Key areas in the learning curve for robotic urological surgery: a Spanish multicentre survey.

BACKGROUND: The number of robotic-assisted procedures offered in Spain is rapidly increasing despite a lack of consensus criteria for training and credentialling. OBJECTIVE: This national multicentre study was designed to analyze the different areas of the robotic urological surgery learning curve. MATERIAL AND METHODS: A questionnaire was sent to all 13 urology units in Spain with an active robotics programme requesting information on training and problems encountered. RESULTS: In most centres (n = 11, 84.6%), training programmes were animal-based; cadavers were used at only 2 (15.4%). Proctoring in initial procedures was practiced by 12 groups (92.3%). When initiating the robotics programme, the console was shared at 8 units (61.5%). Prior experience in open and/or laparoscopic surgery was reported by 10 of the groups (76.9%), and experience in open surgery only by 2 (15.4%) or robotic surgery alone by 1 (7.7%). The procedure with which the robotics programme was started in all 13 participating units was radical prostatectomy. The number of cases needed to complete the learning curve for this procedure was 20-25 cases according to 8 (61.5%) surgery teams. CONCLUSIONS: Up until March 26, 2010, 1,692 operations, mostly radical prostatectomies, were conducted using the da Vinci robot in our country.

[Role of laparoscopy in the presence of a renal mass under 4 cm in size]. / Papel de la laparoscopia ante la masa renal menor de 4 cm.

The increasingly common incidental diagnosis of small renal masses (SRMs) (measuring under 4 cm in size) has led to the consideration of applying minimally invasive techniques to deal with them--particularly in view of the high percentage of non-malignant conditions of this size that are radiologically indistinguishable from tumor lesions. Accordingly, laparoscopic access has gained great importance in the management of these masses, in an attempt to lessen the morbidity associated with lumbotomy. Laparoscopic partial nephrectomy (LPN) is an evolving technique in most centers; on one hand it competes with open partial nephrectomy as the technique of choice, and on the other it will compete in the future with the non-excisional management techniques. These latter procedures in turn have become more precise thanks to laparoscopy. Based on a standardized review of the abundant literature on the treatment of SRMs, the present study examines the technical innovations and improvements afforded by the laparoscopic approach, not only for excision purposes but also a vehicle for minimally invasive treatments. Likewise, the requirements of Services of Urology and the improvements that could be introduced in health systems for advancing the application of LPN in the management of SRMs are commented. Progressive fine-tuning of the technique, with improvement of the laparoscopic repertoire and availability of hemostatic agents, will contribute to increase the indications for LPN in the future. The limited frequency of the disorder and the need to optimize the technique will require health care supervisors to centralize this type of pathology in centers with experience in laparoscopy and open partial nephrectomy.

[Radiofrequency ablation of renal cell carcinoma]. / Ablación del cáncer renal por radiofrecuencia.

INTRODUCTION: The standard treatment of small renal masses is partial nephrectomy, which has showed similar oncologic results when compared with radical nephrectomy. Recently, ablative techniques, including radiofrequency and cryotherapy ablation, has been developed, with the purpose of minimizing adverse effects of standard surgical excision. In this article we review the technique of radiofrequency ablation. MATERIAL AND METHODS: For this review we conducted a search in the Medline database using the terms "renal radiofrequency ablation". RESULTS: The different currently marketed systems for the delivery of radiofrequency energy are examined. The different techniques of delivery (open, laparoscopic and percutaneous) are described; we observe a trend towards the use of the percutaneous method. Among the published clinical studies there are series of patients with midterm follow-up (3 years) that show oncologic outcomes similar to traditional resection techniques, with fewer complications. CONCLUSIONS: Renal tumor radiofrequency ablation has proved an effective therapy with minimal complications. However, it should be used only in selected patients until longer follow-up studies are available.

[Radiofrequency ablation of renal cell carcinoma]. / Ablación del cáncer renal por radiofrecuencia.

INTRODUCTION: Standard treatment for small renal masses is partial nephrectomy, which has shown oncological results similar to radical nephrectomy. Ablation procedures such as radiofrequency and cryotherapy have recently been developed in order to minimize the side effects of conventional surgical excision. This article reviews radiofrequency ablation. MATERIALS AND METHODS: For this review, a search was made in the Medline database using the term "renal radiofrequency ablation". RESULTS: The different currently marketed systems for delivery of radiofrequency energy are examined. The different delivery approaches (open, laparoscopic, and percutaneous) are described. A trend towards use of the percutaneous approach was seen. Published clinical studies already include patient series with mid-term follow-ups (3 years) showing oncological outcomes similar to conventional resection procedures with fewer complications. CONCLUSIONS: Renal tumor radiofrequency ablation has proved to be an effective treatment with minimal complications. However, it should only be used in selected patients until longer follow-up studies are available.

[Manoeuvres to perform a completely laparoscopic nephroureterectomy]. / Maniobras para realizar la nefroureterectomia totalmente por via laparoscopica.

OBJECTIVES: We describe a series of surgical manoeuvres to perform a completely laparoscopic nephroureterectomy. METHODS/RESULTS: We set the patient in the lateral position. The trocars are placed in a rhombus shape, with an accessory trocar for liver retraction on the right side. Once the parietal peritoneum is open the ureter and gonadal vein are localized. We clip and section the gonadal vein. The renal pedicle is localized and dissected. We divide separately the renal artery and vein. We complete the dissection of the kidney. We start the caudal dissection of the ureter from the iliac vessels level down to the pelvis. We clip the ureter. Due to the trocar deployment we reach a point in which ureteral dissection becomes difficult. Then we perform 3 manoeuvres: 1) We change the camera from the lower trocar to the right side one. 2) We move the monitor to the feet of the patient. 3) The surgeon moves to the other side of the patient to work with the superior and inferior trocars. We introduce a retractor through the remaining trocar. With these changes the ureter is in line with the camera and we may have a good access to the pelvis, making the distal dissection of the ureter easier. The dissection ends when the classic image of tent of the vesicoureteral junction is seen. The bladder patch is resected and the bladder is sutured closed with a continuous suture. The specimen is bagged and extracted opening the orifice of the iliac fossa trocar. CONCLUSIONS: With this technique, a completely laparoscopic nephroureterectomy may be performed following the oncological principles of open surgery.

[Ureteroscopy in the follow-up protocol for upper urinary tract urothelial tumors treated endoscopically]. / La ureteroscopia en el protocolo del seguimiento del tumor del urotelio superior tratado por via endoscópica.

OBJECTIVES: To evaluate the role of ureteroscopy (rigid and flexible) in the follow-up protocol for transitional cell tumors treated conservatively in our department by endourological procedures, and to review the articles on this topic available in the literature. METHODS: From February 1997 to June 2003, 10 patients (12 renal units) with upper urinary tract urothelial tumor treated conservatively by endourological procedures were followed by cytology, cystoscopy, retrograde ureteropyelography, and ureteroscopy (rigid and flexible), quarterly during the first year, semi-annually during the second year, and yearly thereafter in order to detect tumor recurrence. RESULTS: Mean follow-up was 31.9 months (R 14-65). Two patients died: one because of a previous metacronous bladder tumor and the other after distant progression. One patient was lost to followup. A total of 42 ureteroscopies were performed (31 flexible and 11 rigid). Flexible ureteroscopy was performed in 6 patients and rigid ureteroscopy in three; neither was feasible in one patient so that follow-up was done by cytology, cystoscopy and urography. Tumor recurrence was detected in 2 patients but ureteroscopy did not inform about tumor stage. Flexible ureteroscopy failed in another patient in which rigid ureteroscopy was feasible. Although this latter was technically easier to perform, procedure discomfort was worse. CONCLUSIONS: The follow-up of transitional cell tumors of the upper urinary tract should be very strict because of the high risk of tumor relapse. Ureteroscopy, mainly flexible, is standing out as the most effective procedure to watch these tumors.

[Splenic hematoma after extracorporeal lithotripsy: apropos of a case]. / Hematoma de bazo tras litotricia extracorpórea: a propósito de un caso.

OBJECTIVE: To emphasise a case of splenic hematoma secondary to ESWL. METHODS: We report the case of a 69 year old patient with the diagnosis of left kidney stone who underwent ESWL. The treatment was performed with an electric lithotripter after pre-treatment antibiotic prophylaxis; 2000 shock waves of 18 Kv were given to the patient. RESULTS: Patient presented abdominal pain and hematocrit descent after lithotripsy. The diagnosis of splenic hematoma was established after abdominal ultrasound and CT-scan and the patient was treated conservatively. He required a posterior emergency splenectomy secondary to infection of the hematoma, with the result of death secondary to septic shock. CONCLUSION: Splenic lesion is an exceptional complication after ESWL. There are no studies about the effect of shock waves on the spleen, having been reported only four cases. It is believed that extreme care should be taken in cases with splenic pathology: leukaemia, lymphoma, etc.

[Intraoperative complications and morbidity of laparoscopic radical prostatectomy (LRP) during the learning curve]. / Complicaciones intraoperatorias y morbilidad de la prostatectomía radical laparoscópica (PRL) durante el periodo de aprendizaje.

OBJECTIVES: To analyze the complications and morbidity during our learning curve of laparoscopic radical prostatectomy (LRP) and compare them with other published series. METHODS: We review the 25 first laparoscopic radical prostatectomies performed in our department, evaluating the operative technique and other features such as surgical time, blood loss, complications and conversion to open surgery. We also evaluate morbidity, postoperative hospital stay, and functional features such as potency and continence. RESULTS: LRP was completed in 22 patients. Overall intraoperative complication rate was 32%. 3 cases were converted to open surgery due to technical difficulties or intraoperative complications. We had complications in 4 patients, that were not severe (bladder injury 2 cases, and epigastric artery injury another 2) and where solved without difficulties during the operation. The most severe intraoperative complication was related to the anesthesia procedure at the time of extubation of a patient who required tracheotomy. There were no severe postoperative complications, being leakage from the anastomosis the most common (7 cases). All of them were managed conservatively, although this resulted in a mean hospital stay of 10.8 days. 2 patients required endoscopic procedures in the immediate postoperative time for bladder catheter repositioning. All patients suffered erectile dysfunction and the continence rate at 3 months was 77.2%. CONCLUSIONS: Although LRP is a long operation and difficult during the learning curve, its complication rate is acceptable because they are not severe and can be managed in a relatively easy way.

[Laparoscopic pyeloplasty. Our experience]. / Pieloplastia laparoscópica. Nuestra experiencia.

OBJECTIVES: To report our experience with laparoscopic pyeloplasty in the treatment of pyeloureteral junction obstruction. METHODS: Between August 2001 and August 2004 14 patients with the diagnosis of pyeloureteral junction obstruction underwent laparoscopic repair. Seven cases had the obstruction on the left side and the other seven on the right side. We describe the technique of laparoscopic dismembered Anderson-Hynes type pyeloplasty, performed to 12 patients in our series. The remainder 2 patients underwent Foley's Y-V plasty and the Fenger's technique. RESULTS: Mean operative time was 199.7 minutes (r: 126-290). There were not intraoperative complications. Mean hospital stay was 4.63 days (r: 3-9). One case of double J catheter obstruction can be cited as late postoperative complication. Only one of the 14 cases suffered a recurrence of the stenosis after double J catheter retrieval. CONCLUSIONS: Laparoscopic pyeloplasty has become the operation of choice in cases of hydronephrosis secondary to crossing vessel, when there is great pyelic dilation, and for the treatment of failures of previous endopyelotomy.

[Radical cystectomy. Bladder substitution (in women)]. / Cistectomía radical. Sustitución vesical (en mujer).

OBJECTIVES: To report our experience with a series of 10 patients undergoing radical cystectomy with bladder substitution. We were supported by a better knowledge of the female continence anatomical mechanisms and the demonstration of the oncological viability of the urethral remnant. METHODS: From 1994 to 2002 10 women underwent radical cystectomy with bladder substitution by means of a modified anterior pelvic exanteration; technical modifications to achieve continence preservation are based on: preservation of the distal 2/3 of urethra, pubourethral ligaments and endopelvic fascia, and limitation of lateral vaginal dissection to avoid damage to the striated sphincter innervation. To avoid the neocystocele effect the vagina is fixed to the uterosacral ligaments and to the sacral promontory. RESULTS: Bladder capacity is 332.9 +/- 35.6 ml with a flow of 17.7 ml/sec. Complete continence wax achieved in 8 patients, the remainder 2 present grade II urinary stress incontinence. All of them empty their neobladder satisfactorily; only one patient needed a bladder re-education program. One bladder fistula and diarrhoea in one patient are the complications to be highlighted. CONCLUSIONS: The results obtained with orthotopic neobladder in females, achieving a high satisfaction level and quality of life, stimulate us to continue with this technique.