NOTES hybrid transvaginal radical nephrectomy for tumor: stepwise progression toward a first successful clinical case.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) has been used to perform nephrectomy in the laboratory; however, clinical reports to date have used multiple abdominal trocars to assist the transvaginal procedure. OBJECTIVE: To present our stepwise technique development and the first successful clinical case of NOTES transvaginal radical nephrectomy for tumor with umbilical assistance without extraumbilical skin incisions. DESIGN, SETTING, AND PARTICIPANTS: The four transvaginal NOTES procedures were performed at two institutions after obtaining institutional review board approval. Various operative steps were developed experimentally in three clinical cases, and on March 7, 2009, we performed the first successful case of NOTES hybrid transvaginal radical nephrectomy without any extraumbilical skin incisions. Using one multichannel access port in the vagina and one in the umbilicus, laparoscopic visualization, intraoperative tissue dissection, and hilar control were performed transvaginally and transumbilically. The intact specimen was extracted transvaginally. MEASUREMENTS: All perioperative data were accrued prospectively. A stepwise progression to the successful completion of the fourth case is systematically presented. RESULTS AND LIMITATIONS: Intraoperatively, at incrementally more advanced stages of the procedure, the first three NOTES clinical cases were electively converted to standard laparoscopy because of rectal injury during vaginal entry, of failure to progress, and of gradual bleeding during upper-pole dissection after transvaginal hilar control, respectively. The fourth case was successfully completed via transvaginal and umbilical access without conversion to standard laparoscopy. Operative time was 3.7 h, estimated blood loss was 150 cm(3), and hospital stay was 1 d. Final pathology confirmed a 220-g, pT1b, 7-cm, grade 2, clear-cell renal cell carcinoma with negative margins. The patient was readmitted for an intraabdominal collection that responded to drainage and antibiotics. CONCLUSIONS: We report our stepwise progression and the initial successful clinical case of NOTES hybrid transvaginal radical nephrectomy for tumor, assisted with only one umbilical trocar. Although transvaginal nephrectomy is feasible in the highly selected patient with favorable intraoperative circumstances, considerable refinements in technique and technology are necessary if this approach is to advance beyond mere anecdote.

Laparoendoscopic single-site surgery simple prostatectomy: initial report.

OBJECTIVES: To report the first case and detailed technique of laparoendoscopic single-site (LESS) surgery simple prostatectomy for benign hypertrophy. METHODS: A 67-year-old man presented with acute urinary retention requiring catheterization. Serum prostate-specific antigen level was 5 ng/mL, and a biopsy revealed benign hypertrophy with a transrectal ultrasound volume estimation of 110 mL. LESS simple prostatectomy was performed using a single multilumen port inserted through a solitary 2.5-cm intraumbilical incision. Standard laparoscopic ultrasonic shears and needle drivers, articulating scissors, and specifically designed bent grasping instruments facilitated dissection and suturing. RESULTS: An R-port was placed intraperitoneally through a 2.5-cm intraumbilical incision. No extraumbilical skin incisions were made. Total operative time was 120 minutes and estimated blood loss was 200 mL. A closed suction drain was externalized through the umbilical incision. No intraoperative or postoperative complications occurred. Hospital stay was 2 days, the retropubic drain was removed at 3 days, and the catheter removed at 1 week. Specimen weight was 95 g and final pathology revealed benign prostatic hyperplasia. At 3 months follow-up, the patient was completely continent and voiding spontaneously with a Q(max.) of 85 mL/s. CONCLUSIONS: We demonstrate technical feasibility and describe the detailed surgical technique of LESS simple prostatectomy. Our initial experience suggests that this technique may be an alternative for large-volume benign prostatic hyperplasia in lieu of open surgery. Comparative studies with other surgical techniques will determine its place in the surgical armamentarium of benign prostatic hyperplasia.

Chicken gizzard: a new training model for laparoscopic urethrovesical anastomosis.

OBJECTIVE: To create a simple, inexpensive, and reproducible animal model to provide a new training option for performing urethrovesical anastomosis during laparoscopic radical prostatectomy. MATERIAL AND METHODS: Development and testing were carried out in 2008. The materials used included a laparoscopic training box, video camera, monitor, needle holder, sutures, and non-eviscerated chickens weighing more than 2 kilograms. The model was prepared with a new perception of a structure similar to the human pelvis. To create the anastomosis, we used the gizzard (bladder neck) and the rectum (urethra). Once the model was placed in the box, the anastomosis was performed under very similar anatomical conditions to real procedures. Anastomosis quality was assessed by means of a permeability test and transanal endoscopy. RESULTS: The operating field is very similar to the human pelvis. The tissues have a quality, texture, and diameter resembling those of the urethra (rectum) and the bladder neck (gizzard), and offer the opportunity to practise anastomosis and anterior racket. CONCLUSIONS: The model for urethrovesical anastomosis using the chicken gizzard and rectum is simple, easily available, inexpensive and reproducible. The anatomy of the chicken and the characteristics of its tissues allow for training under conditions very similar to those present in human cases.

Extragonadal retroperitoneal germ cell tumor: primary versus metastases?

OBJECTIVE: Primary extragonadal germ cell tumors are rare and their histogenetic origin is not clear. We describe two cases presenting as primary retroperitoneal germ cell tumors without clinical evidence of testicular tumor. METHODS: A 21 and 18 years-old patients presented retroperitoneal choriocarcinoma and yolk sac tumor, respectively. In both cases, testicular palpation was not suspicious for testicular cancer. Testicular ultrasound founded alterations in right testes. RESULTS: A right orchitectomy were performed and the final diagnostics were mature teratoma associated with intratubular malignant germ cell. CONCLUSION: Adult mature teratoma is infrequent and the retroperitoneal germ cell tumors should be considered to be metastases of a viable or burned-out testicular cancer.

Extramammary Paget's disease of scrotum. A case with local lymph node metastasis.

OBJECTIVE: We describe the clinical, histological and immunohistochemical studies in a case of extramammary Paget's disease localized in the scrotum with lymph node inguinal metastasis. METHODS/RESULTS: A 80-year old man consulted with a one-year history of a pruritic erythematous skin rash of the scrotum. Physical examination showed demarcated erythematous lesion involving the scrotum and right inguinal adenopathy. Final histological examination revealed extramammary Paget's disease with inguinal metastasis. CONCLUSION: Extramammary Paget's disease of the scrotum is a rare disease. This pathological condition may spread to dermal region and the regional lymph nodes. Although genitourinary cancer may accompany scrotal extramammary Paget's disease, an extensive search for cancer may be unnecessary.

Cellular pseudosarcomatous fibroepithelial stromal polyp of the renal pelvis.

Cellular pseudosarcomatous fibroepithelial stromal polyp is an underrecognized lesion described in the lower female genital tract. We here report the clinical, histological, and immunohistochemical features of a cellular pseudosarcomatous fibroepithelial stromal polyp located in the renal pelvis. A 47-year-old woman was referred with a 4-month history of left flank pain and gross hematuria. Left radical nephrectomy was performed. Gross pathological examination showed irregular pedunculated polypoid masses that had developed from the renal pelvis. Histologically, spindle cells with a patternless appearance were seen. The cells were of different sizes and had discernible cytoplasmic bipolar processes. Atypical stromal cells and atypical mitoses were also found. This case represents a typical cellular pseudosarcomatous fibroepithelial stromal polyp, probably developing from a reactive hyperplastic process involving the subepithelial stroma.

Correlación entre la distancia verumontanum cuello vesical con el tacto rectal y volumen prostático / Correlation among the distance verumontanum neck vesical with the rectal tact and volume prostátic

El objetivo, establecer si la medición de la distancia verumontanun cuello (DVC) se relaciona con el tamaño prostático y con el volumen prostático como predictor de tamaño prostático. Se efectuó la revisión de 350 uretrocistoscopias de pacientes masculinos en el Hospital Vargas de Caracas. Para la conversión de cm a cm³en el tacto digital rectal y DVC se empleó la medida de que cada 1 cm próstata medido equivale a 10 cm³ de tejido prostático. En el análisis estadístico se aplicaron medidas de tendencia central usándose la correlación de Rangos de Spearman (r) para volumen prostático en cm³ DVC en cms, y el tacto rectal prostático en cm. En los 350 pacientes la media de la edad fue de 29,98 + 14,66 años, del DVC en 3,53 + 1,17 cm y del tacto rectal en 3,83 + 1,19 cm. De los 30 pacientes con ecografía endorrectal, la media de la edad 65 + 14,093 años, DVC 3,98 + 1,29 cm y del volumen prostático 46,63 + 12,27 cm³. Al dividir los resultados en < de 40 cm³ por ecografía y > 40 cm³ encontramos, en < de 40 cm³ una media de volumen prostático en de 35,75 cm³ y un DVC de 2,83 + 0,49 cm, al realizar la correlación volumen vs DVC r= 0.82561, r2= 0.681627, p= 0,00094. En próstatas con volumen > 40 cm³ la media del volumen 53,88 + 10,35 cm³, del DVC 4,75 + 1,06 cm con una correlación volumen prostático vs DVC r= 0,85497, r2= 0,73097 p= 0,00001; la media del tacto digital rectal es 4,94 + 1,16 cm que al relacionarla con volumen prostático r= 0,841201, r2= 0,707619, p= 0,000012. Se evidenció una correlación directa entre volumen prostático vs DVC en cm y volumen prostático y tacto digital rectal en cm, siendo esta correlación mayor en próstatas mayores de 40 cm³

Basaloid carcinoma of the prostate gland. An unusual finding.

OBJECTIVES: Carcinoma with basaloid features, known as basaloid carcinoma of prostate, is an extremely rare tumor. We report the clinical, histological and immunohistochemical findings in a case of prostatic basaloid carcinoma. METHODS/RESULTS: A 68-year old man consulted with a two-year history of increasing urinary outflow obstruction that developed into acute urinary retention. A routine suprapubic prostatectomy was carried out, following which normal voiding was achieved. Microscopically, the neoplasm showed different histological aspects; some areas were typical of basal cell hyperplasia, intermixed with other in which there was evidence of basaloid carcinoma. Immunohistochemical staining of the basaloid carcinoma revealed cytokeratin 34betaE12 immunoreactivity without expression of prostatic specific antigen and prostatic acid phosphatase. CONCLUSION: This case is a very unusual basaloid carcinoma and may indicate that there is a spectrum in prostate basal cell proliferation.

Estudio comparativo entre la tomografía axial y la tomografía helicoidal en la estadiación preoperatoria del paciente con cáncer renal / Comparative study between axial tomography in preoperatory stage classification of kidney cancer patients

Comparar la eficacia de la tomografía axial computada (TAC) y la helicoidal (TH) en el estadiaje preoperatorio y determinación del tamaño tumoral en los pacientes con cáncer renal comparada con los resultados de anatomía patológica de los especimenes quirúrgicos. Se incluyeron en el estudio 30 pacientes con diagnóstico de cáncer renal quienes fueron divididos en 2 grupos de 15 pacientes cada uno. Se determinó, la sensibilidad y la especificidad de ambos métodos diagnósticos tomando los siguientes parámetros: Capacidad de los estudios de establecer correctamente el T, el N y el tamaño tumoral, comparando ambos métodos entre si. Para el análisis de los datos se utilizaron el test de Wilconson, la X² corregida de Yates y la prueba exacta de Fisher. Se tomó para todas las pruebas un nivel de significancia de 95 por ciento (P<0.05). La TAC tuvo un 40 por ciento (n=6) de certeza para determinar correctamente el tamaño tumoral mientras que la TH determinó con certeza un 60 por ciento (n=9) de los casos. Con respecto a la estadiación preoperatoria la sensibilidad fue de 60 y 72,22 por ciento y la especificidad de 88,88 y 92,68 por ciento para la TAC y la TH respectivamente. La TH determinó con una eficacia del 100 por ciento todos los pacientes con T1 lo que la hizo más eficaz que la TAC para establecer los pacientes susceptibles de realizarseles una nefrectomía parcial. El sexo, el riñón afectado, el Furhman, el patrón histológico, el patrón arquitectural, no influyeron en la determinación de los parámetros objeto de este estudio. La tomografía helicoidal es actualmente el Standard de oro para el diagnóstico y estadiación de los pacientes con cáncer renal, en nuestro estudio, evidenciamos que era más sensible y específica en varios aspectos, más sin embargo no logramos determinar diferencias estdísticamente significativas entre los 2 métodos, debido al pequeño tamaño de la muestra

Transforming growth factor-beta2 and beta3 expression in carcinoma of the prostate.

OBJECTIVES: The present study reports the clinical and histological features of 14 cases of prostate adenocarcinoma coupled with their expression of the TGF isoforms beta2 and beta3, as well as their receptor endogline (CD105). METHODS: Fourteen (14) cases of adenocarcinoma (ADC) of the prostate were examined. Relevant clinical data were gathered From the histological point of view, the tumor's grade and the evidence of perineural, vascular and/or lymphatic invasion were the key elements taken into account. Immunohistochemical analyses were carried out to assess the expression of TGFbeta-2, TGFbeta-3 and CD105 in tumoral tissue samples. RESULTS: Patient's age ranged between 57 and 74 years. Thirteen (13) had prostatic specific antigen (PSA) values above the 4 ng/dL threshold Eleven (11) ADCs were moderately differentiated. The predominant grade in relation to the nucleus was II/III (7 cases). In two (2) of the 14 cases, no grading classification was applicable as the tumors exhibited changes related to the effect of hormonal therapy. In eleven cases, expression of TGFbeta-2 was detected in the cytoplasm of tumoral cells. Two cases also showed focal expression of TGFbeta-3, as well as in prostatic intraepithelial neoplasia areas of a third case. The areas with the highest intensity of expression were those occupied by basal cells and regions of glandular atrophy. These were also the areas of CD105 expression. CONCLUSIONS: Our results allow us to conclude that the TGF-beta3 family of cytokines, particularly the isoforms beta-2 and beta-3, seem to play a key role in the initiation, progression and transformation of tumoral cells inprostatic ADC. Future studies should be directed to the full understanding of the impact that these factors exert on tumoral behaviour, with an emphasis on those steps susceptible to therapeutic manipulation.

[Use of brachytherapy in the treatment of localized prostate cancer. Preliminary report]. / Uso de la braquiterapia en el tratamiento del cáncer de próstata localizado. Reporte preliminar.

OBJECTIVE: We emphasize the good results obtained by authors of the United States of North America and Europe using prostate brachytherapy in the treatment of localized prostate cancer. METHODS: We report 50 patients with stage T1c-T2c treated during the last twenty one months (September 2000, June 2001). Two groups were made--according to Gleason, PSA, local infiltration and percentage of tumor volume in the Biopsy--in low and high risk patients. We report the methodology used in the surgical procedure. RESULTS: We found the nadir of PSA was 0.5-1 in seven patients followed during eighteen months, and fifteen patients followed during twelve months. We had a failure in two patients. A reference is made about two patients with previously TURP and one with open prostatectomy, with very good post-operative results. Secondary effects are essentially irritative symptoms, well controlled by medical treatment. Four patients had acute urinary retention, one of them persistent. Normal erections were found in thirty five patients, and partial in fifteen, which had a very good respond to Sildenafil. Four cases had partial incontinence, currently only one persist during sleep. CONCLUSION: We have had very good results during the first twenty one months of treatment of cancer of the prostate with brachytherapy. In our opinion the procedure is a very valid option of treatment for this disease.

Expresión de los factores transformantes del crecimiento B2 y B3 en adenocarcinomas prostáticos / Expression of growth B2 and B3 transform factor in prostatic adenocarcinoma

Investigaciones llevadas a cabo sobre la biología y el desarrollo del carcinoma protático han constatado altos niveles de polipéptidos de TGF en el tejido prostático, así como las expresiones de las isoformas activas TGF-ß2, TGF-ß2 y Endoglina (CD105). Se revisaron 14 casos con diagnósticos de carcinoma prostático, durante el período comprendido entre enero de 1992a marzo del2001. Se obtuvieron datos clínicos de interés. Histológicamente, se tomó en cuenta el grado de histológico tumoral, la presencia de invasión perineural y/o vascular linfática. Del material incluido en parafina se realizó estudio inmunohistoquímico para antiTGF ß2, antiTGF ß3 y CD105.

Cirugía mínimamente invasiva de los diverticulos vesicales / Minimize surgery invasive of the vesicals diverticulum

Entre octubre 1994 y febrero 1996 se trataron cuatro pacientes con obstrucción urinaria baja (3 con hiperplasia prostática benigna y 1 con estenosis de uretra bulbar) que presentaban un total de nueve divertículos mayores de 3 cms de diámetro con cuello estrecho que dificultaba el vaciamiento y/o la presencia de litiasis en su interior. Se procedió invariablemente con el siguiente tratamiento: a)incisión con cuchilla de Collins en cuatro cuadrantes del cuello diverticular, b)electrocoagulación de la mucosa diverticular con rodillo;c)Resección transuretral de la próstata; uretrotomía endoscópica en un caso. El control se realizó endoscópicamente y por cistografía, obteniéndose el 85,7 por ciento de los divertículos (siete) y disminución pronunciada de la cavidad en los dos restantes. Los pacientes fueron dados de alta a las 48 horas y se retiró la sonda uretrovesical entre el sexto y octavo día. Se propone que el tratamiento endoscópico transuretral de los divertículos vesicales es un procedimiento seguro y efectivo. En el presente trabajo se presenta la técnica endoscópica y se realiza revisión de la literatura en la evolución del tratamiento del divertículo vesical.