Transvesical Laparoendoscopic Single-Site Management of Distal Ureter During Laparoscopic Radical Nephroureterectomy.

Objective: To describe the management of the distal ureter during radical nephroureterectomy with the transvesical laparoendoscopic single-site surgery (T-LESS) approach. Methods: Between January 2010 and October 2013, five patients underwent laparoscopic radical nephroureterectomy for upper urinary tract carcinoma (UTUC) with the T-LESS approach. Patients were placed in the supine position. A 2.5-cm skin incision was made in the line between the pubis and the umbilicus. The bladder was identified and a multiport was inserted into the bladder. The patients were repositioned to a lateral decubitus position; pneumovesicum was established and the ureteral openings were identified. We marked the bladder cuff with electrocautery all the way through to the extravesical fat. The bladder defect was sealed with sutures. After checking for any leak or bleeding, the multiport was removed and the bladder was closed. At this point, we continued with nephrectomy by standard laparoscopy or LESS. A 18F Foley catheter was placed into the bladder. Results: The mean age was 70 years (range 58-81 years), the mean operative time was 198 minutes (range 115-390 minutes), the mean time for the management of the distal ureter was 35 minutes (range 27-45 minutes), the mean estimated blood loss was 234 mL (range 60-850 mL), and the mean hospital stay was 3.8 days (range 2-8 days). In all patients the bladder cuff was free of disease. Conclusion: The transvesical laparoendoscopic single-site approach to the distal ureter for UTUC appears safe and reproducible, with faster closure of the bladder defect and improved cosmesis.

Robotic simple prostatectomy plus panniculectomy and Giant umbilical hernia repair.

INTRODUCTION: Simple prostatectomy is the gold standard for prostates >80 grams, robotic system has proven to help into speed the recovery of the patient and in morbid obesity the advantages of the robotic system can help to perform a successful surgery. CASE: 80 years old male with morbid obesity (BMI 45) and several other comorbidities, with history of an umbilical hernia and obstructive lower urinary tract symptoms in acute urinary retention. PSA was 7 ng/dl, DRE demonstrates a >100gr prostate gland. A robotic simple prostatectomy, urethropexy, umbilical hernia repair and panniculectomy in Fleur-de-Lis was performed. RESULTS: Operative time (OT) and estimated blood loss (EBL) were 438 min and 160 ml respectively. A JP drain was placed in the pelvis and 2 additional were left in the abdominal cavity with several Penrose drains. No immediate or intraoperative complications were observed. The length of stay (LOS) was 6 days without complications. Pathology report showed prostate of 304gr and benign prostatic tissue. DISCUSSION: In patients with multiple comorbidities robot-assisted surgery provides advantages of shorter LOS, EBL, less transfusion and lower rate of complications. In patients with morbid obesity where the increased girth makes difficult the open approach, robotic surgery is an ideal way to provide definitive treatment; concomitant, Fleur-de-Lis panniculectomy can correct the abdominal contour in both vertical and horizontal orientation at the same time that provides a better plane for trocar insertion, an accurate location of the needle tip and a proper position of the remote center decreasing the possible complication of port placement.

Complications of robotic surgery in urological diseases: are we using standardized methodology to report complications?

PURPOSE OF REVIEW: The current data on complications reporting related to robot-assisted procedures (RAPs) in the urology literature are not comparable and do not use a validated classification. In this review, findings from various studies reporting positive and negative outcomes will be outlined. RECENT FINDINGS: Robotic procedures have outcomes similar to open and laparoscopic techniques but generally cause fewer adverse events. However, the lack of standards for presenting surgical morbidity related to RAP leads to underreporting of surgical complications, makes comparisons of surgical outcomes difficult and prevents adequate knowledge about the outcomes of procedures. SUMMARY: Although a reasonable number of positive outcomes of RAP have been reported in the literature, the extent of underreporting with this process is unknown. Further research and the development of a validated classification for reporting surgical complications will facilitate a better understanding of the actual outcomes.

Laparoscopic anatrophic nephrolithotomy: developments of the technique in the era of minimally invasive surgery.

BACKGROUND AND PURPOSE: The complete removal of the stone is the ultimate goal in management, a result that might not be attained even after several sessions of percutaneous nephrolithotomy (PCNL) and/or extracorporeal shockwave lithotripsy (SWL) and/or retrograde intrarenal surgery (ureteroscopy). The objective of this study is to assess our technique of anatrophic nephrolithotomy, with decreased renal ischemia and reduced patient morbidity. PATIENTS AND METHODS: From 2007 to 2010, we performed eight anatrophic laparoscopic nephrolithotomies in adult patients with staghorn renal calculus. The mean patient age was 49 years (range 35-62 y). The mean stone size was 53 mm (range 35-70 mm). All patients had complex renal calculi, with stones occupying more than 80% of the caliceal system. In all cases, a Double-J stent was placed before surgery. After clamping the hilum, the incision was made laterally and longitudinally through full thickness of cortex using a laparoscopic scalpel. A running cortical suture was performed with Hem-o-lok reinforcement. Renal function was assessed in three patients, using renography with technetium-99m-diethylenetriaminepentacetic acid (99mTc-DTPA), before and 3 months after the surgery. RESULTS: Procedures for all patients were completed laparoscopically. The mean operative time was 142.5 minutes, and the mean warm ischemia time was 20.8 minutes. The estimated blood loss was 315 mL. The hospital stay average was 3.5 days. Only one patient had a complication--a vascular fistula with permanent postoperative hematuria. This patient subsequently underwent successful endovascular embolization. Residual stones were identified in 37% of cases (three patients) during follow-up imaging at 15 days. There were minimal changes on serum creatinine values. CONCLUSIONS: Laparoscopic surgery is feasible when anatrophic nephrolithotomy is indicated. This technique minimizes the barriers of an open flank incision, while achieving excellent stone-free rates. This minimally invasive technique should be considered for complex stones that would necessitate multiple renal access tracks and secondary procedures.

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.

Assay standardization bias: different prostate cancer detection rates and clinical outcomes resulting from different assays for free and total prostate-specific antigen.

OBJECTIVES: Numerous commercial assays are available for measuring total and free prostate-specific antigen (PSA) levels in serum. These assays can be referenced to different laboratory standards, and interassay variability occurs. Patients and physicians might be affected by the variability between PSA assays that results from the use of different PSA standards. METHODS: We prospectively compared the free and total PSA measurements obtained using two commercially available PSA assays in 103 participants from a prostate cancer screening program in Caracas, Venezuela. We recommended biopsy to men with a total PSA level of 3 to 10 ng/mL and a free/total PSA ratio of 20% or less with either assay. We compared the sensitivity, specificity, and concordance index between the two assays to assess the effects of interassay variability on the cancer detection rate and clinical outcomes. RESULTS: Although the total PSA results were similar between the assays, the free PSA level was significantly greater with one assay. Therefore, the free/total PSA ratio was discordant between the two assays, resulting in different biopsy recommendations and cancer detection rates. CONCLUSIONS: Using a free/total PSA ratio of 20% or less as the threshold for biopsy, the differences in assay sensitivity and specificity for detecting prostate cancer are significant. Commercially available assays for PSA and its derivatives are not necessarily interchangeable, and these differences might lead to different clinical outcomes. When using free and total PSA measurements to make clinical decisions, patients and physicians should be aware of the potential standardization bias and which assay is being used.

Estudios sobre las condiciones de vida de los aborígenes

Antecedentes de la colonia Aborigen "Chaco". Marco geográfico. Demografía. Marco Social. Salud. Relación con la administración. Declaración de principios

Estudios sobre las condiciones de vida de los aborígenes

Antecedentes de la colonia Aborigen "Chaco". Marco geográfico. Demografía. Marco Social. Salud. Relación con la administración. Declaración de principios