Does site of specimen extraction affect incisional hernia rate after robot assisted laparoscopic radical prostatectomy?

BACKGROUND: Robot assisted laparoscopic radical prostatectomy (RALP) spread in the last decade as a minimally invasive alternative to open radical prostatectomy for men with localized prostate cancer. It is associated with excellent surgical, functional and oncological results with less postoperative pain and shorter convalescence. Anyway, the development of an incisional hernia (IH), may negate known benefits as it can lead not only to bothersome symptoms but also to severe complications, such as bowel obstruction, strangulation and perforation. Port-site or extraction site hernias, whose incidence rate is underdiagnosed, have become more commonly after minimally invasive surgery; but IH rate after robot-assisted radical prostatectomy has not been well characterized. This study aimed to evaluate the impact of extraction-site location (vertical supra-umbilical incision versus an off-midline incision) on incisional hernia rates in robotic prostatectomy. MATERIALS AND METHODS: We included in the study 800 patients undergone RALP, 400 with a supra-umbilical incision for specimen extraction and 400 with off-midline incision. All were followed up for at least 3 years. The main study end point was IH occurrence at the extraction site (midline versus off-midline). RESULTS: IH rate for the entire series was 4.75%, in particular 5% for the midline group and 4.5% for the off-midline group. The hernias were diagnosed at a mean of 20.2 and 18.2 months after surgery, respectively in the two groups. There was no statistically significant differences in baseline characteristics; anyway larger prostate weight, wound infection and history of prior cholecystectomy were associated with higher proportion of IH. CONCLUSION: Extraction site hernias are a rare but a potentially serious complication following RALP. In our series, the midline extraction doesn't result in a significantly higher IH rate in comparison with the off-midline extraction site.

Enucleación con láser de tulio (ThuLEP) frente a resección transuretral de la próstata en solución salina (TURis): un ensayo prospectivo aleatorizado para comparar resultados intra y postoperatorios tempranos / Thulium laser enucleation (ThuLEP) versus transurethral resection of the prostate in saline (TURis): A randomized prospective trial to compare intra and early postoperative outcomes

Objetivo: Comparar los resultados clínicos intra y postoperatorios tempranos entre la enucleación transuretral con láser de tulio de la próstata (ThuLEP) y la resección bipolar transuretral de la próstata (TURis) para el tratamiento de la hiperplasia prostática benigna (HBP) en un ensayo prospectivo aleatorizado. Métodos: El estudio aleatorizó a 208 pacientes consecutivos con HBP a ThuLEP (n = 102) o TURis (n = 106). Para todos los pacientes se evaluaron preoperatoriamente en cuanto a pérdida de sangre, tiempo de cateterización, volumen de irrigación, estancia hospitalaria y tiempo operatorio. A los 3 meses después de la cirugía también fueron evaluados por la International Prostate Symptom Score (IPSS) el flujo máximo (Qmáx) y el volumen de residuo posmiccional (RPM). Resultados: Los pacientes en cada brazo de estudio no mostraron diferencias significativas en los parámetros preoperatorios. En comparación con TURis, ThuLEP tuvo el mismo tiempo quirúrgico (53,69±31,44 vs 61,66±18,70min; p = 0,123), pero resultó en menos disminución de la hemoglobina (0,45 vs 2,83g/dl, p = 0,005). ThuLEP también necesitó menos tiempo de cateterización (1,3 vs 4,8 días, p = 0,011), volumen de irrigación (29,4 vs 69,2l; p = 0,002) y estancia hospitalaria (1,7 vs 5,2 días, p = 0,016). Durante los 3 meses de seguimiento, los procedimientos no demostraron una diferencia significativa en Qmáx, IPSS, RPM y ECDV. Conclusión: ThuLEP y TURis alivian los síntomas del tracto urinario inferior igualmente, con alta eficacia y seguridad. ThuLEP fue estadísticamente superior a TURis en la pérdida de sangre, el tiempo de cateterización, el volumen de irrigación y la estancia hospitalaria. Sin embargo, los procedimientos no difirieron significativamente en Qmáx, IPSS, RPM y ECDV a través de 3 meses de seguimiento

Objective: To compare clinical intra and early postoperative outcomes between thulium laser transurethral enucleation of the prostate (ThuLEP) and transurethral bipolar resection of the prostate (TURis) for treating benign prostatic hyperplasia (BPH) in a prospective randomized trial. Methods: The study randomized 208 consecutive patients with BPH to ThuLEP (n = 102) or TURis (n = 106). For all patients were evaluated preoperatively with regards to blood loss, catheterization time, irrigation volume, hospital stay and operative time. At 3 months after surgery they were also evaluated by International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and postvoid residual urine volume (PVR). Results: The patients in each study arm each showed no significant difference in preoperative parameters. Compared with TURIS, ThuLEP had same operative time (53.69±31.44 vs 61.66±18.70 minutes, P = .123) but resulted in less hemoglobin decrease (0.45 vs 2.83g/dL, P = .005). ThuLEP also needed less catheterization time (1.3 vs 4.8 days, P = .011), irrigation volume (29.4 vs 69.2 L, P = .002), and hospital stay (1.7 vs 5.2 days, P = .016). During the 3 months of follow-up, the procedures did not demonstrate a significant difference in Qmax, IPSS, PVR, and QOLS. Conclusion: ThuLEP and TURis both relieve lower urinary tract symptoms equally, with high efficacy and safety. ThuLEP was statistically superior to TURis in blood loss, catheterization time, irrigation volume, and hospital stay. However, procedures did not differ significantly in Qmax, IPSS, PVR, and QOLS through 3 months of follow-up

Thulium laser enucleation (ThuLEP) versus transurethral resection of the prostate in saline (TURis): A randomized prospective trial to compare intra and early postoperative outcomes. / Enucleación con láser de tulio (ThuLEP) frente a resección transuretral de la próstata en solución salina (TURis): un ensayo prospectivo aleatorizado para comparar resultados intra y postoperatorios tempranos.

OBJECTIVE: To compare clinical intra and early postoperative outcomes between thulium laser transurethral enucleation of the prostate (ThuLEP) and transurethral bipolar resection of the prostate (TURis) for treating benign prostatic hyperplasia (BPH) in a prospective randomized trial. METHODS: The study randomized 208 consecutive patients with BPH to ThuLEP (n=102) or TURis (n=106). For all patients were evaluated preoperatively with regards to blood loss, catheterization time, irrigation volume, hospital stay and operative time. At 3 months after surgery they were also evaluated by International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and postvoid residual urine volume (PVR). RESULTS: The patients in each study arm each showed no significant difference in preoperative parameters. Compared with TURIS, ThuLEP had same operative time (53.69±31.44 vs 61.66±18.70minutes, P=.123) but resulted in less hemoglobin decrease (0.45 vs 2.83g/dL, P=.005). ThuLEP also needed less catheterization time (1.3 vs 4.8 days, P=.011), irrigation volume (29.4 vs 69.2 L, P=.002), and hospital stay (1.7 vs 5.2 days, P=.016). During the 3 months of follow-up, the procedures did not demonstrate a significant difference in Qmax, IPSS, PVR, and QOLS. CONCLUSION: ThuLEP and TURis both relieve lower urinary tract symptoms equally, with high efficacy and safety. ThuLEP was statistically superior to TURis in blood loss, catheterization time, irrigation volume, and hospital stay. However, procedures did not differ significantly in Qmax, IPSS, PVR, and QOLS through 3 months of follow-up.

Proposal for a "European Scoring System for Laparoscopic Operations in Urology".

PURPOSE: To propose a scoring system of difficulties for the most currently performed laparoscopic procedures in urology. MATERIALS AND METHODS: Each current laparoscopic procedure has been evaluated according to three different criteria: technical difficulty, operative risk and the attention required. Each criterion is scored from 1 (minimal impact of the criteria) to 7 (maximal impact of the criteria). The sum of the 3 criteria is used to classify each operation according to an increasing level of global difficulty, classified into 6 levels: easy (E: sum of criteria between 3 and 5), slightly difficult (SD: sum of criteria between 6 and 8), fairly difficult (FD: sum of criteria between 9 and 11), difficult (D: sum of criteria between 12 and 14), very difficult (VD: sum of criteria between 15 and 17), extremely difficult (ED: sum of criteria greater than 18). RESULTS: Procedures currently performed by laparoscopy have been selected for evaluation according to the above criteria, and retrospectively validated by European experts in laparoscopic urology according to their experience and the international literature. CONCLUSION: This proposal of a scoring scale system is a basis for discussion, teaching and learning of urological laparoscopy. By necessity, this scale is evolving and will be regularly reconsidered and updated every 5 years.

[Urologic laparoscopy in day hospital]. / Laparoscopia urologica in Day Hospital.

Thanks to the less invasiveness that is the limitation of the surgical trauma, the utilization of laparoscopic techniques for managing a wide range of urological disorders has vastly expanded over the past five years. The advantages of less postoperative pain, shorter convalescence and decreased analgesic use collide with the high costs and the necessity of a proper training. Few cases are reported in the literature about urological laparoscopic procedures performed on an outpatient basis. This is due to the requirement of the general anesthesia in most cases with prolonged operative and anesthesiological times. Urological laparoscopic procedures are applicable on an outpatient basis only if the length of the surgery is less than two hours and the patients are able to collaborate and without concurrent medical problems. Therefore we think that the urological laparoscopic diagnostic procedures feasible on an outpatient basis could be: pelvic lymphadenectomy, identification of intra-abdominal testis and intersex, renal biopsy. Varicocelectomy, intra-abdominal orchiectomy, renal cyst resection, pelvic lymphocelectomy and bladder neck suspension can be performed as same-day surgery. We emphasize that the appropriate patient selection is critical: the ability of the patient and his family to care for the patient at home following surgery is of paramount importance in the decision to proceed with outpatient surgery. The availability of appropriately trained and experienced doctors and nurses are crucial for the potential postoperative complications.

Long-term results of intrarenal surgery for branched calculi: is such surgery still valid?

OBJECTIVE: To evaluate whether intrarenal surgery for branched calculi remains valid in the light of current new techniques, e.g. percutaneous nephrolithotomy and extracorporeal shockwave lithotripsy. PATIENTS AND METHODS: Between January 1978 and October 1984, 44 patients (24 male and 20 female, mean age 42.5 years, range 14-66) underwent complex surgery for large stones, requiring opening of the renal pelvis and a transparenchymal approach to the calices; 47 renal units were operated in 49 procedures. The evaluation before surgery included creatinine and blood nitrogen levels, blood pressure measurement, urine culture, abdominal plain X-ray (44 patients), intravenous urography (42) and isotopic renography with renal scintigraphy (five). Renal lithiasis was categorized and all patients underwent extended pyelolithotomy with a transparenchymal approach, achieved by partial nephrectomy (six patients), radial paravascular nephrotomy (10), posterior lower nephrolithotomy (29), resection of the posterior segment (two), and posterior segmentotomy and reconstruction (2); 16 operations were performed under ischaemia. In October 1996, the patients were clinically evaluated by serum creatinine levels (42), urine cultures (42), abdominal plain X-ray (42), IVU (34), isotopic renography (eight), renal ultrasonography (eight) and blood pressure measurement (44). The mean follow-up was 14.8 years. RESULTS: The major postoperative complications were; residual stones (six patients), fistula with ureteric stenosis (one, with a permanent nephrostomy), toxic temporary hepatic failure (one), femoral arterial embolism (one, resolved using a Fogarty catheter) and recurrent large stones (two, operated 1 and 5 years later). From 1984 to 1996, 19 patients had recurrent stones and two underwent dialysis. In October 1996, the renal function of 47 renal units was stable or normal in 36 (77%), reduced in seven (15%) and lost in four (8%); 24 patients were hypertensive (12 preoperatively), nine have urinary tract infection, three are positive for hepatitis B or C virus, and lithiasis has recurred in 15 renal units. CONCLUSIONS: Intrarenal surgery, conducted using modern anatomical guidelines, was an effective treatment for renal branched stones. The long-term results are satisfactory after appropriate correction of the urinary tract, with the consequent prevention of stasis and chronic infection. The definitive comparison between surgical and combined endoscopic/extracorporeal methods will only become clear when there is a comparable follow-up. Currently, surgery remains preferable in patients with giant calculi, a small pelvis and prevalent calyceal development.

Transurethral electrovaporization of the prostate vs. transurethral resection. Results of a multicentric, randomized clinical study on 150 patients.

AIM OF THE STUDY: To evaluate clinical, urodynamic efficacy and safety of TURP and TVP in patients with symptoms due to obstructive benign prostatic hypertrophy with a prospective multicentric randomized study. MATERIALS AND METHODS: 150 patients with BPH, urodynamically obstructed, were randomized to receive TURP or TVP. At the end of the recruitment phase, 80 patients underwent TURP and 70 patients underwent TVP. Patients were clinically evaluated by the I-PSS score at months 0, 1, 3, 6 and 12. Preoperative evaluation included complete blood routine examination, PSA, transrectal ultrasound and pressure/flow studies. Pressure/flow studies were also performed after 3 months. RESULTS: There was no statistical difference between groups in any of the preoperative parameters. All patients were considered urodynamically obstructed at preoperative pressure studies. As for catheter days and hospitalization days, statistical differences between TVP and TURP were found; catheter days were 2.71 days (SE 0.12) in the TURP group vs. 1.9 (SE 0.24) in the TVP group (p < 0.000). Hospitalization was 4.7 days (SE 0.22) after TURP and 3.9 days (SE 0.24) after TVP (p < 0.000). Mean preoperative I-PSS score was 18.84 and 18.19 in the TVP and TURP groups, respectively. At 3, 6 and 12 months, IPSS was 5.52 and 5.50, 3.77 and 4.94, 3.52 and 4.04 for TURP and TVP, respectively. Mean preoperative peak flow rate (PFR) was 8.78 and 7.26 ml/s for TURP and TVP, respectively; after 3, 6 and 12 months, PFR was 19.21 and 18.8, 20.77 and 20.13, 20.30 and 20.31 ml/s, respectively. After 3 months, 6 patients in the TURP group (7.5%) and 7 patients in the TVP group (10%) were borderline obstructed. 1 patient in the TVP group (1.4%) was still obstructed and underwent TURP. As for complications, 4 patients (5.7%) in the TVP group had stress urinary incontinence after 12 months vs. 1 (1.25%) in the TURP group. DISCUSSION: The present study clearly demonstrates that TVP is as effective as TURP in relieving urinary obstruction due to BPH, it offers some advantages in terms of catheterization and hospital stay, but at the price of a higher incidence of postoperative urine incontinence. Technical improvements might solve this problem in the future, perhaps combining TVP with TURP of the apical tissue.

[Conservative therapy in renal carcinoma: follow-up]. / Terapia conservativa nel carcinoma renale: follow up.

Due to the increasing use of sophisticated imaging techniques, up to 30% of diagnosed renal cell carcinoma (RCC) are asymptomatic and diagnosed incidentally. Getting the cue from our personal survey of conservative renal surgery for renal cell carcinoma with a cancer specific survival of 95.5% after a mean follow up of 32.7 months, a review of the literature is illustrated: numerous studies have documented the technical success rate with this approach as well as long term disease free survival, comparable to that obtained by radical nephrectomy, in patients with unilateral, small, low stage tumors and normal opposite kidney. Patient selection is of extreme importance in case of partial resection in the presence of a normal contralateral kidney. The tumor must be < 3-4 cm, solitary, well delineated on CT, without invasion of the perinephric far or pyelocaliceal system (T1 and T2), easily resectable with at least 1 cm of healthy parenchyma. Only well informed patients who agree on a careful follow up after surgery can be candidates for kidney sparing surgery. In case of imperative surgery the follow up must be strict and personified for every single patient. Those patients who underwent a partial nephrectomy in presence of a normal contralateral kidney should be monitored with a conventional follow up monitored in order to detect an eventual local recurrence: 12 monthly ultrasonography and contrast enhanced CT scan alternately every 6 months for the first five years after surgery and then lifelong once a year by echography and/or CT scan.

Variation in nocturnal urinary excretion of melatonin in a group of patients older than 55 years suffering from urogenital tract disorders.

Melatonin (MLT) is directly or indirectly related to cell growth (both of normal and neoplastic cells), to the immune system stimulation and to the endocrine system modulation. This controlled study was carried out to evaluate urinary excretion of MLT in patients suffering from urogenital tract disorders. Eighty-one patients affected by urogenital disorders were divided in two groups (neoplastic and non-neoplastic) and urinary excretion of MLT was evaluated. Mean diurnal (from 8 a.m. to p.m.) urinary excretion of MLT was 4.97 + 6.08 pg/12 h in non-oncologic patients and 4.82 + 6.21 pg/12 h in oncologic patients (p = 0.50). Mean nocturnal (from 8 p.m. at 8 a.m.) urinary excretion of MLT was 11.97 + 9.34 pg/12 h in non-oncologic patients while in oncologic patients it was 7.86 + 8.95 pg/12 h. Statistically significant variation in nocturnal urinary excretion of melatonin was observed in oncologic patients (p = 0.022) versus non oncologic patients.

[100 orthotopic neobladders in men after cystectomy: a 5-year experience]. / 100 neovesciche ortotopiche nel maschio cistectomizzato: esperienza di 5 anni.

Urethral bladder substitution is traditionally suggested to good prognosis cystectomized patients. In our series this diversion was chosen for all but the salvage cystectomized men. Between the 1st of February 1991 and the 30th of April 1996, one hundred consecutive men underwent lower urinary tract reconstruction after radical cystoprostatectomy for bladder cancer. An orthotopic ileal neobladder was constructed (in 84 cases according to Kock's technique and in 16 to Studer's technique). Total early complication rate was 29% (29/100), including one perioperative death due to sepsis (mortality rate 1%). 13 patients required surgery (6 retroperitoneal hematomas, 2 wound dehiscences, 1 urinary fistula, 1 lymphocele, 1 rectal-neobladder fistula, 1 rectal-cutaneous fistula, 1 necrosis of the terminal ureter). The late complication rate was 19% (19/100); in 8 cases reparative surgery was required (1 mechanical ileus, 2 bladder neck stenoses, 3 stenoses of the ureteral anastomosis, 2 laparoceles). Four patients were lost at the follow-up; out of the 96 remaining patients only 85 were evaluable for continence: continence during the day was achieved in a period between there to six months in 78 patients (91.7%); night continence was achieved with planned awakenings in 60 patients (70.5%). Eight patients recovered potency, another 7 had successful intercourses after PGE1 intracavernous injection. Renal function based on creatinine value was mildly impaired in 5/78 evaluable patients (6.4%) (peak creatinine 2.8 mg%). In 29 patients tumour progression was observed (29%): 9 pelvic and 20 metastatic. Among the latter 2 urethral recurrences were observed (2%). Twenty-four patients died for metastatic cancer, one for primitive lung cancer, one patient for postoperative septic shock. Adjuvant chemotherapy was administered in 11 patients without complication with an indwelling catheter in the neobladder to avoid drug reabsorption. Four patients showed complete response (2 are alive after a mean of 12 months), 6 were non responders and 1 had a partial response. In our series the ileal neobladder is a feasible method of urinary diversion when urethral cancer involvement is ruled out. Early and late complications are proportionally decreasing with experience and overall continence is satisfactory. The fate of the neobladder depends on both the technique and patient's compliance. Only educated patients can cope successfully with neobladder diversion without major complications. All the patients operated for non salvage cystectomy deserve to be diverted with a continent urethral bladder substitution.

Is laparoscopy a worthy method to treat varicocele? Comparison between 160 cases of two-port laparoscopic and 120 cases of open inguinal spermatic vein ligation.

Because it is still a puzzling debate whether ligation of a unilateral varicose spermatic vein is worth performing by laparoscopy, even with the two-port technique, we conducted a study in which 280 patients with palpable left varicoceles were treated with spermatic vein ligation either by open surgery (120 patients) or by laparoscopy (160 patients). The inclusion criteria were the same for each group, and the two groups were homogeneous in preoperative clinical features and patient characteristics. The clinical outcomes were compared 6 months after surgery, and the costs of each treatment were analyzed. The procedures showed the same effectiveness and intraoperative safety. Open surgery scored a shorter operating time, whereas hospitalization was significantly shorter in the laparoscopic group. Postoperative complications occurred more frequently in the open surgery than in the laparoscopic group (7.5% and 0.6%, respectively). Of the patients treated, 197 were eligible for seminal analysis: 82 and 115 in the open surgery and laparoscopic groups, respectively. Significant improvement in seminal analysis was recorded in both groups, whereas no difference was found between the groups. Laparoscopy costs about 60% more than open surgery. It can thus be concluded that laparoscopy is not a worthy method to treat unilateral varicocele.

[T1G3 of the bladder: our experience]. / T1G3 della vescica: la nostra esperienza.

From June 1991 to June 1995 we treated 20 patients affected by T1 G3 TCC of the bladder, 18 men and 2 women, with a mean age of 65.1 years (46-71). In 11 patients the disease was monofocal, with diameter of the tumor under 3.5 cms; in 5 patients monofocal with diameter of the tumor over 3.5 cms; in 1 patient multifocal and in 3 patients complex (mono or multifocal associated with CIS). The 11 patients with monofocal disease under 3.5 cms were treated with TUR-B, the other 9 (all males) were submitted to radical cystectomy with OINB diversion as first choice treatment. The mean follow up (all patients) was 3.2 years (6 months-14 years). Out of the patients of the former group only 3 did not show any relapse, the other 8 showed multiple relapses or metachronous tumors: 5 were treated with TUR-B+BCG, 3 were cystectomized. The patients submitted to cystectomy as first choice treatment did not show any progression of the disease after a mean follow-up of 19.8 months.

[Physiopathology of BPH obstruction]. / Fisiopatologia dell'ostruzione da IPB.

The underlying BPH related mechanisms of outlet obstruction are outlined (modification of the shape of the bladder neck, failure of funnel formation, geometric variations of the urethra, alpha 1 adrenoceptors mediated sympathetic hyperactivity at the level of the lower genito-urinary tract). Bladder voiding dysfunction in response to prostate obstruction is also discussed and correlated to ultrastructural patterns and clinical symptoms. Finally, a pathogenetic mechanism for detrusor overactivity in obstructed bladder is suggested.

[Alpha blockers, TUS-P and TUR-P in the treatment of benign prostatic hypertrophy. A comparison using multivariate statistical analysis]. / Alfa-litici, TUS-P, TUR-P nel trattamento dell'IPB. Confronto con analisi statistica multivariata.

To evaluate the effectiveness of Alpha-blockers, TUI-P and TUR-P in the treatment of obstruction due to BPH, 50 patients, never before treated, were considered. Fifteen were treated with alfuzosin chlorhydrate 7.5 mg/day for four months, 15 were submitted to TUI-P and 20 to TUR-P. In all patients linear purr was carried out before treatment and was repeated from 60 to 90 days after intervention in surgical patients and during the fourth month of treatment in patients treated with alfuzosin. The data obtained were analyzed with the T-test both for dependent and independent samples. The results show that Alpha-blocker contain an increase in maximal flow, without decreasing bladder voiding pressures. On the contrary TUI-P and TUR-P, besides the increase in maximal flow obtain a significant reduction of bladder pressures. The conclusions are the following: maximal flow alone is not a sufficient parameter to evaluate the work of the bladder, the entity of the obstruction and the effectiveness of the therapy. The treatment with Alpha-blockers is unable to reduce the obstruction due to BPH. TUI-P and TUR-P realize an effective deobstruction. Under the same deobstructing effect TUR-P assures a better voiding performance by obtaining higher flow values.

Retroperitoneoscopy.

From October 1992 to June 1994, 12 nephrectomies (all for benign diseases), one nephropexy and 7 adrenalectomies (one pheochromocitoma, three adenomas, one cyst) were performed. In all the cases the retroperitoneal working space was created with direct CO2 insufflation (without balloon) with the patient in prone position. Four 10-12 mm ports were always inserted in the lumbar area. Eighteen procedures were successful (90%), 2 failed (one nephrectomy and one adrenalectomy) and underwent open surgery. Twelve procedures were carried out with the patients in prone position, six (one nephropexy and 5 nephrectomies) were performed with the patients in lateral de cubitus. The removal of organs was managed either through an enlarged port (phi 2 cm.) or by joining vertically the stabs of the two ports lateral to the sarcospinalis muscle. The average operative time was 4.10 hours) range 2.30-5.20). Both CO2 absorption and blood loss were negligible. No major complications were observed. Postoperative pain never required medications. All patients were able to stand on the 1st postoperative day. Mean postoperative hospitalisation was 4 days. Direct retroperitoneal approach provides optimal access for laparoscopic renal, proximal ureteral and adrenal surgery, avoiding extensive dissection and handling of intraperitoneal structures.

[Familial multiple bilateral carcinoma of the kidney: clinical strategy and surgical approach]. / Carcinoma renale bilaterale multiplo familiare: strategia clinica e tattica chirurgica.

A case of familiar bilateral multicentric RCC in a young woman is an ideal model to evaluate preoperative and intraoperative diagnostic and surgical tools in order to achieve two distinct goals: the oncologic radicalness and the renal function preserved. Radical bilateral nephrectomy, the renal hypothermia by perfusion of both kidneys, the bench high resolution sonography of parenchyma, the choose of one kidney suitable for conservative surgery, the resection of suspect lesions with intraoperative pathology, the reconstructive bench surgery, the autotransplantation, are the steps accurately performed with particular concern to eradication of all the tumoral lesions present in the kidneys. The results confirm that renal function has been preserved with this method. Radicalness should be appointed by a longlasting follow up. However, as it is discussed, conservative surgery, when accurately performed can give results not different from radical demolitive surgery. In this paper tools to improve diagnostic and therapeutic methods are described in order to increase the diagnostic accuracy and the therapeutic efficacy. The possibility that this multiple RCC can be a part of the abnormalities occurring in the Von Hippel-Lindau syndrome does not change the surgical approach, being the RCC the worst prognostic factor of the syndrome.

[Retroextraperitoneal laparoscopic nephrectomy]. / Nefrectomia laparoscopica per via retroextraperitoneale.

The authors describe a new technique of laparoscopic nephrectomy; the retroextraperitoneal approach has been successfully performed in 4 patients with the following indications: 2 non functioning hydronephrotic kidneys, 2 atrophic chronic pyelonephritic kidneys. The patient was put in a proneoblique position after the retrograde placement of a ureteral catheter up to the renal pelvis, through which the contrast medium was injected. The Veress needle is inserted under fluoroscopic guidance into the perirenal fatty space which was insufflated with CO2. One 12 mm and three 10 mm Trocars were inserted into the cavity created by gas in the trapezoid area whose boundaries are: the 12th rib, the iliac crest, the posterior axillary line and the sacrospinalis muscle. The kidney was progressively dissected free with the traditional laparoscopic instruments (forceps and scissors). The artery has always been closed with clips. In two patients the vein has been stapled and cut with EndoGIA. After the section of the clipped ureter the kidney was removed en block by pulling it out through the 20 mm Kleiber Trocar in two cases and in the other two cases by extending to a length of 4 cm the port of one Trocar. The average total operating time was 4.35 hours and blood loss < 200 cc. The patients were all discharged on the fourth postoperative day. The advantages of the retroextraperitoneal approach with respect to open surgery are synthetically the following: a less traumatic and a more accurate dissection almost always bloodless; a shorter hospitalization period; an almost painless postoperative course.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ligation of the internal spermatic vein through 2 laparoscopic ports]. / La legatura della vena spermatica interna attraveso due porte laparoscopiche.

Thirty-three two port laparoscopic internal spermatic vein ligations have been performed in 31 patients in our Department. The procedure carried out through two 10 mm ports in a mean time of 25 minutes decreases both the invasivity of intervention and the costs when reusable instruments are used. The technique is feasible with an operative laparoscope (working channel diameter 4 mm) through which a grasp can be maneuvered. The two port procedure is as safe as the three port procedures. Preliminary follow up indicated only one recurrence of varicocele (4%). Out of the 19 patients treated for male subfertility who have at least a 6 month follow up, eleven reported an improvement in seminal quality. All the patients but one were discharged on the first postoperative day. Laparoscopic internal spermatic vein ligation provides a real alternative to different surgical techniques decreasing postoperative pain and shortening period of convalescence with immediate return to full activity. The advantages of laparoscopic internal spermatic vein ligation are increased with the two port procedure.