Single-port robot-assisted retroperitoneal surgery: A feasible approach.

INTRODUCTION: The concept of surgery through a single incision has been pursued in the field of minimal invasion for the treatment of different pathologies. This, added to a retroperitoneal approach, implies less aggression for the patient at different levels. We describe the first cases of single-port robot-assisted retroperitoneal surgery (SP-RARS) in our country using the da Vinci Xi® system. MATERIAL AND METHODS: We present two cases of patients with right adrenal masses larger than 4 cm. The first case was a 55-year-old woman with an incidental diagnosis of angiomyolipoma, and the second case was a 62-year-old man with a non-functioning adrenal adenoma. Both cases were operated through a single 4-cm subcostal incision using the da Vinci Xi® system, annulling arm 4 without reallocating laterality on the surgeon's console. RESULTS: Both surgeries were performed with console times of 75 and 150 min, respectively, with access and docking times below 30 min. Bleeding was less than 100 cc in both surgeries without the need to make accessory incisions or leave a drainage tube. The surgical specimens were removed through the same initial incision without the need for enlargement. Postoperative intravenous analgesia was not necessary in any case (VAS 0) and hospital stay was less than 24 h in both patients without reporting any complications. CONCLUSIONS: SP-RARS is a feasible approach using the da Vinci Xi® system.

Single-port retroperitoneoscopic adrenalectomy: Initial experience and standardization of the technique.

INTRODUCTION AND OBJECTIVE: The minimally invasive surgical approach to adrenal gland pathology is the most widely used nowadays, and retroperitoneoscopy occupies a relevant place. However, the evolution of these techniques towards even less invasive surgery through single-port access is anecdotal. The aim of this work is to describe our initial experience in single-port retroperitoneoscopic surgery (SPORS) of the adrenal gland focusing on perioperative data and postoperative pain. MATERIAL AND METHODS: We collected and analyzed the demographic and operative data of a series of patients undergoing adrenalectomy through SPORS. All procedures were performed through a single 3-4 cm subcostal incision with a multichannel port. Surgical data such as operative time, bleeding, length of stay and presence of complications were collected. We used the visual analog scale (VAS) for postoperative pain assessment. RESULTS: From December 2018 to August 2020, 6 patients with different types of adrenal pathology underwent consecutive surgeries in our Department by the same surgeon using SPORS. All surgeries were performed without requiring accessory trocar placement or reconversion to open surgery. The mean operative time was 91.6 ±â€¯16.3 min, with <150 mL bleeding, mean length of stay of 35.8 ±â€¯13.3 h and postoperative pain of VAS ≤3 (median 0.5). The mean size of specimens was 57.8 ±â€¯18 mm. No complications were reported according to the Clavien-Dindo scale. CONCLUSIONS: Even in initially adverse cases, SPORS adrenalectomy is a feasible and safe technique with good cosmetic and perioperative results.

Single-port retroperitoneoscopic adrenalectomy: Initial experience and standardization of the technique. / Suprarrenalectomía retroperitoneoscópica por puerto único: experiencia inicial y estandarización de la técnica.

INTRODUCTION AND OBJECTIVE: The minimally invasive surgical approach to adrenal gland pathology is the most widely used nowadays, and retroperitoneoscopy occupies a relevant place. However, the evolution of these techniques towards even less invasive surgery through single-port access is anecdotal. The aim of this work is to describe our initial experience in single-port retroperitoneoscopic surgery (SPORS) of the adrenal gland focusing on perioperative data and postoperative pain. MATERIAL AND METHODS: We collected and analyzed the demographic and operative data of a series of patients undergoing adrenalectomy through SPORS. All procedures were performed through a single 3-4cm subcostal incision with a multichannel port. Surgical data such as operative time, bleeding, length of stay and presence of complications were collected. We used the visual analog scale (VAS) for postoperative pain assessment. RESULTS: From December 2018 to August 2020, 6 patients with different types of adrenal pathology underwent consecutive surgeries in our Department by the same surgeon using SPORS. All surgeries were performed without requiring accessory trocar placement or reconversion to open surgery. The mean operative time was 91.6±16.3minutes, with <150mL bleeding, mean length of stay of 35.8±13.3hours and postoperative pain of VAS ≤3 (median 0.5). The mean size of specimens was 57.8±18mm. No complications were reported according to the Clavien-Dindo scale. CONCLUSIONS: Even in initially adverse cases, SPORS adrenalectomy is a feasible and safe technique with good cosmetic and perioperative results.

[Neprhon sparing surgery for renal tumours on kidney transplantation]. / Cirugía conservadora en el tratamiento de los tumores renales de novo en injertos de trasplante renal.

INTRODUCTION: Nowadays, nephron sparing surgery for renal carcinoma achieves good oncological results, similar to radical surgery, with the advantage of preserving renal function. Renal cell carcinomas appear de novo in 4.6% of post-transplant patients compared with 3% of tumors in the general population, affecting less than 10% to renal allograft. OBJECTIVE: The purpose is to analyze our experience and make a literature review about the role of nephron sparing surgery to treat de novo renal tumours in renal grafts. MATERIAL AND METHODS: A retrospective and descriptive analysis has been realized, finding four patients who presented with de novo renal tumours over renal graft after kidney transplantation and treated by nephron sparing surgery. A Medline review is done to search similar series published. Oncological and functional results were reviewed and analyzed. We worked with SPSS 12.0 software. RESULTS: Medium age at diagnosis was 46.5 y (42-62). Medium size was 2.4cm. (1.5-3.5) and final histology showed medium tumours size of 3.0cm. (1.7-3.5). Medium hospital stay was 6.0d. Medium time from transplantation to diagnosis was 92 months (42-192). NSS was done in all cases, in 3 cases tumorectomy and one partial nephrectomy. Transfusion was only needed in one case. All cases had pT1aN0M0 RCC histology exam. Renal function did not change from preoperative. All patients are free of progression with a medium follow-up of 46.5 months (15-58). CONCLUSIONS: NSS could be an option to treat graft tumours in selected cases, preserving renal function. In our experience, is a safe and efficient treatment in patients with small de novo renal tumours over renal graft.

[Insignificant prostate cancer. Analysis our series]. / Cancer de próstata insignificante. Análisis de nuestra serie.

The objective of this study is to analyse the specimen of radical prostatectomy of patients who had, prior to the surgery insignificant prostate cancer biopsies. The end point is demonstrate the possibility of an active surveillance as a therapeutic option for prostate cancer in selected is the possibility of an active surveillance as therapeutic for the prostate cancer, in selected individuals if we are able to find diagnostic algorisms to predict the real insignificant tumours. The selected group of patients for the study has a PSA less or equal 10, one positive core of prostatic transrectal ultrasound biopsy with a Gleason score less than 7. This group of patients is considerate as having a potential insignificant tumour. We will consider prostatectomy's specimens and the Gleason sore is less than 7 and the tumoral volume is les or equal to 5%. Of 394 patients with prostate cancer and homogeneous criterias for our study, we have selected 53 patients according to the criteria of insignificant tumour in the biopsy. Our results showed that only 22 of 53 (41.5%) patients were identified as having an insignificant prostate cancer in the RP specimens. Moreover 92.2% of this tumours were organ-confined. In conclusion we are able to say that tumours of low-risk and low tumoral volume in the biopsy, do not correlate always to insignificant tumours in PR specimens, but we have observed that the majority are organ-confined tumours. Finally, the diagnostic's algorisms dies not to predict tumours that may safely treated with active monitoring.

[Inferior caval agenesis and renal trauma]. / Agenesia de vena cava inferior y traumatismo abdominal cerrado.

We are publishing a case of sixteen years old male, with inferior caval agenesis suffering a fall, and having a serious trauma over the left renal unit. We review the recommendations of intervention in front of high grade renal trauma and we too study the existing knowledge on the literature in order to get a posible higher incidence of this kind of trauma in patients with these anomaly.

[Radical prostatectomy with minilaparotomy "minilap" for patients with prostate cancer]. / Técnica de minilaparotomía "minilap" en pacientes sometidos a prostatectomía radical por cáncer de próstata.

INTRODUCTION: prostate cancer is the most frequent tumor in males. The use of PSA contributes to diagnose tumors with low stage. Radical Prostatectomy (R.P.) is the gold standard to treat this tumor; however such is not exempt of risks. Different technical modifications like minimal incisions minilaparotomy "minilap" had contributed to improve results. We review our experience with Minilap on patients underwent a RP. MATERIAL AND METHODS: Between April 1997 and September 2005 carry out 110 RP with Minilap technique. All cases were performed with minimal incision 7-8 cm of length. We use and specific retractor developed in our hospital. Median age at time of surgery was 65 (47-79). Clinical stage in 39 (35.4%) were T1c, 64 (58.3%) T2 and 7 (6.3%) T3. Sixty eight percent were Gleason score < or =6, 34(30.9%) 7 and 1 (0.9%) Gleason 8. RESULTS: In 86 cases (38.5%) pathological stage were pT2, 21 (19%) pT3, 1 (0.9%) pT4 and 2 (1.8%) pT0. Nine patients (8%) had postoperative complications. No re-interventions were necessary and 101 (90%) were discharge without per operatives complications. Mean length of stay was 4 days and 97 (88.8%) of patients were discharge with only five days length of stay. Urinary continence rate with a year like minimal follow up is 92.3% and 40% preserve sexual activity. CONCLUSIONS: Minimal invasive techniques like minilap can be done in regular form with good results and without long learning curve.

[Vesicoureteral reflux in spinal cord injured patients. Treatment results and statistical analysis]. / Reflujo vesicoureteral en pacientes lesionados medulares. Analisis estadistico de resultados en el tratamiento.

INTRODUCTION: VUR in spinal cord injured patients is cause of important morbidity and mortality. The aim of this paper is to make a statistical, retrospective and descriptive study to analyze VUR treatment results, in neurogenic bladder SCI patients. MATERIAL AND METHOD: We study 40 patients (80 renal units) with VUR in neurogenic bladders and SCI, between March, 1990 and November, 2004. Median age is 43.05 y (9-76). 77.5% of patients are males (3.4:1). Time from injury to VUR is 24.7m (0.2-87). Median follow up is 8.23a (0.5-29). Traumatic lesions are most frequent (70%). Median bladder capacity is 244.9 ml (43-555) and median bladder compliance is 16.12 ml/cm H2O (0.3-61.6). Detrusor overactivity is found in 72.2% and detrusor-sphincter dyssynergia in 71.8%. Initial conservative treatment is done with indwelling catheter and anticholinergics RESULTS: Complete remission was found in 57.5% of RU, descending VUR a 23.7% (66.2% previously to 42.5% after; p<0.02), and predominant in unilateral reflux. Partial response was found in 3.8%, progression in 12.5% and recidiva post CR in 10.9%. Younger patients have better remission rates (39.4 to 47.6 y; p=0.04). Urodinamycs variables don't found any significant differences in treatment results. Endoscopic treatment with bulking agents gets a good response rate (56.3%) (p=0.18). CONCLUSIONS: Initial conservative treatment gets a 23.7% reduction of VUR, especially in men, young and unilateral reflux patients. Anyhow, we observe some progression and recidiva. Detrusor overactivity and detrusor-sphincter dyssynergia didn't influence in treatment results, but they are found in all patients with recidiva. With longer reflux evolution, we observe better responses, but also a higher recidiva rate (p=0.007). Endoscopic bulky injection techniques found out a good response rate (56.3%), also in patients with recidiva after conservative treatment.

[Stress urinary incontinence surgical treatment with suburethral suprapubic SPARC sling]. / Tratamiento quirúrgico de la incontinencia urinaria de esfuerzo mediante cabestrillo suburetral SPARC. Análisis de nuestra experiencia.

INTRODUCTION: Stress urinary incontinence (SUI) has a high incidence and important morbidity. Multiple surgical techniques have been described to treat it, with despair results. Suburethral slings have become, in recent years, a simpler and less invasive method to treat SUI surgically. MATERIAL AND METHOD: The purpose of this paper is to review, retrospectively, 86 patients treated at our institution, from 10/01 to 12/05 of SUI, with a suprapubic suburethral sling (SPARC). RESULTS: Medium (range) age is 58.7 (39-80), hospital stay was 2.43 d (1-8) and catheter was removed 1.52 d (1-10). 14.5% of patients underwent other vaginal surgeries at same time, most frequently anterior colpoperineoplasty (10.7%). Complications are not very frequent; bladder perforation (5.8%), acute urinary retention (7%), chronic urinary retention (3.5%) and UTI (15.3%). Sling release was performed in 3.5% of women with chronic urinary retention. Total continence was found in 71.4% of patients with 10.1 months medium follow up (1-32). De novo urge symptoms were found in 26.2% of women, with urge incontinence in 54.5% of them. (p < 0.002; OR 5.0 (IC 95% 1.75-14.28). CONCLUSIONS: Suprapubic suburethral SPARC sling is a simple method, with few complications and fast social recovery. Outcome can be measured soon, with a high continence rate. De novo urge symptoms are high and they worsen functional results. It is necessary longer follow-up to evaluate long term outcomes.

[External beam radiotherapy on locally advanced prostate carcinoma following iliac staging lymphadenectomy]. / La radioterapia en el cáncer de próstata localmente avanzado tras estadiaje ganglionar con linfadenectomía.

INTRODUCTION AND OBJECTIVES: Locally advanced prostate cancer supposes a high risk condition of post-treatment progression due to the limit situation that represents. Our purpose was to analyze prognoses factors in function of progression probability after using a treatment with external source radiotherapy on patients with this kind of tumors. MATERIAL AND METHODS: We retrospectively reviewed a set of 128 patients submitted to pelvic staging limphadenectomy prior to accomplish an external radiotherapeutic treatment. We employed the Kaplan-Meier curves to study the probability of progression, logarithmic ranks test were used for detection of possible statistically significant differences and proportional risks Cox model was employed to study possible risk factors of progression (employing astro criteria). RESULTS: 5 years freedom probability from progression was of 49,93%; in spite of appreciating important differences in the groups stratified by the predictive variables used (total PSA, gleason of pathological biopsy, clinical stage and % of cores affection on biopsy), none of them reached statistical meaning, being the level of total PSA the closest to it. CONCLUSIONS: The external radiotherapeuthic treatment represents a valid alternative in the treatment of locally advanced prostate cancer, with a tolerable index of secondaries. It must be used combined with hormonotherapy. It seems that the use of higher radiation doses, in a safer way thanks to 3D conformed radiotherapy, allows to improve the results. The most powerful clinical predictor of evolution must be the total PSA.

[Renal angiomyolipomatosis and pulmonary lymphangiomyomatosis. Its relationship with Bourneville syndrome]. / Angiolipomatosis renal y linfangioleiomiomatosis, su relación con la enfermedad de Bourneville.

INTRODUCTION: Renal angiomyolipomas are not very frequent in urologic activities. Pulmonary lymphangioleiomyomatosis is a rare disease that occurs mainly in women of reproductive age. Tuberous sclerosis shows lesions to different organs, including these both entities. MATERIAL AND METHOD: We retrospectively analyze patients treated in our center. Three most representatives cases are reported. An indexed literature review is done, in order to establish a clinical protocol to manage these kinds of patients. RESULTS: [corrected] Between 1990 and 2004, eight patients have been attended with an angiomyolipoma renal diagnostic. Five women (62%) and three men (38%). Medium age is 52,3y (29-69). In 3 of them (all women), it was also done a diagnostic of pulmonary lymphangioleiomyomatosis. CONCLUSIONS: Bourneville syndrome is not very frequent. Associated angiomyolipomas usually are multiple, bilateral, with tender to grow and require more interventions. Previous diagnostic let us prevent future complications with vigilance, selective arterial embolization and nephron-spare surgery. Tumour size and the presence of symptoms are more decisive to decide best therapy alternative. Young patients with pulmonary lymphangioleiomyomatosis should be advise against pregnancy and the use of preparations containing estrogens.

[Role of nephrectomy in metastatic renal cell carcinoma. Experience of the Department of Urology Juan Canalejo Hospital]. / Papel de la nefrectomía en el adenocarcinoma renal metastático: experiencia del Servicio de Urología del Hospital Juan Canalejo.

OBJECTIVES: We expose our experience in nephrectomy in metastatic renal cell carcinoma, and also show complications, evolution and survival of these patients. MATERIAL AND METHODS: We performe a retrospective review of renal cell carcinoma treated at our service in the period between January 1st 1991 and December 31st 2002. We only studied those which presented in a metastatic pattern (31), and divide these in two groups: the ones which were nephrectomized and those which were not. We try to showw the differences between the two groups in order of status performance (E.C.O.G.), associated morbidity and median survival. In the first group we also study complications of surgery and treatment that patients underwent. RESULTS: we performed nephrectomy in 19 cases, all of them E.C.O.G. 0-1. Median postoperative stay was 12 days, and complication rate was 11.5%. Of these patients, 45% underwent some type of systemic treatment, and median survival was 31 months. We didn't performed nephrectomy in 12 patients, of which 9 were E.C.O.G. 2-3. Associated co-morbidity was higher in this group. Only in three patients any treatment was offered always with palliative reason. Median survival was 3.8 months. CONCLUSIONS: In those patients with good performance status this approach does not represent more morbility nor mortality than in non-metastatic patients, and that is a cornerstone in their management. We also make a literature review in which we see the last pathways in the management of these patients, and that show the needing for a combined approach both quirurgical and inmunotherapical. We have review with special interest the studie's conclusions of SWOG and EORTC groups.