surgical specimen and endoscopic view showing that all the tissue of the region was resected, 12) Removal of the surgical specimen through the initial orifice, 13) Vacuum drainage and synthesis of the incisions. COMMENTS: The VEIL technique is feasible and allows the radical removal of inguinal lymph nodes in the same limits of conventional surgery dissection. The main anatomic repairs of open surgery can be identified by the endoscopic view, confirming the complete removal of the lymphatic tissue within the pre-established limits. Preliminary results suggest that this technique can potentially reduce surgical morbidity. Oncologic follow-up is yet premature to demonstrate equivalence on the oncologic point of view.

Prospective randomized controlled trial comparing three different ways of anesthesia in transrectal ultrasound-guided prostate biopsy.

PURPOSE: To make an objective controlled comparison of pain tolerance in transrectal ultrasound-guided prostatic biopsy using intrarectal topic anesthesia, injectable periprostatic anesthesia, or low-dose intravenous sedation. MATERIALS AND METHODS: One hundred and sixty patients were randomized into 4 groups: group I, intrarectal application of 2% lidocaine gel; group II, periprostatic anesthesia; group III, intravenous injection of midazolam and meperidine; and group IV, control, patients to whom no sedation or analgesic was given. Pain was evaluated using an analogue pain scale graded from 0 to 5. Acceptance of a repetition biopsy, the side effects of the drugs and complications were also evaluated. RESULTS: 18/20 (90%) and 6/20 (30%) patients reported strong or unbearable pain in the group submitted to conventional biopsy and topical anesthesia (p = 0.23, chi-square = 1.41); whereas those submitted to periprostatic blockade and sedation, severe pain occurred in only 2/60 (3%) patients (p < 0.001, chi-square = 40.19) and 3/60 (5%) patients (p < 0.001, chi-square = 33.34). Acceptance of repetition of the biopsy was present in only 45% of the patients submitted to conventional biopsy, 60% of those that were given topical anesthesia (p = 0.52, chi-square = 0.4), compared to 100% of those submitted to periprostatic anesthesia (p < 0.01, chi-square = 15.17), and 95% of those who were sedated (p < 0.001, chi-square = 25.97%). CONCLUSIONS: Transrectal ultrasound-guided prostatic biopsy is an uncomfortable experience; however application of periprostatic blockade and intravenous analgesia are associated to higher tolerance of the exam and patient comfort. Low dose sedation by association of intravenous meperidine and midazolam is an emerging and safe outpatient option.

Prospective randomized controlled trial comparing three different ways of anesthesia in transrectal ultrasound-guided prostate biopsy

PURPOSE: To make an objective controlled comparison of pain tolerance in transrectal ultrasound-guided prostatic biopsy using intrarectal topic anesthesia, injectable periprostatic anesthesia, or low-dose intravenous sedation. MATERIALS AND METHODS: One hundred and sixty patients were randomized into 4 groups: group I, intrarectal application of 2 percent lidocaine gel; group II, periprostatic anesthesia; group III, intravenous injection of midazolam and meperidine; and group IV, control, patients to whom no sedation or analgesic was given. Pain was evaluated using an analogue pain scale graded from 0 to 5. Acceptance of a repetition biopsy, the side effects of the drugs and complications were also evaluated. RESULTS: 18/20 (90 percent) and 6/20 (30 percent) patients reported strong or unbearable pain in the group submitted to conventional biopsy and topical anesthesia (p = 0.23, chi-square = 1.41); whereas those submitted to periprostatic blockade and sedation, severe pain occurred in only 2/60 (3 percent) patients (p < 0.001, chi-square = 40.19) and 3/60 (5 percent) patients (p < 0.001, chi-square = 33.34). Acceptance of repetition of the biopsy was present in only 45 percent of the patients submitted to conventional biopsy, 60 percent of those that were given topical anesthesia (p = 0.52, chi-square = 0.4), compared to 100 percent of those submitted to periprostatic anesthesia (p < 0.01, chi-square = 15.17), and 95 percent of those who were sedated (p < 0.001, chi-square = 25.97 percent). CONCLUSIONS: Transrectal ultrasound-guided prostatic biopsy is an uncomfortable experience; however application of periprostatic blockade and intravenous analgesia are associated to higher tolerance of the exam and patient comfort. Low dose sedation by association of intravenous meperidine and midazolam is an emerging and safe outpatient option.

Hand-assisted laparoscopic nephrectomy as a minimally invasive option in the treatment of large renal specimens

INTRODUCTION: We describe our experience with hand-assisted laparoscopy (HAL) as an option for the treatment of large renal specimens. MATERIALS AND METHODS: Between March 2000 and August 2004, 13 patients candidate to nephrectomies due to benign renal conditions with kidneys larger than 20 cm were included in a prospective protocol. Unilateral nephrectomy was performed in cases of hydronephrosis (6 patients) or giant pyonephrosis (4 patients). Bilateral nephrectomy was performed in 3 patients with adult polycystic kidney disease (APKD) with low back pain refractory to clinical treatment previous to kidney transplant. The technique included the introduction of 2 to 3 10 mm ports, manual incision to allow enough space for the surgeon's wrist without a commercial device to keep the pneumoperitoneum. The kidney was empty, preferably extracorporeally, enough to be removed through manual incision. We have assessed operative times, transfusions, complications, conversions, hospital stay and convalescence. RESULTS: The patients mean age (9 women and 4 men) was 58 years. Mean operating time was 120 n 10 min (hydronephrosis), 160 n 28 min (pyonephrosis) and 190 n 13 min (bilateral surgery for APKD). There was a need for a conversion in 1 case and another patient needed a transfusion due to a lesion in the renal vein; 2 patients had minor complications. CONCLUSION: HAL surgery is a minimally invasive alternative in the treatment of large renal specimens, with or without significant inflammation.

Laparoscopic surgery for treatment of incisional lumbar hernia.

OBJECTIVE: To present results obtained with laparoscopic correction of incisional lumbar hernia in patients with minimum follow-up of 1 year. MATERIALS AND METHODS: We prospectively studied 7 patients diagnosed with incisional lumbar hernia after physical examination and computerized tomography. We used laparoscopic transperitoneal access through 3 ports. One polypropylene mesh was introduced in the abdominal cavity and fixed by titanium clamps to the margins of the hernia ring following release of the peritoneum. RESULTS: All cases were successfully completed with no conversion required. Mean surgical time was 120 minutes and discharge from hospital occurred between the 1st and the 2nd postoperative days. There were no intraoperative complications or hernia recurrence in any case. Postoperatively, we had 2 minor complications: one case of seroma that resolved spontaneously after 60 days and one patient presenting lumbar pain that persisted until the 3rd postoperative month. The return to usual activities occurred on average 3 weeks following intervention. Of the 7 patients, 6 were satisfied with the esthetical and functional effect produced by the procedure. CONCLUSIONS: The surgical correction of incisional lumbar hernia by laparoscopic access is an excellent option for a minimally invasive treatment, with adequate long-term results.

Laparoscopic surgery for treatment of incisional lumbar hernia

OBJECTIVE: To present results obtained with laparoscopic correction of incisional lumbar hernia in patients with minimum follow-up of 1 year. MATERIALS AND METHODS: We prospectively studied 7 patients diagnosed with incisional lumbar hernia after physical examination and computerized tomography. We used laparoscopic transperitoneal access through 3 ports. One polypropylene mesh was introduced in the abdominal cavity and fixed by titanium clamps to the margins of the hernia ring following release of the peritoneum. RESULTS: All cases were successfully completed with no conversion required. Mean surgical time was 120 minutes and discharge from hospital occurred between the 1st and the 2nd postoperative days. There were no intraoperative complications or hernia recurrence in any case. Postoperatively, we had 2 minor complications: one case of seroma that resolved spontaneously after 60 days and one patient presenting lumbar pain that persisted until the 3rd postoperative month. The return to usual activities occurred on average 3 weeks following intervention. Of the 7 patients, 6 were satisfied with the esthetical and functional effect produced by the procedure. CONCLUSIONS: The surgical correction of incisional lumbar hernia by laparoscopic access is an excellent option for a minimally invasive treatment, with adequate long-term results.

Preliminary experience with extraperitoneal endoscopic radical prostatectomy through duplication of the open technique.

OBJECTIVE: To describe surgical and functional results with extraperitoneal laparoscopic radical prostatectomy with duplication of the open technique, from the experience obtained in the treatment of 28 initial cases. MATERIALS AND METHODS: In a 36-month period, we prospectively analyzed 28 patients diagnosed with localized prostate cancer undergoing extraperitoneal laparoscopic radical prostatectomy. RESULTS: Mean surgical time was 280 min, with mean blood loss of 320 mL. As intraoperative complications, there were 2 rectal lesions repaired with laparoscopic suture in 2 planes. There was no conversion to open surgery. Median hospital stay was 3 days, with return to oral diet in the first post-operative day in patients. As post-operative complications, there were 3 cases of extraperitoneal urinary fistula. Two of these cases were resolved by maintaining a Foley catheter for 21 days, and the other one by late endoscopic reintervention for repositioning the catheter. Five out of 18 previously potent patients evolved with erectile dysfunction. The diagnosis of prostate cancer was confirmed in all patients, with focal positive margin occurring in 3 cases. During a mean follow-up of 18 months, 2 patients presented increased PSA, with no clinical evidence of disease. CONCLUSION: Laparoscopic radical prostatectomy is a laborious and difficult procedure, with a long learning curve. Extraperitoneal access is feasible, and it is possible to practically duplicate the principles of open surgery. The present technique can possibly offer advantages in terms of decreased blood loss, preservation of erectile function and prevention of positive margins.

Preliminary experience with extraperitoneal endoscopic radical prostatectomy through duplication of the open technique

OBJECTIVE: To describe surgical and functional results with extraperitoneal laparoscopic radical prostatectomy with duplication of the open technique, from the experience obtained in the treatment of 28 initial cases. MATERIALS AND METHODS: In a 36-month period, we prospectively analyzed 28 patients diagnosed with localized prostate cancer undergoing extraperitoneal laparoscopic radical prostatectomy. RESULTS: Mean surgical time was 280 min, with mean blood loss of 320 mL. As intraoperative complications, there were 2 rectal lesions repaired with laparoscopic suture in 2 planes. There was no conversion to open surgery. Median hospital stay was 3 days, with return to oral diet in the first post-operative day in patients. As post-operative complications, there were 3 cases of extraperitoneal urinary fistula. Two of these cases were resolved by maintaining a Foley catheter for 21 days, and the other one by late endoscopic reintervention for repositioning the catheter. Five out of 18 previously potent patients evolved with erectile dysfunction. The diagnosis of prostate cancer was confirmed in all patients, with focal positive margin occurring in 3 cases. During a mean follow-up of 18 months, 2 patients presented increased PSA, with no clinical evidence of disease. CONCLUSION: Laparoscopic radical prostatectomy is a laborious and difficult procedure, with a long learning curve. Extraperitoneal access is feasible, and it is possible to practically duplicate the principles of open surgery. The present technique can possibly offer advantages in terms of decreased blood loss, preservation of erectile function and prevention of positive margins.

Retroperitoneoscopic surgery with extracorporeal uretero-ureteral anastomosis for treating retrocaval ureter.

We present a case of retrocaval ureter featuring laparoscopic technique treatment using extraperitoneal access and extracorporeal suture of the ureteral stumps. Surgical time was 130 minutes, and the anastomosis was performed in 40 minutes. There were no intra- or postoperative complications, and the patient was discharged from hospital on the second postoperative day. The medium-term outcome featured similar results to pure laparoscopic technique. We conclude that this technical variation for treatment of retrocaval ureter makes the procedure easier and provides a drastic reduction in surgical time, without compromising the minimally invasive aspect of this kind of approach.

Retroperitoneoscopic surgery with extracorporeal uretero-ureteral anastomosis for treating retrocaval ureter

We present a case of retrocaval ureter featuring laparoscopic technique treatment using extraperitoneal access and extracorporeal suture of the ureteral stumps. Surgical time was 130 minutes, and the anastomosis was performed in 40 minutes. There were no intra- or postoperative complications, and the patient was discharged from hospital on the second postoperative day. The medium-term outcome featured similar results to pure laparoscopic technique. We conclude that this technical variation for treatment of retrocaval ureter makes the procedure easier and provides a drastic reduction in surgical time, without compromising the minimally invasive aspect of this kind of approach.

Laparoscopic nephrectomy in inflammatory renal disease: proposal for a staged approach.

INTRODUCTION: The present study shows and discusses the preliminary experience of customized and staged approach in the minimally invasive treatment of inflammatory renal diseases, using either pure laparoscopic surgery or the hand-assisted technique. MATERIALS AND METHODS: We prospectively assessed 17 patients with inflammatory renal diseases operated by laparoscopic approach. Mean age was 41 years and the surgical indication was repeated pyelonephritis in 8 cases, pyonephrosis in 4 cases and renal exclusion due to staghorn stone in 5 cases. The staged laparoscopic approach was chosen based on kidney size and on the presence or not of tomographic findings showing significant perirenal infiltration. Thus, retroperitoneal access was chosen in cases where the kidney was smaller than 12 cm or in the absence of signs of significant perirenal infiltration on the computerized tomography. For the remainder, transperitoneal access was employed. RESULTS: Of the 17 patients, 11 underwent laparoscopic nephrectomy by retroperitoneal access, and all cases were successful. Mean surgical time was 160 minutes. In 6 cases where the nephrectomy was performed by laparoscopic transperitoneal access, the use of hand assistance was required. Four surgeries were successfully completed with mean time of 190 minutes and 2 were converted to open surgery with mean time of 220 minutes. CONCLUSION: The laparoscopic nephrectomy for inflammatory renal disease is feasible, but presents a high degree of complexity, requiring a customized approach. The use of hand assistance is an attractive option when the inflammatory process is intense, and can avoid conversions, maintaining the advantages of minimally invasive treatments.

Laparoscopic nephrectomy in inflammatory renal disease: proposal for a staged approach

INTRODUCTION: The present study shows and discusses the preliminary experience of customized and staged approach in the minimally invasive treatment of inflammatory renal diseases, using either pure laparoscopic surgery or the hand-assisted technique. MATERIALS AND METHODS: We prospectively assessed 17 patients with inflammatory renal diseases operated by laparoscopic approach. Mean age was 41 years and the surgical indication was repeated pyelonephritis in 8 cases, pyonephrosis in 4 cases and renal exclusion due to staghorn stone in 5 cases. The staged laparoscopic approach was chosen based on kidney size and on the presence or not of tomographic findings showing significant perirenal infiltration. Thus, retroperitoneal access was chosen in cases where the kidney was smaller than 12 cm or in the absence of signs of significant perirenal infiltration on the computerized tomography. For the remainder, transperitoneal access was employed. RESULTS: Of the 17 patients, 11 underwent laparoscopic nephrectomy by retroperitoneal access, and all cases were successful. Mean surgical time was 160 minutes. In 6 cases where the nephrectomy was performed by laparoscopic transperitoneal access, the use of hand assistance was required. Four surgeries were successfully completed with mean time of 190 minutes and 2 were converted to open surgery with mean time of 220 minutes. CONCLUSION: The laparoscopic nephrectomy for inflammatory renal disease is feasible, but presents a high degree of complexity, requiring a customized approach. The use of hand assistance is an attractive option when the inflammatory process is intense, and can avoid conversions, maintaining the advantages of minimally invasive treatments.