[Knowledge, attitude and perception about obstetric fistula by Cameroonian women]. / Connaissance, attitude et perception vis-à-vis des fistules obstétricales par les femmes camerounaises Une enquête clinique conduite à Maroua, capitale de la province de l'extrême Nord du Cameroun.

INTRODUCTION: This study seeks to identify what the women who live in Maroua Cameroon know and think about obstetric fistula. POPULATION AND METHOD: It is a single hospital, cross-sectional, descriptive and comparative study. Ninety-nine women in the maternity service of the Maroua Provincial Hospital were interrogated on obstetric fistula between May and July 2005, by enquirers who were trained health agents using a questionnaire which required both closed and open answers. RESULTS: The women who had no previous knowledge of it were generally the illiterate (41.7% compared to 18.8%). More than a third of the women who had an idea of the fistula do not know that there is a surgical treatment for it. Whether they had the previous information on fistula or received it from us, one-tenth of the women suggested that suicide was the solution to fistula where as one-third of the women suggested that a patient suffering from fistula should be isolated. CONCLUSION AND INTERPRETATION: Illiteracy contributes significantly to the lack of knowledge of this affection. The population has a poor perception and a strong negative attitude towards obstetric fistula as they see isolation or suicide as the solution to it.

In vivo retroviral mediated gene transfer into bladder urothelium results in preferential transduction of tumoral cells.

OBJECTIVES: Superficial bladder tumours are at high risk for recurrence, relapse after resection, escape to intravesical immunotherapy and they may become invasive. New therapeutics are therefore needed to achieve cure. Thus, gene therapy is an attractive new treatment modality for malignant bladder tumours. The purpose of this study was to evaluate the feasibility and the efficiency of retroviral mediated reporter gene transfer into malignant urothelial cells both in vitro and in vivo. METHODS: We evaluated the feasibility of the transfection of bladder tumour with direct intravesical instillation of a defective retrovirus. The vector was derived from LXSN. The efficiency of transduction with the Moloney Leukaemia Murine virus-based vector, amphotrophic retroviral vector, was monitored through the expression of two marker genes (nls-LacZ and NeoR). The canine animal was chosen since it can present with spontaneous bladder carcinomas mimicking human pathology. Primary cultures of two normal canine bladder urothelium and two canine primary bladder tumours were first studied. We then investigated in vivo, in two normal and two spontaneous tumour bearing dogs, the transduction of urothelial cells following direct intravesical instillation of 2.10(4) to 3.10(6) of the retroviral vector. RESULTS: Transduced cells were evidenced in all primary cultures of canine normal urothelium and transitional cell carcinoma. Bladder biopsies from sound dogs instilled with the viral solution showed long lasting transduction up to 60 days long. Bladder cryosections from tumour-bearing dogs displayed transduction of superficial layers of urothelial cancer cells without passing through lamina propria. In vivo transduction was evidenced in 1 to 15% (mean 5%) of the cells in the tumours and preferentially addressed malignant cells. Normal epithelium either originating from sound or tumour-bearing animals was not transduced. CONCLUSION: These results demonstrate for the first time the feasibility of in vivo retroviral transduction of bladder cancer using a clinically relevant procedure.

[Therapeutic strategy in urinary calculi]. / Stratégie thérapeutique des calculs urinaires.

Most of the urinary stones are treated with ESWL. Endoscopic techniques are more frequently used as alternatives. Open surgery is rarely used. Laparoscopy is in the phase of evaluation and seems to be promising for some indications. This paper summarises the present strategy of urinary stones treatment.

Percutaneous implantation of subcutaneous prosthetic ureters: long-term outcome.

PURPOSE: We have used an extra-anatomic subcutaneous alloplastic ureteral replacement initially to bypass ureteral obstruction secondary to advanced pelvic malignancies in patients with a short life expectancy. Following the encouraging preliminary results, our list of indications has broadened to include complex benign ureteral strictures. We herein report the long-term outcome. PATIENTS AND METHODS: A series of 35 subcutaneous prosthetic ureters were implanted percutaneously in 27 patients (19 unilateral and 8 bilateral) to bypass extrinsic ureteral obstructions. The nature of obstruction was neoplastic in 22 patients and benign in 5. A composite prosthesis, consisting of two coaxial tubes--internal pure smooth silicone covered by coiled e-PTFE--has been designed to serve as the ureteral replacement. This tube is inserted percutaneously into the renal pelvis, tunnelled subcutaneously, and introduced through a small suprapubic incision in the bladder. All patients were followed to date or until death from tumor. The mean follow-up was 6.3 months for the deceased patients and 47 months for the surviving ones, the longest follow-up being 84 months. RESULTS: No operative or immediate postoperative deaths were observed. Initial difficulty in placing the prosthesis was encountered in 5 of the 27 patients (19%). Secondary parietal complications occurred in 8.5% of cases (3/35). The prosthetic ureter had to be removed in one patient because of skin erosion. Return to a standard percutaneous nephrostomy was needed in two patients because of local tumor progression with bladder fistulae. Five patients are alive with the prosthesis in place and a follow-up as long as 84 months without encrustation, infection, obstruction, or skin problems and with normally functioning kidneys. CONCLUSION: The subcutaneous urinary diversion using a silicone-PTFE prosthesis is an efficient and minimally invasive way to bypass malignant or complex benign obstructions of the ureters that otherwise would necessitate permanent nephrostomy drainage.

[Hand-assisted laparoscopic bi-nephrectomy for refractory arterial hypertension in kidney transplantation]. / Bi-néphrectomie laparoscopique assistée manuellement pour hypertension artérielle réfractaire chez le transplanté rénal.

OBJECTIVE: The authors report their preliminary experience of a manually assisted laparoscopic bilateral nephrectomy technique for refractory hypertension in renal transplant recipients. MATERIAL AND METHODS: Between April and May 1999, 2 laparoscopic bilateral nephrectomies were performed with manual assistance using the Hand-Port. One patient was operated 4 months before renal transplantation and the other was operated 13 months after renal transplantation. Both patients presented severe hypertension refractory to several antihypertensive drugs. An 8 cm midline supra-umbilical incision and 3 trocars were necessary. One hand was introduced into the abdominal cavity via the Hand-Port at the beginning of the operation. The intra-abdominal hand assisted all phases of dissection of the kidney and control of vessels. The renal vessels and ureter were clipped. The kidneys were removed by the intra-abdominal hand through the supra-umbilical incision. RESULTS: Operating times were 200 min and 130 min. Blood loss was 220 ml. No conversion was performed. The duration of major postoperative analgesics was 3 days. Length of hospital stay was 6 days and 7 days. There were no complications. Blood pressure was controlled by bilateral nephrectomy in both cases, with significant reduction of antihypertensive therapy. One year after the operation, both patients were satisfied with the aesthetic result. CONCLUSIONS: Laparoscopic bilateral nephrectomy manually assisted by the Hand-Port is an alternative to open bilateral nephrectomy. Larger series are necessary to evaluate the morbidity of this technique.

[Treatment of stress urinary incontinence with percutaneous colposuspension: unsatisfactory technique]. / Traitement de l'incontinence urinaire d'effort par colposuspension percutanée: une technique non satisfaisante.

OBJECTIVE: The objective of this study was to evaluate the results of a percutaneous needle colposuspension technique with bone fixation (Vesica system) in the treatment of female urinary stress incontinence (USI) of the woman, with a minimum follow-up of one-year. MATERIAL AND METHODS: 34 women aged 35 to 86 years (mean: 62 years) were treated for USI due to bladder neck hypermobility according to the Vesica technique. All patients had a positive preoperative Bonney manoeuvre without sphincter incompetence on urethral pressure profile. RESULTS: Overall, 1 year postoperatively, 9 patients (26%) were completely dry and did not wear any protection, 19 (56%) were improved, but still presented occasional leaks and 6 (17%) were considered to be failures. Physical examination revealed postoperative leaks in 24 patients with recurrence of hypermobility and positive Bonney manoeuvre in every case. There was one subcutaneous abscess and 2 cases of persistent pain at the bone implant site. No cases of bone infection or screw explantation were observed. No cases of retention beyond the 3rd postoperative day were observed. CONCLUSION: The percutaneous colposuspension technique gives disappointing results at one year due to recurrence of urethral hypermobility in every case.

Hand-assisted laparoscopic live donor nephrectomy in a patient with renal artery aneurysm.

Among the transplantation teams there is an increasing interest in laparoscopic live donor nephrectomy. For technical reasons, the use of the left kidney is recommended. However, considering the shortage of organ donors, it is likely that right-side laparoscopic live donor nephrectomy will need to be considered in selected donors, even those with vascular anomalies. Here we report the first case of right-side live donor laparoscopic nephrectomy in a patient with a renal artery aneurysm. Arteriography showed a 3-cm saccular aneurysm of the main right renal artery located at the bifurcation of the secondary branches and associated with an inferior polar artery coming directly from the aorta. The patient was placed in the lumbotomy position. An 8-cm midline incision was made above the umbilicus to insert the HandPort system (Smith & Nephew S.A., 72019 Le Mans Cedex2, France). Four additional trocars were introduced. Dissection of the renal artery was carried out beyond the level of relieving the aneurysm behind the vena cava. The main and polar arteries were clipped, and the renal vein was stapled. The kidney was removed through the HandPort and perfused cold ex vivo. The warm ischemia time for the kidney was 1 min, and the total operative time was 280 min. Vascular abnomalies were corrected ex vivo. The postoperative course of the donor was uneventful. At 6 months after transplantation, the graft function was normal. The hand-assisted approach is of particular value on the right side where the dissection must be carried out behind the vena cava. The HandPort may save few precious minutes over the sac extraction technique of the standard laparoscopic procedure.

[Hemorrhagic cystitis: etiology and treatment]. / Cystite hémorragique: étiologie et traitement.

Haemorrhagic cystitis consists of acute or insidious diffuse bleeding from the bladder mucosa. Although the aetiology of haemorrhagic cystitis is varied, the two predominant causes are chemical and irradiation. The chemical compounds most frequently responsible for haemorrhagic cystitis are oxaphosphorines (cyclophosphamide, ifosfamide). Haemorrhagic cystitis may also be due to toxic or infectious causes (bacterial, fungal, parasitic or viral). Finally, haemorrhagic cystitis can occur in the context of a systemic disease or may be isolated and idiopathic. Prevention of haemorrhagic cystitis, based on general measures and specific measures, is essential, but is not always effective. In the case of proven haemorrhagic cystitis, various treatment options are available, including and can associate clot extraction, continuous bladder irrigation, bladder instillations of haemostatic factors, formalin, hyperbaric oxygen therapy, arterial embolization or salvage surgery. Although therapeutic management is usually effective, it can sometimes be difficult due to the severity of the bleeding and its repercussions on the patient's general state. Deaths are not exceptional, emphasizing the seriousness of haemorrhagic cystitis. Based on a review of the literature, the authors review the aetiology and treatment of haemorrhagic cystitis.

[Esthetic and functional results of the transperitoneal laparoscopic approach in nephrectomy]. / Conséquences esthétiques et fonctionnelles de l'abord laparoscopique transpéritonéal pour la néphrectomie.

OBJECTIVE: To evaluate the aesthetic and functional sequelae of laparoscopic transperitoneal nephrectomy. MATERIAL AND METHODS: Twenty-one laparoscopic transperitoneal nephrectomies were performed between 1996 and 1999. Four trocars were used in 9 patients and 3 trocars were used in 12 patients. In all patients of the series, nephrectomy was performed without manual assistance and the kidney was extracted from the iliac fossa after enlarging a trocar orifice. A questionnaire evaluating the aesthetic sequelae of the operation, resumption of everyday activities and the patient's general satisfaction was sent to each patient by mail. RESULTS: 17 patients completed the questionnaire after a mean follow-up of 12.2 months (range: 2 to 33 months). Scars were cosmetically satisfactory in 100% of cases, painless in 100% of cases and were considered to be invisible in 58.8% of cases. All patients were satisfied with the operation, but only 70.6% would have recommended this procedure to a friend or relative. 57.1% of the patients hospitalised for less than 5 days considered the hospital stay to be too brief and 42.9% considered it to be barely sufficient. Time to resumption of everyday activity varied considerably (7 to 70 days) with a mean of 32 days and was not correlated with operative complications. CONCLUSION: Laparoscopic transperitoneal nephrectomy achieves good aesthetic and functional results, but patients are not satisfied with the short hospital stay. Resumption of everyday activity does not appear to depend on the postoperative course.

A new prostatic stent for the treatment of benign prostatic hyperplasia in high-risk patients.

OBJECTIVES: The objective of this study was to evaluate the efficacy and safety of a new prostatic stent (Trestle((R)), Boston Scientific Microvasive) for the treatment of BPH in patients with complete urinary retention and considered to be inoperable. METHODS: The efficacy of the stent was evaluated in terms of return of micturition, level of patient satisfaction, uroflowmetry and residual urine. Any stents removed were examined by infrared spectrophotometry for the presence of crystalline encrustations. RESULTS: From December 1997 to April 1999, 20 stents were inserted under local anaesthesia in 17 patients aged 54-90 years. Stents remained in place for an average of 3.5 months. Two migrations were reported. The mean maximum flow rate was 13.7 ml/s and the mean residual urine was 110 ml. The infrared spectrophotometry study revealed a glycoprotein film on stents in place for 1-6 months, accompanied by uric acid crystals on stents in place for 9 months. CONCLUSION: The Trestle prostatic stent is effective and constitutes a good alternative to surgical treatment in patients with a high operative risk.

Percutaneous management of grade II upper urinary tract transitional cell carcinoma: the long-term outcome.

PURPOSE: We report the long-term outcome of our experience with percutaneous treatment of grade II upper urinary tract transitional cell carcinoma. MATERIALS AND METHODS: A total of 61 patients with transitional cell carcinoma of the upper urinary tract were treated percutaneously between 1984 and 1998. Of the patients 24 (39%) had grade II disease. Immediate nephroureterectomy was performed due to muscle invasive disease in 2 patients, bleeding in 1 and inability to resect the whole tumor in 1. Percutaneous resection was the actual treatment in 15 patients with stage Ta and 5 with stage T1 disease. RESULTS: Recurrence was noted in 5 patients (25%), including 3 (20%) with stage Ta tumors and 2 (40%) with stage T1 disease after a median followup of 48 months (range 9 months to 12 years). All stage Ta disease recurrences were superficial. In 1 patient with a stage T1 tumor invasive and metastatic disease developed. Disease specific survival was 95% overall, and 100% for stage Ta and 80% for stage T1 disease. No tumor seeding was detected along the percutaneous tract. CONCLUSIONS: Percutaneous surgery has proved safe and effective in treating superficial grade II upper tract transitional cell carcinoma. Offering an endoscopic approach electively to healthy individuals with a normal contralateral kidney seems viable.

Telomerase activity as a potential marker in preneoplastic bladder lesions.

OBJECTIVE: To assess telomerase activity (involved in cell immortalization and detectable in most malignant tumours but not in normal somatic tissues) as a marker in cancer diagnosis. PATIENTS AND METHODS: Tissue telomerase activity was assayed by two different techniques, the telomeric repeat amplification protocol-polymerase chain reaction (TRAP-PCR) and a telomerase PCR-enzyme linked immunosorbent assay. Malignant and inflammatory bladder lesions and their adjacent normal tissues were assessed for telomerase activity in a group of 18 patients, 14 of whom had urothelial carcinoma and four a nonspecific inflammatory lesion of the bladder. RESULTS: Eleven of the 14 tumour samples analysed were telomerase-positive and two of the three telomerase-negative tumour samples had a detectable 'telomerase inhibitor'. In the apparently normal tissues next to bladder tumours, four of the 14 specimens were telomerase-positive. Interestingly, these lesions were always next to high-grade muscle-invasive bladder tumours (pT2G3). Two of the four nonspecific inflammatory lesions (one of cystitis glandularis and one of severe dysplasia), known to be preneoplastic lesions, were also telomerase-positive. CONCLUSION: These results strongly suggest that the reactivation of telomerase may be an early event in bladder carcinogenesis, preceding morphological changes related to malignant transformation. Telomerase activity may therefore be useful both as an indicator of malignant potential in preneoplastic lesions, e.g. cystitis glandularis and severe dysplasia, and as a prognostic marker of bladder tumour relapse or progression.

[Kidney harvesting in living donors with manually assisted laparoscopy: technique and results]. / Prélèvement de rein chez le donneur vivant par laparoscopie assistée manuellement: technique et résultats.

OBJECTIVE: To evaluate the feasibility and complications of manually assisted laparoscopic live donor kidney harvesting. MATERIAL AND METHOD: Since June 1999, all related live donor kidney harvests have been performed by manually assisted laparoscopy. The patient is placed in the lumbotomy position and an 8 cm midline periumbilical incision is made. The assistant's hand is introduced through a watertight port (HandPort). Three trocars are used. The assistant presents the structures to be dissected and controls the ureter. The artery is clipped and the vein is stapled or clipped, depending on its diameter. The kidney is extracted via the midline incision and washed. RESULTS: Five kidney harvests were performed (three right kidneys and two left kidneys) with a mean operating time of 220 +/- 30 minutes. Conversion was necessary in one case following the intraoperative discovery of two right renal veins. Warm ischaemia lasted 5 minutes for the first patient and one to two minutes for the other four non-converted patients. Blood losses were minimal. The mean duration of major analgesia was 2.4 days and the mean length of hospital stay was 7.2 days. Complications were: bacteriuria in 2 cases and prolonged lymphorrhoea in 1 case. One transplanted kidney had to be removed because of immediate thrombosis of the recipient iliac artery. With a mean follow-up of 6 months (1 to 12 months), no ureteric or venous complications have been observed in the 4 evaluable transplanted kidneys. CONCLUSION: An intra-abdominal hand during laparoscopic live donor kidney harvesting simplifies dissection, ensures intraoperative security and allows rapid extraction of the kidney.

The effects of transurethral resection and cystoprostatectomy on dissemination of epithelial cells in the circulation of patients with bladder cancer.

This study was undertaken to evaluate the risk of haematogenous dissemination of epithelial cells induced by endoscopic resection and/or cystoprostatectomy for transitional cell carcinoma of the bladder. Thirty-three patients were studied. Thirty-one had different stages and grades of bladder cancer and two patients had benign bladder conditions. Twenty-five cancer patients required transurethral resection of their bladder tumour. Of those, 20 had superficial disease (pTaG1-G2: n = 19; pT1G2: n = 1) and five had muscle invasive tumours (pT2G3: n = 2; pT3aG3: n = 1; pT4G3: n = 2). Five patients underwent radical cystoprostatectomy for muscle invasive cancers (pT2G3: n = 3; pT3bG3: n = 1; pT4G3: n = 1) and one man received chemotherapy for metastatic disease. Venous blood (10 ml) was obtained from the antecubital fossa in each patient, before and 1-2 h after completion of surgery, and prior to treatment in the metastatic patient. An indirect immunocytochemical technique was used to detect circulating epithelial cells after centrifugation on Ficoll gradient and fixation of mononuclear cells on slides, using a monoclonal antibody directed against three cytokeratins: CK8, CK18 and CK19. Circulating epithelial cells were detected only in the patient with metastatic disease. None of the other patients had evidence of epithelial circulating cells before or after surgery. The results suggest that irrespective of disease stage and grade, neither endoscopic nor open bladder surgery leads to detectable dissemination of urothelial cells in the peripheral circulation. These procedures are therefore unlikely to increase the risk of progression and metastasis in transitional cell carcinoma of the bladder.

The conservative management of corynebacterium group D2 encrusted pyelitis.

OBJECTIVE: To evaluate the conservative management of encrusted pyelitis (EP), an infectious disease caused by urea-splitting micro-organisms (Corynebacterium group D2 being the most common), and characterized by stone encrustation of the collecting system. PATIENTS AND METHODS: Four patients (aged 17-62 years) with EP caused by Corynebacterium group D2 were treated conservatively with intravenous vancomycin and percutaneous acidification of the renal collecting system. Percutaneous nephrostomy tubes were placed to allow irrigation with Thomas' acid solution, the outflow being ensured by ureteric catheters. Patients were monitored and the results of and tolerance to treatment evaluated clinically, by biological assays, and by imaging techniques (ultrasonography, computed tomography and pyelography). RESULTS: No kidneys were lost and in all patients with initial renal failure, creatinine levels recovered to previous values. The adverse effects were moderate, consisting of flank pain or discomfort, and low-grade fever. Three patients developed asymptomatic fungal urinary tract infections requiring antifungal agents. The encrustations were treated effectively and almost disappeared in two patients, while the other two had no residual calcification. One transplanted-kidney recipient developed a ureteric stricture requiring surgical repair. Within a mean follow-up of 16 months, there was no recurrence of EP and the residual encrustation remained small. CONCLUSION: The conservative treatment of EP can avoid surgery in many cases, although there are some adverse effects of irrigation. The long-term follow-up and prevention of recurrent EP are nevertheless required.

The rectal administration of lidocaine gel and tolerance of transrectal ultrasonography-guided biopsy of the prostate: a prospective randomized placebo-controlled study.

OBJECTIVE: To evaluate the effect of the rectal administration of lidocaine gel on the tolerance of systematic sextant transrectal ultrasonography (TRUS)-guided prostatic biopsies. PATIENTS AND METHODS: From January to September 1997, patients undergoing initial biopsy mapping of the prostate (with six systematic TRUS-guided transrectal biopsies) were randomized using a pre-established randomization list into two groups. In group 1, 15 mL of 2% lidocaine gel (Astra, Södertälje, Sweden) was administered intrarectally 15 min before the biopsies. In group 2 (placebo), 15 mL of trans-sonic hydrophilic gel (Rivadis Laboratory, Thouars, France) was administered transrectally under the same conditions. Patients were randomized and the gel administered by a nurse; neither the patients nor the urologists were aware of which product was administered. At the end of the procedure, patients were asked to score the severity of discomfort of the biopsies, using a self-administered rating scale. RESULTS: In all, 109 patients were included, in either group 1 (56 patients) or group 2 (53 patients). Slight pain or no pain was experienced by the vast majority of patients in both groups. Moderate to severe pain was experienced in 12.5% of patients in group 1 and 11.3% of patients in group 2. There was no difference in patient tolerance between the groups (P=0.39). Only minor complications occurred and complication rates were not significantly different between the groups. CONCLUSION: The rectal administration of lidocaine has no impact on the tolerance to prostatic biopsy.

An experimental model of bulbar urethral stricture in rabbits using endoscopic radiofrequency coagulation.

OBJECTIVES: To develop an experimental model of endoscopic urethral stricture mimicking the human clinical situation. METHODS: Twenty-four New Zealand male rabbits were included. Eighteen animals (study group) underwent videourethroscopy with a pediatric resectoscope, and a 3 to 5-mm-long circumferential electrocoagulation of the bulbar urethra was performed, without postoperative urinary diversion. Six animals underwent the same procedure without application of electrocautery (control group). Each animal was assessed for urethral stricture on day 15 and day 30 by videourethroscopy and voiding cystogram. Among the study group, 8 animals were killed on day 15 and 10 on day 30 for histologic evaluation. All the control animals were killed on day 30 for histologic examination. RESULTS: Nine animals (50%) in the study group developed a significant bulbar stricture (reducing the lumen by more than 50%) at day 15. Histologic examination confirmed the presence of hyalin fibrosis mutilating the urethral wall. No spontaneous improvement of the stricture was observed on day 30. None of the controls developed urethral stricture, and histologic examination showed a normal urethra in each case. CONCLUSIONS: Endoscopic electrocoagulation of the urethral wall provides a reproducible model of stricture in the rabbit.

A 3 trocar technique for transperitoneal laparoscopic nephrectomy.

PURPOSE: Additional trocars and retractor instruments may enhance the risk of iatrogenic injuries during laparoscopic nephrectomy. We describe a modified technique of laparoscopic nephrectomy requiring only 3 ports of entry and no extra instruments instead of the 5 ports, 2 of which are used for retractors, usually required. MATERIALS AND METHODS: With the patient in full flank position a 10 mm. trocar is inserted between the umbilicus and subcostal margin, a 5 mm. trocar is placed subcostal in the midclavicular line and a 12 mm. trocar is inserted over the iliac crest in the anterior axillary line. The first step is incision of the line of Toldt and medial reflection of the colon. During the second step of vascular controls the posterosuperior attachments of the kidney are left untouched, keeping the renal vessels stretched, with no need for an extra instrument. The third step consists of severing the remaining posterior and superior attachments of the kidney followed by specimen retrieval. A total of 14 consecutive patients underwent laparoscopic nephrectomy with this technique. RESULTS: All 14 procedures were completed without an additional port. There were no intraoperative or postoperative complications, except 1 abdominal wall hematoma. Mean operating time was 120 minutes (range 70 to 230) and mean hospital stay was 5 days (range 3 to 7). CONCLUSIONS: Transperitoneal laparoscopic nephrectomy with laparoscopic access limited to 3 trocars is a reliable and safe technique.