Sexual dysfunction after elective laparoscopic or endovascular abdominal aortic aneurysm repair in men.

INTRODUCTION: Infrarenal abdominal aortic aneurysm (AAA) repair can lead to ejaculation and erection troubles in men. There are few studies on sexual dysfunction after endovascular repair (EVAR) but they suggest less retrograde ejaculation than after open repair. We assessed the sexual dysfunction and ejaculation troubles after elective laparoscopic repair or EVAR. METHODS: We conducted a monocentric prospective study on 124 patients undergoing AAA repair between 2013 and 2015. Sexual function was evaluated using the IIEF-15 questionnaire and questions on ejaculation. RESULTS: Only 45 patients (36.3%) accepted to complete the IIEF preoperatively with 20-37.8% having preoperative sexual dysfunction. Among them, 21 (46.7%) accepted to complete the questionnaire at 3, 6 and 12 months. Mean age at inclusion was 65±5.6 years in the laparoscopic group and 77±10.5 years in the EVAR group (P=0.003). Erectile and sexual function were slightly improved at 12 months in the laparoscopic group (+1.4 for erectile score and +4.6 for IIEF score) with no significant difference (P=0.83 and 0.74) whereas 8 patients (61.5%) had persistent ejaculation troubles at 3 months. In the EVAR group, patients had moderate sexual dysfunction at baseline without improvement at 12 months, but only one patient reported ejaculation troubles. CONCLUSIONS: Most patients eligible for AAA repair present with baseline erectile and sexual dysfunction. Laparoscopic AAA repair provides no onset of erectile or sexual dysfunction but a global improvement after surgery. Ejaculation troubles are frequent and persistent at 1 year. However, EVAR treatment, doesn't allow recovering of sexual function at 1 year. LEVEL OF EVIDENCE: 4.

A Comprehensive Review of In Situ Fenestration of Aortic Endografts.

OBJECTIVE: Despite technical advances of fenestrated and branched endografts, endovascular exclusion of aneurysms involving renal, visceral, and/or supra-aortic branches remains a challenge. In situ fenestration (ISF) of standard endografts represents another endovascular means to maintain perfusion to such branches. This study aimed to review current indications, technical descriptions, and results of ISF. METHOD: A review of the English language literature was performed in Medline databases, Cochrane Database, Web of Science, and Scopus using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Sixty-seven relevant papers were selected. Thirty-three papers were excluded, leaving 34 articles as the basis of the present review. RESULTS: Most experimental papers evaluated ISF feasibility and assessed the consequences of ISF on graft fabric. Regarding clinical papers, 73 ISF procedures have been attempted in 58 patients, including 26 (45%) emergent and three (5%) bailout cases. Sixty-five (89%) ISF were located at the level of the arch, and eight (11%) in the abdominal aorta. Graft perforation was performed by physical, mechanical, or unspecified means in 33 (45%), 38 (52%), and two vessels (3%), respectively. ISF was technically successful in 68/73 (93%) arteries. At 30 days, two (3.4%) patients died in the setting of an aorto-bronchial fistula and an aorto-oesophageal fistula, respectively. No post-operative death, major complication, or endoleak was described as secondary to the ISF procedure. With follow-up between 0 and 72 months, four (6.9%) late deaths were noted, unrelated to the aorta. One (1.7%) LSA stent was stenosed without symptoms. CONCLUSIONS: Although there may be publication bias, multiple techniques were described to perform ISF with satisfactory short-term results. Long-term data remain scarce. Aortic endograft ISF is an off-label procedure that should not be used outside emergent bailout techniques or investigational studies. A comparison with alternative techniques of preserving aortic side branches is needed.

[Cystic lymphangioma: an unusual cause of lower limb lymphedema]. / Malformation lymphatique kystique : cause rare d'un lymphoedème unilatéral des membres inférieurs.

We report an unusual cause of unilateral lymphedema of the right limb rapidly increasing in a young woman. Ultrasonography ruled out the diagnosis of iliac deep venous thrombosis or extrinsic compression: the B mode scan revealed a mass located below the aortic bifurcation and along the iliac vessels, without any compressive effect. The lesion was heterogeneous associating both tissular and cystic aspects. The lower limb lymphoscintigraphy showed an interruption of the colloid circulation at the right iliac level. Computed tomography did not give any additional information. Magnetic resonance imaging before then after gadolinium showed typical aspects of cystic lymphangioma and confirmed the ultrasonography hypothesis. Considering that this tumor is benign, that surgery would be difficult because of the anatomic situation of the mass, and that post-operative involution of the edema is uncertain, the treatment was based on compressive stockings and regular follow up.

Totally laparoscopic tube graft bypass for infrarenal aortic aneurysm: a well-established surgical technique.

Abdominal aortic aneurysm (AAA) repair enters the field of laparoscopic surgery. Main advantage of laparoscopic AAA repair is to perform the gold standard endoaneurysmorraphy with a reduced surgical trauma. Since 2001, the technique has evolved and is now well-established. We describe the standard technique of totally laparoscopic endoaneurysmorraphy with tube graft interposition through a transperitoneal left retrorenal approach. Main technical points are discussed.

Undiagnosed aorto-caval fistula during total laparoscopic abdominal aortic aneurysm repair: a cause of conversion.

Total laparoscopic aortic repair is evolving and is now the technique of choice for the treatment of infrarenal abdominal aortic aneurysms (AAA) in our department. With growing experience, surgeons will be confronted with the same peroperative situations than open surgery. We report a case of total laparoscopic AAA repair with peroperative diagnosis of aorto-caval fistula (ACF).

Total laparoscopic abdominal aortic aneurysms repair.

AIM: The aim of the study was to describe our experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. METHODS: Between February 2002 and September 2004, we performed 49 total laparoscopic AAA repair in 45 men and 4 women. Median age was 73 years (range, 46-85 years). Median aneurysm size was 52 mm (range, 30-95 mm). ASA class of patients was II, III and IV in 16, 32 and 1 cases, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 47 patients. Seven patients were operated via a tranperitoneal left retrorenal approach and one patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 19 and 30 patients, respectively. Median operative time was 290 min (range, 160-420 min). Median clamping time was 81.5 min (range, 35-230 min). Median blood loss was 1800 cc (range, 300-6900 cc). Mortality was 6.1% (3 patients). In our early experience, two patients died of myocardial infarction. The 3rd death was due to a multiple organ failure. Thirteen major non lethal postoperative complications were observed in 9 patients (18%). Four patients had local/vascular complications, which required reintervention (8%). Nasogastric tube is now removed at the end of procedure. Median duration of ileus, return to general diet, ambulation and hospital stay were 2, 3, 3 and 10 days. With a median follow-up of 19 months (range, 8-39 months), complete recovery with patent graft was observed in 44 patients. Two patients needed a crossover femoral graft for one iliac dissection and one graft limb occlusion. CONCLUSIONS: These results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. It remains technically demanding and a previous training in videoscopic sutures is essential. Initial learning curve in laparoscopic aortic surgery with aortoiliac occlusive lesions is preferable before to begin laparoscopic AAA repair.

Total laparoscopic aortic surgery: transperitoneal direct approach.

OBJECTIVE: We describe the laparoscopic transperitoneal direct approach to the abdominal aorta. OPERATIVE TECHNIQUE: The patient is placed in the right lateral decubitus position, which allows dropping of the small bowel into right side of the abdomen. Anatomical exposure of the abdominal aorta follows the same steps as in open surgery. DISCUSSION: Laparoscopic transperitoneal direct approach allows a reproducible exposure of the abdominal aorta. This technique was useful when retrocolic and/or retrorenal approaches were not possible because of previous left nephrectomy.

Robotically assisted aorto-femoral bypass grafting: lessons learned from our initial experience.

OBJECTIVE: The da Vinci trade mark Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) is a computer-enhanced telemanipulator that may help to overcome some limitations of traditional laparoscopic instruments. This prospective study was performed to assess the safety and feasibility of robotically assisted aorto-femoral bypass grafting (AF). METHODS: Five patients undergoing elective AF were enrolled in this study. In three patients, a laparotomy of 6 cm was first performed, the aorta being exposed using an Omnitract degrees retractor. In two patients, aortic dissection was performed with laparoscopy, with the patient in a modified right lateral decubitus position. In all patients, the proximal anastomosis was attempted with the da Vinci trade mark system by a remote surgeon. The role of the assistant at the patient's side was limited to exposure, haemostasis and maintaining traction on the running sutures performed by the robot. Six weeks after the operation, all patients underwent a duplex scan of the graft. RESULTS: Mean operative time was 188 min. Robotically assisted aortic anastomoses were successfully completed in four out of five patients. In these four patients, adequate blood flow was observed within the graft with no need for conversion for haemostasis. In the fifth patient, despite an adequate laparoscopic aortic dissection, the anastomosis was impossible to perform due to external conflicts between the robotic arms. A conversion using conventional suture was successfully performed. No robot-related complications were noted. Six weeks after the operation, the duplex scans demonstrated a graft patency of 100%. CONCLUSION: Robotically assisted anastomoses are possible by their unique ability to combine conventional laparoscopic surgery with stereoscopic 3D magnification and ultra-precise suturing techniques due to the flexibility of the robotic-wristed instruments using different motion scaling of surgeon hand movements. In addition, prior training in laparoscopic aortic surgery is not necessary for surgeons to obtain the level required for suturing. Further clinical trials are needed to explore the clinical potential and value of robotically assisted AF.

[Features of prostatic cancer in French individuals of African-Caribbean origin]. / Caractéristiques des cancers prostatiques chez les français d'origine afro-antillaise.

OBJECTIVES: To evaluate the clinical, laboratory and histological characteristics of prostate cancer at the time of diagnosis and after radical treatment in various ethnically different patient groups. PATIENTS AND METHODS: Prostatic biopsies were performed in 466 consecutive patients because of an abnormal digital rectal examination and/or isolated elevation of PSA (greater than 3 ng/ml). In this series, 40 patients were Black and 426 were Caucasian. The other aspect of the study concerns 320 patients undergoing radical prostatectomy for stage T1 T2 prostatic tumour (25 Black, 295 Caucasian). In the biopsied group, we analysed mean age, mean PSA, mean cancer length on biopsies and mean Gleason score. In the operated group, we studied preoperative characteristics, histological stage, resection margin status, laboratory progression (PSA greater than 0.05 ng/ml) and time to progression. RESULTS: At the time of diagnosis, the mean age was 61.4 years (48-73) for Blacks and 65.2 years (42-87) for Caucasians (p < 0.05). The median Gleason score was 7 in the two groups. The PSA was 13.4 (1.7-105) ng/ml versus 14.4 (0.4-600) ng/ml, respectively. The mean percentage of invaded tissue on biopsies was 24% versus 18.8% and the mean percentage of positive biopsies was 53% versus 39%, respectively. In the operated group, capsular effraction rates were 39% in Blacks and 48.1% in Caucasians. Positive resection margin rates were 21.7% versus 36.6%, respectively. The laboratory progression rate with a mean follow-up of 33 months (6-126) was identical in the 2 groups (42.1% versus 41.1%), but the time to progression was shorter for Blacks (9 months versus 12.3 months). CONCLUSIONS: In this patient series, Black patients had the same laboratory profile as Caucasian patients at the time of diagnosis. However, they were younger at the time of discovery of the disease, had more positive biopsies and more tumour-invaded tissue on biopsies, and Black patients undergoing radical prostatectomy developed laboratory recurrence more rapidly.