Laparoscopic Management of Chylous Leakage Using a Direct Lymph Node Injection with Methylene Blue as a Leakage Point Location Strategy in a Patient with Retroperitoneal Extragonadal Seminoma.

Background: The first-line treatment in cases of chylous leakage is conservative, and operation should be considered only in patients who fail to respond to this treatment. The main clinical concern is the difficulty of intraoperative localization of the site of leakage that can affect surgical outcome. Case Presentation: A 33-year-old man presented with a 4-month history of abdominal pain and weight loss. CT scan revealed enlarged retroperitoneal lymph nodes. Retroperitoneal lymph node biopsy was performed owing to the suspicion of lymphoproliferative disease, with a pathological result of nonspecific adenitis. Because of persistence of pain, an abdominal CT scan showed a large left retroperitoneal fluid collection that was found to be compatible with chyle after drainage. Conservative treatment was established, but because of its failure, surgical management was attempted by the laparoscopic approach. Intraoperative direct lymph node injection of methylene blue was used as a leakage point location strategy that allows selective ligation of the site of leakage. Thereafter a gradual reduction in chyle output to zero was observed. Conclusion: The laparoscopic approach could be a feasible and successful method for the management of chyle leakage in patients refractory to conservative treatment. Intraoperative direct lymph node injection of methylene blue could be a useful technique to facilitate detection of the site of leakage during operation.

[Laparoscopic renal cryotherapy: preliminary experience]. / Crioterapia renal laparoscópica: experiencia inicial.

OBJECTIVE: Renal cryotherapy has been described as a minimally invasive procedure that represents an alternative for selected patients with small renal tumors. Our preliminary experience with this procedure is reported. MATERIAL AND METHODS: [corrected] Eighteen patients with 21 tumors with a mean tumor size of 2.2 cm (1-4) in the preoperative CT scan underwent renal cryotherapy using a double freeze-thaw cycle. The group consisted of 14 males (64%) and 4 females (18% with a mean age of 68 years (32-84). All patients had undergone prior surgery for renal tumor in the treated or the opposite kidney. A transperitoneal laparoscopic approach was used in all patients. RESULTS: Mean operating time was 196 minutes (120-140), and no patient received transfusions during or after surgery. No complications occurred in 14 patients (64%). Perirenal abscess, splenic laceration, ureteral lesion, and polar artery lesion occurred in one patient each. Peroperative biopsy was performed in 5 patients (22.7%) and was positive for renal cancer in two cases, while material was insufficient in three patients. Mean hospital stay was 6 days (2-16). Creatinine levels were 106 mg% (48-230) before surgery and 123 mg/% (52-270) 6 months after surgery. A CT scan was performed in all patients one and six months after surgery, showing a residual enhancement area in two of them. Sixteen patients (88.8%) are disease-free after a mean follow-up time of 46 months (6-116). Metastatic disease occurred in two patients (11%) in the setting of a prior renal tumor in the same or the opposite kidney and required treatment with antiangiogenic agents. CONCLUSIONS: This is the largest series reporting renal cryosurgery in Spain, in complex cases and with adequate follow-up. Results are encouraging and allow for considering renal cryotherapy among the minimally invasive procedures for nephron-sparing surgery.

Crioterapia renal laparoscópica: experiencia inicial / Laparoscopic renal cryotherapy: preliminary experience

Objetivo: La crioterapia renal se ha descrito como una técnica mínimamente invasiva que constituye una alternativa para pacientes seleccionados con tumores renales de pequeño tamaño. Presentamos nuestra experiencia preliminar con este procedimiento. Material y métodos: Dieciocho pacientes (21 tumores) con un tamaño medio de 2,2 cm (1-4) en TC prequirúrgico se trataron mediante crioterapia renal con doble ciclo de congelación. Catorce (64%) varones y 4 (18%) mujeres con una edad media de 68 años (32-84). Todos los pacientes habían tenido cirugías previas: 3 por tumor renal en el riñón que recibió el tratamiento o en el contralateral. El abordaje fue laparoscópico transperitoneal en todos los pacientes. Resultados: La media de tiempo operatorio fue de 196 min (120-420) y ningún paciente recibió transfusión intra o postoperatoria. No presentaron complicaciones 14 (64%) pacientes, y hubo un absceso perirrenal en 1 caso, laceración esplénica (1), lesión ureteral (1) y lesión de la arteria polar (1). Se realizó biopsia peroperatoria en 5 (22,7%) casos, que resultó positiva para carcinoma renal en 2 casos y material insuficiente en 3. La estancia media fue de 6 días (2-16). Los valores de creatinina preoperatorios fueron de 106 mg/% ( 48-230) y a los 6 meses de 123 mg/% (52-270). En todos los pacientes se realizó una tomografía computariza al mes y a los 6 meses de la cirugía; en 2 de ellos había una zona hipercaptante residual. Con un tiempo medio de seguimiento de 46 meses (6-116), 16 (88,8%) pacientes se encuentran libres de enfermedad. En 2 (11%) casos apareció enfermedad metastásica en el contexto de un enfermedad previa tumoral en el mismo riñón o en el contralateral, que requirió tratamiento con antiangiogénicos. Conclusiones: Se trata de la serie más amplia en nuestro país, en casos complejos y con un buen seguimiento. Los resultados son prometedores y permiten considerar la crioterapia del tumor renal dentro de las técnicas mínimamente invasivas de cirugía conservadora renal (AU)

Objective: Renal cryotherapy has been described as a minimally invasive procedure that represents an alternative for selected patients with small renal tumors. Our preliminary experience with this procedure is reported. Material y methods: Eighteen patients with 21 tumors with a mean tumor size of 2.2 cm (1-4) in the preoperative CT scan underwent renal cryotherapy using a double freeze-thaw cycle. The group consisted of 14 males (64%) and 4 females (18% with a mean age of 68 years (32-84). All patients had undergone prior surgery for renal tumor in the treated or the opposite kidney. A transperitoneal laparoscopic approach was used in all patients. Results: Mean operating time was 196 minutes (120-140), and no patient received transfusions during or after surgery. No complications occurred in 14 patients (64%). Perirenal abscess, splenic laceration, ureteral lesion, and polar artery lesion occurred in one patient each. Peroperative biopsy was performed in 5 patients (22.7%) and was positive for renal cancer in two cases, while material was insufficient in three patients. Mean hospital stay was 6 days (2‑16). Creatinine levels were 106 mg% (48-230) before surgery and 123 mg/% (52-270) 6 months after surgery. A CT scan was performed in all patients one and six months after surgery, showing a residual enhancement area in two of them. Sixteen patients (88.8%) are disease-free after a mean follow-up time of 46 months (6-116).Metastatic disease occurred in two patients (11%) in the setting of a prior renal tumor in the same or the opposite kidney and required treatmet with antiangiogenic agents. Conclusions: This is the largest series reporting renal cryosurgery in Spain, in complex cases and with adequate follow-up. Results are encouraging and allow for considering renal cryotherapy among the minimally invasive procedures for nephron-sparing surgery (AU)

[Limits of laparoscopic surgery in the treatment of renal tumors]. / Límites de la cirugía laparoscópica en el tratamiento del tumor renal.

Laparoscopic radical nephrectomy is considered to be the technique of choice in the mangement of stage T1 and T2 renal cancer, though increased mastery of this alternative type of surgery has served to expand its indications. In any case, these procedures have a series of limitations which are tied to the intrinsic characteristics of laparoscopic surgery, and which are associated with the patient and tumor characteristics, and the experience of the surgeon. The present study discusses the different indications and establishes the current limits of laparoscopic surgery applied to the management of renal tumors. Its role in cell-reducing therapy in metastatic disease, and the methods available for reducing tumor implantation in the surgical ports are also commented.

[Robotic radical prostatectomy: first 100 patients in Fundació Puigvert]. / Prostatectomía radical robótica: análisis después de 100 casos en la Fundació Puigvert.

OBJECTIVE: We present the 100 first robotic radical prostatectomy with Da Vinci (RRPdaV), corresponding to the first experience in Spain. METHODS: We reviewed the first 100 patients that underwent transperitoneal RRPda performed in Fundació Puigvert between July 2005 and January 2007. All cases were performed by 5 surgeons, being the learning curve for all of them. We analyzed surgical time, blood loss, conversion rate, intra and postoperative complications, hospital stay and days of bladder catheterization. Also, rates and location of surgical margins, as well as functional outcomes with an average follow up of 10.3 months. RESULTS: Mean operating time was 180 minutes (100-310) and blood loss 210 mL (100-390). Blood transfusion was required in 2 cases. There were no intraoperative complications and neither any conversion to open surgery. There were 3 outstanding postoperative events, a compartmentalize syndrome, an acute urinary retention after removal of urethral catheter, and a paresthesias due to brachial plexus compression. Mean hospital stay were 3.7 days. (2-21). We had 21 cases of positive surgical margins (21%). The most frequent location was posterior lateral. 69 of 100 patients (69%) reached early (<3 months) total continence, 91% achieved in 9 months, and remaining 9% required use of at least one pad. Concerning to sexual function, 13 of 100 patients (13%) had preoperative erectile dysfunction, of remaining cases, 62% preserved potency at review, and 38% had postoperative erectile dysfunction. CONCLUSIONS: RRPDAv is a safe and reproducible procedure, and offers promising oncological and functional results with a minimal invasive technique. In spite of include the learning curve of 5 surgeons; we obtain an excellent rate of continence, and an acceptable sexual function. The individual improvement, with more experience, and a longer follow-up, will allow to value evolution of the technique, and it results.

Límites de la cirugía laparoscópica en el tratamiento del tumor renal / Limits of laparoscopic surgery in the treatment of renal tumors

Actualmente se considera la nefrectomía radical laparoscópica como la técnica de elección en el tratamiento del cáncer renal en estadios T1 y T2, aunque el dominio de este tipo de alternativa quirúrgica han ido ampliando sus indicaciones. De todas formas existen límites a este tipo de técnicas que van ligadas a la propia idiosincrasia de la laparoscópica; límites que están en relación con las características del paciente, las características del tumor y la experiencia del cirujano. Se discuten las distintas indicaciones y se establecen los límites actuales de la cirugía laparoscópica en el tratamiento del tumor renal, así como su papel en la terapia citoreductora en enfermedad metastásica y los métodos para disminuir el implante tumoral en los puertos de entrada (AU)

Laparoscopic radical nephrectomy is considered to be the technique of choice in the mangement of stage T1 and T2 renal cancer, though increased mastery of this alternative type of surgery has served to expand its indications. In any case, these procedures have a series of limitations which are tied to the intrinsic characteristics of laparoscopic surgery, and which are associated with the patient and tumor characteristics, and the experience of the surgeon. The present study discusses the different indications and establishes the current limits of laparoscopic surgery applied to the management of renal tumors. Its role in cell-reducing therapy in metastatic disease, and the methods available for reducing tumor implantation in the surgical ports are also commented (AU)

Prostatectomía radical robótica: Análisis después de 100 casos en la Fundació Puigvert / Robotic radical prostatectomy: first 100 patients in Fundació Puigvert

Objetivo: Realizar un análisis de los primeros 100 casos de nuestra serie de prostatectomía radical robótica con Da Vinci (PRRdaV) realizadas en nuestro Centro, que corresponden a la primera serie en España. Material y Métodos: Se realiza un estudio retrospectivo de las 100 primeras PRRdaV consecutivas realizadas en la Fundació Puigvert entre Julio de 2005 y Enero de 2007. El procedimiento fue realizado por 5 cirujanos distintos, siendo la curva de aprendizaje para todos ellos. El abordaje fue transperitoneal en todos los casos. Se analizan, tiempo operatorio, pérdidas hemáticas, tasa de conversión, complicaciones intra y postoperatorias, estancia hospitalaria y días de sonda vesical. También se revisan las tasas y la localización de los márgenes positivos, así como los resultados funcionales, con un seguimiento medio de 10,3 meses. Resultados: La media de tiempo operatorio fue de 180 minutos (100-310) y la pérdida hemática media de 210 mL (100- 390). En 2 casos se realizó transfusión postoperatoria. No se presentaron complicaciones intraoperatorias, y tampoco ninguna reconversión. Como acontecimientos postoperatorios destacan un síndrome compartimental, una retención aguda urinaria tras retirada de sonda vesical, y unas parestesias por compresión del plexo braquial. La estancia hospitalaria media fue 3,7 días (2-21). Se obtuvieron 21 casos con márgenes quirúrgicos positivos (21%). La localización más frecuente fue posterolateral. El 69% fueron continentes de forma precoz (<3 meses), el 91% lo fueron a los 9 meses, el 9% restante requiere de compresa de seguridad. Referente a la función sexual, el 62% conservan potencia y el 38% presentaron disfunción eréctil postoperatoria. Conclusiones: La PRRdaV es un procedimiento seguro, reproducible y que ofrece unos resultados oncológicos y funcionales muy prometedores con un abordaje mínimamente invasivo. A pesar de incluir la curva de aprendizaje de 5 cirujanos, obtenemos una excelente tasa de continencia, y una buena función sexual. La mejora individual, con mayor experiencia, así como un mayor seguimiento, permitirá valorar la evolución de la técnica, así como de sus resultados (AU)

Objective: We present the 100 first robotic radical prostatectomy with Da Vinci (RRPdaV), corresponding to the first experience in Spain. Methods: We reviewed the first 100 patients that underwent transperitoneal RRPda performed in Fundació Puigvert between July 2005 and January 2007. All cases were performed by 5 surgeons, being the learning curve for all of them. We analyzed surgical time, blood loss, conversion rate, intra and postoperative complications, hospital stay and days of bladder catheterization. Also, rates and location of surgical margins, as well as functional outcomes with an average follow up of 10.3 months. Results: Mean operating time was 180 minutes (100-310) and blood loss 210 mL (100-390). Blood transfusion was required in 2 cases. There were no intraoperative complications and neither any conversion to open surgery. There were 3 outstanding postoperative events, a compartmentalize syndrome, an acute urinary retention after removal of urethral catheter, and a paresthesias due to brachial plexus compression. Mean hospital stay were 3.7 days. (2-21). We had 21 cases of positive surgical margins (21%). The most frequent location was posterior lateral. 69 of 100 patients (69%) reached early (<3 months) total continence, 91% achieved in 9 months, and remaining 9% required use of at least one pad. Concerning to sexual function, 13 of 100 patients (13%) had preoperative erectile dysfunction, of remaining cases, 62% preserved potency at review, and 38% had postoperative erectile dysfunction. Conclusions: RRPDAv is a safe and reproducible procedure, and offers promising oncological and functional results with a minimal invasive technique. In spite of include the learning curve of 5 surgeons; we obtain an excellent rate of continence, and an acceptable sexual function. The individual improvement, with more experience, and a longer follow-up, will allow to value evolution of the technique, and it results (AU)

Intravesical bacillus Calmette-Guèrin for the treatment of superficial bladder cancer in renal transplant patients.

BACKGROUND: Intravesical instillations with bacillus Calmette-Guérin (BCG) is considered the treatment of choice in the prophylaxis of high-grade superficial bladder carcinoma and in the treatment of carcinoma in situ (CIS) of the bladder. METHODS: There is no previous experience with BCG treatment in patients with renal transplantation. Theoretically, immunosuppression is a contraindication because of the risk of severe morbidity and sepsis. We present our experience with endovesical BCG in three renal transplant patients, under immunosuppressive treatment, with high-grade superficial bladder cancer and CIS. RESULTS: Two patients are free of disease at 17 and 60 months. One patient developed disease recurrence and underwent a radical cystectomy. There was neither change in renal function nor any clinical evidence of tuberculous infection. CONCLUSIONS: Intravesical BCG in superficial bladder cancer and/or CIS is a valid option, with no added morbidity to renal transplant patients.

Quality of life in prostate cancer patients and controls: psychometric validation of the FACTP-4 in Spanish, and relation to urinary symptoms.

OBJECTIVES: To assess the feasibility and a validity of the Spanish version of the FACT-P and its relation to urinary symptoms. METHODS: The Spanish version of the FACT-P was self-administered to 60 Prostate Cancer patients (pts) waiting to undergo radical treatment and 20 age-matched controls (con) with a negative biopsy. Clinical stage for patients was T1c in 34 and T2 in 26. FACT-P was analysed for internal consistency (Chronbach's a) and relation to symptom scales (IPSS, IPSS bother score and incontinence questionnaire (ICI-SF)). RESULTS: Feasibility (evaluable questionnaires) was 80.9 for con and 95% for pts. Internal consistency was high for all sub-scales (alpha > 0.7). Emotional well-being subscale and IPSS were significantly higher in pts. (worse emotional wellbeing and more lower urinary tract symptoms). There were no statistically significant differences between pts and con. in any of the other FACT-P sub-scores nor in symptom scores. Correlations were found between some FACT-P sub-scores and bother score. CONCLUSIONS: The Spanish version of the FACTP is feasible and psychometrically valid. Pts undergoing treatment for localized disease have similar QoL that a control group, but higher scores for emotional distress and IPSS.

[Laparoscopic adrenalectomy]. / Adrenalectomía laparoscópica.

OBJECTIVES: To review indications, techniques and results of laparoscopic adrenalectomy. METHODS: We retrospectively review our experience with 8 cases of transperitoneal laparoscopic adrenalectomy (2 pheochromocytomas, 4 aldosteromas, 1 myelolipoma and 1 non functioning adenoma). RESULTS: Mean operative time was about 3 hours, with an mean estimated blood loss of 200 cc. Mean Hospital stay was 2.5 days, complication rate was 10%, being conversion to open surgery between 5 and 10%. CONCLUSIONS: Laparoscopic adrenalectomy is the operation of choice for functioning adrenal tumours and for incidentally diagnosed tumours < or = 6 cm that have increased in size in successive radiographic examinations.

Seguimiento cistoscópico de los tumores vesicales G3T1 iniciales tratados con BCG / Initial cystoscopic follow-up of G3T1 bladder tumors treated with BCG

OBJETIVO: Valorar los hallazgos cistoscópicos durante el seguimiento inicial, la correlación anatomopatológica con el aspecto endoscópico tumoral y los resultados de la biopsia múltiple normatizada (BMN) de control realizada a los 6 meses de la resección transuretral inicial en pacientes con carcinoma transicional G3T1 tratados con BCG. MÉTODOS: 114 pacientes con tumor vesical G3T1 inicial (52 por ciento asociados a Cis) fueron tratados con instilaciones endovesicales de 81 mg BCG Connaught semanal durante seis semanas consecutivas. El seguimiento fue realizado con cistoscopia y citología a los 3 meses, con cistoscopia y BMN a los 6 meses. Fueron descritas las siguientes características endoscópicas: normalidad vesical, lesión macroscópicamente tumoral y lesión eritematosa. RESULTADOS: Durante los primeros 6 meses de seguimiento se constató en un 16 por ciento recurrencia superficial y en un 5 por ciento progresión a infiltración muscular; la recurrencia o progresión fue en el 61 por ciento y en el 39 por ciento a 3 y 6 meses respectivamente. La mayoría de las lesiones macroscópicamente tumorales resultaron ser tumor a los 3 como a los 6 meses en un 56 por ciento y 64 por ciento respectivamente, siendo el resto principalmente granulomas inflamatorios producidos por BCG. Veinte biopsias sobre áreas eritematosas detectaron un solo caso de Cis (5 por ciento) y 98 BMN practicadas sobre mucosa endoscópicamente sana detectaron 10 casos de Cis (3 a los 3 meses y 7 a los 6 meses); excepto un caso, todos iban precedidos de Cis inicial. CONCLUSIONES: La cistoscopia realizada a los 3 meses es muy importante ya que detecta el 61 por ciento de las recurrencias superficiales y el 66 por ciento de los casos con progresión a infiltración de la capa muscular durante los primeros 6 meses. No tiene sentido biopsiar de forma rutinaria las zonas eritematosas visualizadas por cistoscopia debido al gran número de biopsias innecesarias que esto comportaría a la vista del rendimiento que se obtiene (5 por ciento). Dado que el 90 por ciento de Cis detectado en los primeros 6 meses de seguimiento eran pacientes con Cis en el tumor inicial, creemos oportuno realizar la BMN de control solamente en este subgrupo de paciente si la sensibilidad de la citología es baja en tumores de alto grado o Cis (AU)