[Laparoendoscopic single site (LESS) ureteral reimplantation.] / Reimplante ureteral laparoscópico por puerto único.

OBJECTIVE: To present in detail our surgical technique and to show our initial experience with ureteral reimplantation using the transumbilical LESS approach to treat patients with ureteral stenosis secondary to various diseases and surgical complications. METHODS: We performed 7 ureteral reimplantations from February 2012, using the multichannel Richard- Wolf (KeyPort) platform placed transumbilical by a small 2-2,5 cm transversal incision. We always use a 3.5 mm minilaparoscopy accessory trocar in the right iliac fossa, that is crucial to perform the laparoscopic suturing safely for the patient and in an optimal time. The etiology of ureteral lesions was: 1 endometriosis, 1 symptomatic ureterocele not responding to endoscopic treatment, 1 ureteral lesion after ureteroscopy for lithiasis, 1 ureteral lesion after radical prostatectomy and 3 gynecologic iatrogenic lesions (1 laparoscopically assisted vaginal hysterectomy, 2 radical hysterectomies with double anexectomy for cervix carcinoma). 5 ureteral reimplantations were left and 2 right sides. Before surgery, 5 patients had nephrostomy tubes inserted and the patient with endometriosis had a double J catheter. The patient with ureterocele did not require urinary diversion before the operation and endoscopic intraoperative catheterization was not feasible. RESULTS: We present the operative and postoperative results of the patients undergoing surgery. They had a mean age of 49.3 [28-78] years. Mean intraoperative estimated blood loss was 132.1 [100-250] ml, with no transfusions required. Mean operative time was 127.4 [120-210] minutes, with no conversions to laparoscopic or open surgery required. Mean hospital stay was 2.1 [2-3] days and all patients had drainage removed at 48 hours. There were minor Clavien-Dindo complications in one patient presenting urinary tract infection 10 days after the operation. All patients had double J catheters that were removed with a mean of 34.3 [30-45] days. Mean time for bladder catheter removal was 7.8 [7-10] días. With a mean follow up of 32.6 [14-54] months no ureteral stenosis recurrence has been observed. CONCLUSIONS: LESS ureteral reimplantation, in our initial experience, shows a low complication rate, similar to current laparoscopic series, offering less postoperative pain and abdominal wall aggression with great cosmetic results that are perceived by patients very positively, in addition to rapid recovery and return to normal daily life.

Reimplante ureteral laparoscópico por puerto único / Laparoendoscopic single site (LESS) ureteral reimplantation

OBJETIVO: Explicar de manera detallada nuestra técnica quirúrgica y mostrar nuestra experiencia inicial con la reimplantación ureteral utilizando el abordaje laparoendoscópico transumbilical por puerto único para tratar pacientes con estenosis ureteral producida por distintas patologías y complicaciones quirúrgicas. MÉTODOS: Se realizaron 7 reimplantaciones ureterales desde febrero de 2012, utilizando la plataforma multicanal de Richard-Wolf (KeyPort) colocada transumbilical mediante una pequeña incisión transversal de 2-2,5 cm. Utilizamos siempre un trocar accesorio de minilaparoscopia de 3,5 mm que se coloca en fosa iliaca derecha y que es fundamental para realizar la sutura laparoscópica de una manera segura para el paciente y en un tiempo óptimo. La etiología de las reimplantaciones ureterales fueron: 1 endometriosis, 1 ureterocele sintomático que no respondió al tratamiento endoscópico, 1 lesión ureteral post-ureteroscopia por litiasis, 1 lesión ureteral post-prostatectomía radical y 3 iatrogenias ginecológicas (1 histerectomía vaginal asistida por laparoscópica, 2 histerectomías radicales con doble anexectomía por Ca de cérvix). 5 reimplantaciones ureterales fueron del lado izquierdo y 2 del lado derecho. Previamente a la cirugía se realizó colocación de nefrostomía percutánea a 5 pacientes, y colocación de doble J a la paciente de la endometriosis. El paciente del ureterocele no precisó derivación urinaria previa a la cirugía y no se pudo cateterizar por endoscopia intraoperatoriamente. RESULTADOS: Se muestran los resultados peri y postoperatorios de los pacientes intervenidos que tenían una edad media de 49,3 [28-78] años. El sangrado medio intraoperatorio fue de 132,1 [100-250] ml, siendo la tasa de transfusión del 0%. El tiempo medio operatorio fue de 127,4 [120-210] minutos, no precisando ningún paciente reconversión a cirugía laparoscópica ni abierta. La estancia media fue de 2,1 [2-3] días y a todos los pacientes se les retiró el drenaje a las 48 horas. Hubo complicaciones menores de Clavien-Dindo en 1 paciente que presento infección urinaria a los 10 días de la cirugía. En todos los pacientes se dejó doble J que se retiró con una media de 34,3 [30-45] días. La media de retirada de sonda vesical fue de 7,8 [7-10] días. Con un seguimiento medio de 32,6 [14-54] meses no se ha objetivado recidiva de la estenosis ureteral en ningún paciente. CONCLUSIÓN: La reimplantación ureteral por puerto único, en nuestra experiencia inicial, muestra una tasa baja de complicaciones, similar a las series de laparoscopia actuales, ofreciendo menos dolor postoperatorio y agresión de la pared abdominal con unos resultados estéticos estupendos que son percibidos por los pacientes de manera muy positiva, además de una rápida recuperación e incorporación a la vida cotidiana

OBJECTIVE: To present in detail our surgical technique and to show our initial experience with ureteral reimplantation using the transumbilical LESS approach to treat patients with ureteral stenosis secondary to various diseases and surgical complications. METHODS: We performed 7 ureteral reimplantations from February 2012, using the multichannel Richard-Wolf (KeyPort) platform placed transumbilical by a small 2-2,5 cm transversal incision. We always use a 3.5 mm minilaparoscopy accessory trocar in the right iliac fossa, that is crucial to perform the laparoscopic suturing safely for the patient and in an optimal time. The etiology of ureteral lesions was: 1 endometriosis, 1 symptomatic ureterocele not responding to endoscopic treatment, 1 ureteral lesion after ureteroscopy for lithiasis, 1 ureteral lesion after radical prostatectomy and 3 gynecologic iatrogenic lesions (1 laparoscopically assisted vaginal hysterectomy, 2 radical hysterectomies with double anexectomy for cervix carcinoma). 5 ureteral reimplantations were left and 2 right sides. Before surgery, 5 patients had nephrostomy tubes inserted and the patient with endometriosis had a double J catheter. The patient with ureterocele did not require urinary diversion before the operation and endoscopic intraoperative catheterization was not feasible RESULTS: We present the operative and postoperative results of the patients undergoing surgery. They had a mean age of 49.3 [28-78] years. Mean intraoperative estimated blood loss was 132.1 [100-250] ml, with no transfusions required. Mean operative time was 127.4 [120-210] minutes, with no conversions to laparoscopic or open surgery required. Mean hospital stay was 2.1 [2-3] days and all patients had drainage removed at 48 hours. There were minor Clavien-Dindo complications in one patient presenting urinary tract infection 10 days after the operation. All patients had double J catheters that were removed with a mean of 34.3 [30-45] days. Mean time for bladder catheter removal was 7.8 [7-10] días. With a mean follow up of 32.6 [14-54] months no ureteral stenosis recurrence has been observed. CONCLUSIONS: LESS ureteral reimplantation, in our initial experience, shows a low complication rate, similar to current laparoscopic series, offering less postoperative pain and abdominal wall aggression with great cosmetic results that are perceived by patients very positively, in addition to rapid recovery and return to normal daily life

Results of simplified urethropexy in the recovery of continence after radical laparoscopic prostatectomy.

PURPOSE: To analyze the effectiveness of simplified urethropexy in the evolution of urinary incontinence after radical laparoscopic prostatectomy. PATIENTS AND METHODS: Between January 2007 and December 2008, 104 patients were included in a randomized trial to assess the effectiveness of simplified urethropexy. The simplified urethropexy technique was performed on conclusion of a urethrovesical anastomosis with running suture and, before cutting the suture material, a suture was applied using the same material with a needle through the pubic tubercle, tightening it and securing it with a Hem-o-lok. Fifty-one patients qualified for the trial in the simplified urethropexy group (group 1) and another 51 in the control group without urethropexy (group 2). Incontinence was defined as the lack of the need for protection for normal life, and the degree of continence was compared at 3, 6, and 12 months after surgery. RESULTS: Surgery lasted 141 minutes in group 1 and 139 in group 2 (NS). There were no secondary complications such as urine retention, osteitis pubis, or bladder perforation. After 3 months, 47.1% of patients in each group declared continence (NS). After 6 months, 72.6% of patients in group 1 and 66.7% in group 2 (P<0.05) declared continence. After 12 months, 92.2% of patients in group 1 and 84.3% in group 2 declared continence. CONCLUSIONS: In our experience, simplified urethropexy is a simple, nontime-consuming technique that shows a slight clinical improvement in continence within 6 and 12 months, without reaching significant differences with the Fisher Test. It would be necessary to perform a trial with a greater number of patients to confirm these data.

Feasibility of lymphadenectomy in laparoscopic radical cystectomy.

OBJECTIVES: The number of lymph nodes obtained through lymphadenectomy during radical cystectomy has prognostic and therapeutic value. We analyzed the number of nodes obtained during laparoscopic radical cystectomy to assess whether this approach allows satisfactory lymphadenectomy. METHODS: A total of 80 consecutive laparoscopic radical cystectomies with lymphadenectomy were performed by the same surgical team from 2005 to 2008. The male/female ratio was 5.7:1, the mean age was 65.3 years (range 47-87), and average body mass index was 26.7 kg/m(2) (range 20.6-40.1). Iliac-obturator lymphadenectomy up to the aortic bifurcation was performed after excising and pocketing the bladder. We analyzed the total number of lymph nodes identified by the pathologist and investigated a possible correlation with the variables presumably related to anatomic characteristics and other circumstances. RESULTS: The mean operative time of this step was 32 minutes (range 17-70). Minor vascular morbidity was present in 5 cases (6.25%). The average number of lymph nodes obtained was 22.3 (range 7-74, median 21). In 75 cases (93.8%), ≥10 nodes were obtained, and in 33 cases (41.2%), lymph node metastasis was diagnosed. No association or correlation was found in the number of nodes extracted regarding age, body mass index, or number of positive nodes. Also, no differences were found in association with gender, use of induction therapy, or the indication for cystectomy. CONCLUSIONS: Laparoscopic lymphadenectomy performed at radical cystectomy achieved an adequate number of lymph nodes. This technique did not entail an important increase in the duration of surgery. The complication rate was low. In experienced hands, laparoscopic lymphadenectomy is feasible and seems a secure oncologically correct procedure.

Surgical approach to a large left adrenocortical mass with associated tumour thrombosis of the left renal vein: preservation of the ipsilateral kidney.

A sixty-years-old male with diagnosis of a left adrenal mass (146 x 99 x 126 mm) with associated tumour thrombosis of the left renal vein with no clear signs of thrombosis of the inferior vena cava was admitted for elective surgery Finally an adrenalectomy and excision of tumour thrombus preserving the ipsilateral kidney was made. Despite of the complex vascular management, this kind of approaches allow to preserve normal renal function in patients with future nephrotoxic treatment like cisplatin.

Reparación laparoscópica de la fístula vesicovaginal (O’Connor laparoscópico) / Laparoscopic repair of the vesicovaginal fistula (laparoscopic O’Connor repair

Introducción: La causa más frecuente de fístula vesicovaginal en los países desarrollados es la histerectomía, mientras que en países del tercer mundo es el periodo relacionado con el trabajo del parto. Cualquier lesión iatrogénica quirúrgica implica dificultades añadidas de diversa índole en el momento de su resolución. Material y método: Comunicamos el primer caso de fístula vesicovaginal resuelta por vía laparoscópica realizada en nuestro centro. Presentamos el caso de una mujer de 50 años sometida a una histerectomía por vía abdominal, que presenta un cuadro compatible con fístula vesicovaginal. Es remitida a nuestro servicio tras un intento infructuoso de resolución por vía vaginal. Describimos el procedimiento laparoscópico de fistulorrafia vesicovaginal. Resultados: El procedimiento quirúrgico duró aproximadamente 3,5 h. La paciente inició tolerancia oral a las 48 h, recuperó el tránsito intestinal normal al quinto día y fue dada de alta al octavo día postoperatorio. Tras más de un año y medio de seguimiento, la paciente se encuentra asintomática. Conclusiones: La resolución por vía laparoscópica de la fístula vesicovaginal es perfectamente factible y segura y, siempre que reproduzcamos los principios que aplicamos en cirugía abierta, ofrece la misma tasa de éxito con la menor morbilidad posible (AU)

Introduction: The most frequent cause of vesicovaginal fistula in developed countries is hysterectomy, while in the third world it is related to time in labour. Any surgical iatrogenic trauma implies encountering added difficulties of various kinds when repairing the condition. Material and method: We report the first case of vesicovaginal fistula to be resolved laparoscopically in our department. The patient is a woman 50 years of age who had undergone an abdominal hysterectomy 8 months previously, and who presented a syndrome compatible with vesicovaginal fistula. She was referred to our division after an unsuccessful attempt at vaginal repair. We will now describe the laparoscopic vesicovaginal fistula repair procedure. Results: The surgical procedure lasted approximately 3 hours and 30 minutes. The patient began oral intake 48 hours after surgery, normal intestinal transit was restored by the 5thday, a cystography was performed on the 7th day, and the patient was discharged on the8th day. The patient remains asymptomatic after more than a year and a half. Conclusions: Laparoscopic resolution of vesicovaginal fistula is perfectly feasible and safe. If we consistently reproduce the principles applied in the open surgery, it offers the same success rate with the lowest possible morbidity (AU)

Radical laparoscopic salvage prostatectomy: medium-term functional and oncological results.

AIM: To analyze the surgical, functional, and oncological results of radical laparoscopic salvage prostatectomy in local postradiotherapy recurrence. PATIENTS AND METHODS: Between May 2005 and April 2007, we treated nine patients with radical laparoscopic salvage prostatectomy. Five patients had received prior treatment with brachytherapy and the other four with external radiotherapy. The average age of the patients was 59.3 years (range 51-68). The average preoperative prostate-specific antigen was 9.1 ng/mL (range 2.6-30). The average follow-up period was 26.8 months (range 15-39). RESULTS: The average duration of surgery was 170 minutes (from 120 to 240). There was no need to resort to open surgery or transfusions. There were no cases of rectal injuries. Four cases were pT2c, 1 pT3a, 3 pT3b, and 1 pT4a. The Gleason score was 7 in three cases, 8 in two cases, and 9 in another four. Two patients had nodal metastasis. Postoperative prostate-specific antigen was undetectable in seven of the nine patients. Two patients experienced biochemical recurrence 16 and 13 months after the surgery. After a minimum follow-up period of 15 months, they were free from recurrence. There were no cases of urethrovesical anastomotic stenosis. Three patients manifested severe incontinence (more than two diapers per day), which was corrected in two cases by implanting an artificial sphincter. The other six patients required 0 to 1 pads/day. Before the surgery, only one of the five potential patients maintained his erectile function. CONCLUSIONS: Radical laparoscopic salvage prostatectomy is a complex technique that seems to allow attaining high and long-lasting rates of biochemical remission in patients with local postradiotherapy recurrence. Although there is less morbidity in our series in comparison with the anastomotic stenosis and rectal injuries rate published in radical retropubic salvage prostatectomy, more extensive comparative studies are required to confirm this fact.

Laparoscopic repair of the vesicovaginal fistula (laparoscopic O'Connor repair).

INTRODUCTION: The most frequent cause of vesicovaginal fistula in developed countries is hysterectomy, while in the third world it is related to time in labour. Any surgical iatrogenic trauma implies encountering added difficulties of various kinds when repairing the condition. MATERIAL AND METHOD: We report the first case of vesicovaginal fistula to be resolved laparoscopically in our department. The patient is a woman 50 years of age who had undergone an abdominal hysterectomy 8 months previously, and who presented a syndrome compatible with vesicovaginal fistula. She was referred to our division after an unsuccessful attempt at vaginal repair. We will now describe the laparoscopic vesicovaginal fistula repair procedure. RESULTS: The surgical procedure lasted approximately 3 hours and 30 minutes. The patient began oral intake 48 hours after surgery, normal intestinal transit was restored by the 5th day, a cystography was performed on the 7th day, and the patient was discharged on the 8th day. The patient remains asymptomatic after more than a year and a half. CONCLUSIONS: Laparoscopic resolution of vesicovaginal fistula is perfectly feasible and safe. If we consistently reproduce the principles applied in the open surgery, it offers the same success rate with the lowest possible morbidity.