Laparoscopic adenomectomy versus Eraser laser enucleation of the prostate.

PURPOSE: To evaluate functional outcomes and morbidity rates after laparoscopic adenomectomy (LA) and Eraser laser enucleation of the prostate (ELEP). MATERIALS AND METHODS: Forty patients with lower urinary tract symptoms suggesting bladder outlet obstruction, with a prostate heavier than 70 g on transrectal ultrasound, were selected to undergo laparoscopic adenomectomy or Eraser laser enucleation of the prostate. All patients were consecutively enrolled without randomization and assessed preoperatively, 3 and 6 months postoperatively. Baseline characteristics, perioperative data, and postoperative outcomes were compared. RESULTS: The total operating time was significantly longer in the LA group (138.8 ± 11.4 vs. 78.4 ± 10.0 min, p < 0.000001). Catheter removal was performed earlier (61.2 ± 21.3 vs. 174.0 ± 13.2 h, p < 0.000001) and the hospital stay was significantly shorter (62.4 ± 21.2 vs. 187.2 ± 12.6 h, p < 0.000001) in the ELEP group. The latter group experienced significantly less perioperative hemoglobin (Hb) loss (0.71 ± 0.25 vs. 2.15 ± 1.08 g/dl, p < 0.000001), and their postoperative Hb levels (14.1 ± 1.21 vs. 11.7 ± 1.31 g/dl, p < 0.000001) were significantly higher. The resected tissue was significantly greater in the LA group (58.5 ± 23.3 vs. 87.9 ± 22.4 g, p = 0.0002). Significant improvements in Qmax, Qol, and symptom scores from baseline to each follow-up time point were noted in both groups. No statistically significant difference in symptom scores or Qmax was registered between the LA and the ELEP group throughout the follow-up period. CONCLUSION: Laparoscopic adenomectomy and ELEP were equally effective for relieving bladder outflow obstruction and lower urinary tract symptoms. The advantages of ELEP include less blood loss, shorter catheterization times, and shorter hospital stays.

The use of mannitol in partial and live donor nephrectomy: an international survey.

PURPOSE: Animal studies have shown the potential benefits of mannitol as renoprotective during warm ischemia; it may have antioxidant and anti-inflammatory properties and is sometimes used during partial nephrectomy (PN) and live donor nephrectomy (LDN). Despite this, a prospective study on mannitol has never been performed. The aim of this study is to document patterns of mannitol use during PN and LDN. MATERIALS AND METHODS: A survey on the use of mannitol during PN and LDN was sent to 92 high surgical volume urological centers. Questions included use of mannitol, indications for use, physician responsible for administration, dosage, timing and other renoprotective measures. RESULTS: Mannitol was used in 78 and 64 % of centers performing PN and LDN, respectively. The indication for use was as antioxidant (21 %), as diuretic (5 %) and as a combination of the two (74 %). For PN, the most common dosages were 12.5 g (30 %) and 25 g (49 %). For LDN, the most common doses were 12.5 g (36.3 %) and 25 g (63.7 %). Overall, 83 % of centers utilized mannitol, and two (percent or centers??) utilized furosemide for renoprotection. CONCLUSIONS: A large majority of high-volume centers performing PN and LDN use mannitol for renoprotection. Since there are no data proving its value nor standardized indication and usage, this survey may provide information for a randomized prospective study.

Tissue effects resulting from eraser laser enucleation of the prostate: in vivo investigation.

UNLABELLED: BACKGROUND/AIMS/OBJECTIVES: To describe the depth of the laser coagulation zone in vivo based on histological examinations and the functional outcome of a 1,318-nm diode laser for enucleation in benign prostatic enlargement (BPE). METHODS: A total of 20 patients with BPE were treated by laser Eraser® enucleation of the prostate (ELEP). Prostatic tissue wedges were evaluated to assess the depth of the ELEP coagulation zones. Additionally, patients were assessed preoperatively and 12 months postoperatively. RESULTS: The coagulation zones were 0.36 ± 0.17 mm in epithelial tissue, 0.28 ± 0.15 mm in stromal tissue, and 0.25 ± 0.12 mm in mixed tissue. The coagulation area at the cutting edge completely sealed capillary vessels, reaching a depth of 0.35 ± 0.15 mm. The diameter of the coagulated vessels measured 1.75 ± 0.83 mm. Mean blood loss was 115.54 ± 93.12 ml, catheter time 1.35 ± 0.33 days, and hospital stay 1.89 ± 0.52 days. The International Prostate Symptom Score, maximal flow rate, and quality of life significantly improved 12 months after the procedure. CONCLUSIONS: ELEP is safe and effective for BPE treatment and yields good results at a follow-up of 1 year. Because of the limited penetration depth, damage to the urinary sphincter is not expected.

Delayed detection of injury to an ectopic ureter of a duplicated collecting system following laparoscopic radical prostatectomy for early organ-confined prostate cancer.

In the era of early detection of organ-confined prostate cancer, guidelines support the fact that many patients will not need an aggressive staging work-up, to avoid unnecessary investigations. This strategy may lead to serious repercussions in rare incidences. We present a rare case of urinary extravasation following laparoscopic radical prostatectomy caused by injury of the upper pole ectopic ureter of an undetected duplex system on 1 side, an injury which is the first of its kind in laparoscopic urology.

[Radical and partial nephrectomy for RCC: laparoscopy or open surgery]. / Laparoskopische oder offene Tumornephrektomie und Nierenteilresektion?

After initial scepticism laparoscopic radical nephrectomy has rapidly been developed to a standard of care which should be offered to all patients as an alternative to open surgery. This procedure is indicated for all renal tumours clinical stage 1-2 which are not considered for partial nephrectomy. Many studies now show that the oncologic outcome is good and comparable to open surgery. Follow-up, however, is limited to about 10 years. Laparoscopic radical nephrectomy has become a standardized procedure. Removal of the kidney by morcellation, favoured by the majority some time ago, has been abandoned to a great extent. Also the controversy about the advantages and disadvantages of the respective approach has been settled. Several prospective randomized studies proved that both the transperitoneal and retroperitoneal approaches are equally effective. Excluding the bias of the learning curve the complication rate of laparoscopy is not higher than that of open surgery, but morbidity is clearly lower. Since the rate of elective partial nephrectomy is increasing rapidly, laparoscopy may be a good choice for this indication as well. When performed during ischaemia all principles of open surgery--excision of the tumour with clear margins, haemostasis using sutures, closure of the collecting system, suture repair of the renal parenchyma--can be duplicated. The problem of long warm ischaemia time can be managed by the evolution of the surgical technique, but also by induction of hypothermia. Complication rates are comparable to open surgery. Oncologic results, with limited follow-up however, are promising.

[Sentinel lymph node dissection for localized prostate cancer]. / Papel de la biopsia dinámica del ganglio centinela en el cáncer de próstata organoconfinado.

Proper assessment of lymph node status is of crucial importance in the management of newly diagnosed prostate cancer. Early stage metastatic disease takes the form of microscopic tumor-cell deposits rather than grossly enlarged nodes. So far there is no imaging technique, however, which allows detecting small metastases in the range of a few millimetres. Therefore pelvic lymph node dissection (PLND) is the only reliable method of staging for clinically localized prostate cancer. The cornerstone of radioguided prostate surgery is a radiopharmaceutical--a carrier molecule labeled by radionuclide. After injection to at the prostate, the radiopharmaceutical crosses the lymphatic pores and migrates into the lymph vessels and from there to the first echelon of lymph nodes. We were the first to show that sentinel PLND can be performed by means of laparoscopy preceding laparoscopic radical prostatectomy. Our most recent publication presents data of 140 patients with clinically localized prostate cancer in which laparoscopic sentinel PLND was performed preceding radical prostatectomy from November 2001 to January 2005. On the preoperative scintigraphy SLNs were detected bilaterally,unilaterally, not on the pelvic-walls in 113 (80.7%), 20 (14.2%) and 6 (4.2%) patients and intraoperatively in 96 (68.6%), 36 (25.7%), 8 (5.7%) patients respectively. In 99 out of 140 patients (70.7%) intraoperatively SLN was detected in the same position as on preoperative scan. At least one SLN was detected in 133 patients (95.3%). Whenever PLND is indicated it should not be limited to lymph node sampling as provided by standard limited PLND but has to be performed in the template of extended PLND. There is only limited experience with sentinel PLND, but all the data collected so far indicate that this method has the potential to become an alternative to extended PLND since it allows for reduction of the extent of PLND without compromising diagnostic accuracy.

[Reconstructive procedures in laparoscopic urology]. / Rekonstruktive laparoskopische Eingriffe in der Urologie.

The introduction of laparoscopic pyeloplasty was the first step towards the development of suturing and knotting techniques. The final breakthrough came with the development of radical prostatectomy since the performance of the urethrovesical anastomosis required highly developed skills in reconstructive surgery. For most laparoscopic surgeons suturing and knot tying became quite familiar henceforth. As a consequence, the interest for other reconstructive procedures has increased tremendously since. Within a very short time pyeloplasty was developed to a surgical standard, and the results compare very favorably with open surgery. A very attractive method is the ureteral reimplantation according to the psoas hitch technique, which, however, does not completely duplicate the open surgical operation. Many patients can potentially be attracted by sacrocolpopexy to treat genital prolapse. The long-term success rate is 92% which is excellent for this indication. Urinary diversion following cystectomy is usually not performed completely intracorporeally, but laparoscopically assisted.

[Laparoscopic pyeloplasty]. / Pyéloplastie laparoscopique.

Ureteropelvic junction (UPJ) obstruction in adults is usually symptomatic, secondary, and it tends to progress. Surgical correction of obstructed UPJ is necessary to preserve the renal function of the affected kidney. Pyeloplasty as a surgical management for UPJ obstruction in adults has proven its efficacy with high success rates on long-term results. Laparoscopic pyeloplasty in the management of primary or secondary UPJ obstruction in adults technically duplicate the open surgical technique. Laparoscopic pyeloplasty has developed to match success, morbidity and complication rates of open surgical pyeloplasty. However it was shown that laparoscopy had consistently a shorter convalescence than open surgery. Endopyelotomy is utilized to manage UPJ obstruction. Early results for endopyelotomy were promising but long-term results were not encouraging. In the management of UPJ obstruction in adults, long-term success rates for laparoscopic pyeloplasty were found to be superior to those of endopyelotomy. Therefore we believe that laparoscopic pyeloplasty will become as a standard management for UPJ obstruction in adults.

28-Year Survival following Several Metastasectomies, Going through 8th Line Systemic Therapy in a Case of mRCC.

Metastatic renal cell carcinoma (mRCC) has been one of the most treatment-resistant cancers because of its unpredictable clinical course, resistance to chemo- and radiotherapy, and the limited response to immunotherapy and targeted agents. We present a case of long-term survival, that is, 28 years, after primary diagnosis (longest survival in the literature up to our knowledge) with mRCC after several metastasectomies (from local site recurrence, liver, and lung) and eight lines of systemic targeted therapy. This case report shows how crucial is the regular follow-up of patients with RCC after primary management and positive impact of early metastasectomy and systemic targeted therapy in case of mRCC on patients' condition and overall survival.

Preserved adrenocortical function after laparoscopic bilateral adrenal sparing surgery for hereditary pheochromocytoma.

BACKGROUND: Familial pheochromocytoma, increasingly diagnosed in asymptomatic subjects with inherited syndromes such as multiple endocrine neoplasia type 2 and Von Hippel-Lindau disease, is frequently bilateral and multifocal, but very rarely malignant. Therefore, bilateral adrenalectomy and subsequent lifelong steroid replacement, with its attendant side effects, is not desirable. Minimally invasive adrenal sparing surgery by means of laparoscopy was explored for the treatment of bilateral pheochromocytoma. We report on the cure rate and adrenocortical function in a series of patients treated accordingly. PATIENTS AND METHODS: Four patients (three male, one female, ages 9-60 yr) with hereditary bilateral adrenal pheochromocytoma were treated by laparoscopic surgery in an organ sparing fashion. Postoperatively, all patients were reevaluated for complete tumor removal and for adrenocortical function. RESULTS: Two to 24 months after surgery, all patients were normotensive, had normal sodium potassium, glucose, aldosterone, renin, and cortisol serum concentrations, 24-h excretion of norepinephrine, epinephrine, and vanillylmandelic acid. Abdominal magnetic resonance imaging (n = 3) and computed tomographic scan (n = 1) disclosed no remnant or relapsing tumor tissue. ACTH stimulation testing resulted in normal cortisol responses. CONCLUSION: By adrenal sparing laparoscopic surgery not only bilateral pheochromocytoma can be successfully removed, but also adrenocortical function preserved. This may become the treatment of choice for familial pheochromocytoma.

Percutaneous nephrostomy tube with perirenal balloon fixation.

Despite a variety of available systems the fixation of nephrostomy catheters has not been solved satisfactorily so far. Secure and comfortable fixation of the presented nephrostomy tube is provided by its inflatable balloon which is placed in the perinephric space so that the abdominal wall will retain it.

Laparoscopic and retroperitoneoscopic repair of ureteropelvic junction obstruction.

OBJECTIVES: The aim of this study was to evaluate laparoscopic and retroperitoneoscopic pyeloplasty and to compare the efficacy of dismembered and nondismembered techniques. METHODS: Since May 1993, a modified laparoscopic transperitoneal (14 patients) and a retroperitoneoscopic approach (3 patients) have been used for the management of ureteropelvic junction obstruction. In 7 patients aberrant vessels were encountered; 1 patient had a horseshoe kidney. Surgical repair was achieved by dismembered pyeloplasty (8 patients), nondismembered Fenger-plasty (longitudinal incision, transverse closure; 3 patients), transaction and reanastomosis of the renal pelvis (1 patient), ureterolysis and displacement of crossing vessels (4 patients). RESULTS: In 1 patient dismembered pyeloplasty could not be scheduled because of cardiovascular problems. A minimal transient lesion of the sympathetic nerve was observed postoperatively in 1 patient and pulmonary embolism in another. The operative time in dismembered pyeloplasty was between 240 and 360 minutes (mean, 280); the results were good in all patients. Equally good results were obtained with nondismembered Fenger-plasty, and the operating time was shorter (120 to 180 minutes). Ureterolysis was found to have a failure rate of 50%. CONCLUSIONS: Laparoscopic dismembered pyeloplasty yielded good results but it is too complicated to become a standard procedure. Nondismembered Fenger-plasty, which also showed good results, is more suitable for laparoscopy and retroperitoneoscopy. The indications for this technique should be defined more precisely as more experience is being collected. The results of ureterolysis when used as a single measure were poor, and, therefore, this technique should be abandoned.

Prostate zones in three-dimensional transrectal ultrasound.

OBJECTIVES: This study was undertaken to evaluate the efficacy of three-dimensional transrectal ultrasound to identify and measure the prostate zones. METHODS: In an anatomic-sonographic study, eight specimens were investigated by means of three-dimensional transrectal ultrasound. Subsequently, the volumes of the prostate and the transition zone were measured by means of a special planimetric program; the images and results obtained were compared with anatomic sections and water displacement volume measurement. Then two groups of patients were investigated by means of three-dimensional transrectal ultrasound; the first group included 90 patients ranging in age from 55 to 85 years who presented with benign prostatic hyperplasia (BPH), which was verified by means of histologic examination. Three-dimensional transrectal ultrasound was performed prior to ultrasound-guided biopsies of the prostate. The second group comprised 10 patients aged between 17 and 30 years whose prostates were free of disease. RESULTS: Three-dimensional transrectal sonography is the first imaging technique that can simultaneously demonstrate relevant structures in three planes; apart from the sagittal and the horizontal (or axial) plane, the region of interest can be examined in the coronal plane as well. The structural differences of the prostatic zones in BPH and the juvenile gland can be clearly identified with the help of three-dimensional transrectal ultrasound. The coronal plane provides important additional information; the central zone and the enlarged transition zone can be identified best in this third plane. CONCLUSIONS: The prostate zones, their interrelations, and, in particular, the hyperplasia of the transition zone in BPH are clearly demonstrable. Furthermore, the size of the enlarged transition zone can be exactly measured.

Prenatal diagnosis of neuroblastoma by sonography.

Herein we report the first case in the literature in which a neuroblastoma in a fetus was recognized before birth and its growth could be observed. The diagnosis was made by ultrasonography. Other helpful diagnostic procedures in prenatal diagnosis are: determination of catecholamines, sonographic examination of the placenta, and search for metastases. As more and more centers perform ultrasound examinations routinely in pregnancy, similar findings such as fetal tumors or congenital malformations are to be expected more frequently.

Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular tumor.

OBJECTIVES: An appropriate laparoscopic technique for diagnostic retroperitoneal lymph node dissection in clinical Stage I testicular tumors is presented and its efficiency and morbidity are evaluated. METHODS: A two-step procedure has been developed. In the first step, a ventral approach is used. The colon is dissected free, then the spermatic vein is excised and the borders of dissection are defined. Via the ventral approach removal of retroaortic and retrocaval nodal tissue is technically not feasible. Therefore, in the second step, a lateral approach is used, which is the key to success because it permits straightforward transection of the lumbar vessels. Thus, complete lymph node dissection within the boundaries described by Weissbach can be achieved. Between August 1992 and March 1994, this procedure was performed in 15 patients. In 9 patients, the tumor was on the right side and in 6 it was on the left. RESULTS: Conversion to open surgery was necessary in 2 patients because of uncontrollable bleeding and a large metastasis. Microscopic metastasis were detected in 2 other patients. Apart from the bleeding just mentioned, no major complications occurred; no blood transfusions were required. CONCLUSIONS: The results obtained so far demonstrate that the technique is feasible and decreases postoperative morbidity. It therefore warrants further consideration.

Laparoscopic nephrectomy for renal cell cancer: evaluation of efficacy and safety: a multicenter experience.

OBJECTIVES: Although laparoscopic radical nephrectomy is a safe and minimally invasive alternative to open surgery, the long-term disease-free outcome of this procedure has not been reported. We evaluated our experience with the laparoscopic management of renal cell carcinoma to assess the clinical efficacy of this surgical modality. METHODS: Between February 1991 and June 1997, 157 patients at five institutions were retrospectively identified who had clinically localized, pathologically confirmed, renal cell carcinoma and had undergone laparoscopic radical nephrectomy. Operative and clinical records were reviewed to determine morbidity, disease-free status, and cancer-specific survival. Of the patients followed up for at least 12 months (n = 101), 75% had an abdominal computed tomography scan at their last visit. RESULTS: The mean age at surgery was 61 years (range 27 to 92) and all patients were clinical Stage T1-2,NO,MO. Fifteen patients (9.6%) had perioperative complications. During a mean follow-up of 19.2 months (range 1 to 72; 51 patients with 2 years or more of follow-up), no patient developed a laparoscopic port site or renal fossa tumor recurrence. Four patients developed metastatic disease, and 1 patient developed a local recurrence. The 5-year actuarial disease-free rate was 91%+/-4.8 (SE). At last follow-up, there were no cancer-specific mortalities. CONCLUSIONS: The laparoscopic surgical management of localized renal cell carcinoma is feasible. Short-term results indicate that laparoscopic radical nephrectomy is not associated with an increased risk of port site or retroperitoneal recurrence. Longer follow-up is necessary to compare long-term survival and disease-free rates with those of open surgery.

Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective.

OBJECTIVES: To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy. METHODS: A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed. RESULTS: Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51. CONCLUSIONS: Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Laparoscopic retroperitoneal lymph node dissection.

Laparoscopic RPLND for clinical stage I testicular tumors is superior to open surgery in terms of efficiency, morbidity, and costs and has equal diagnostic accuracy. A quality of life study has shown that patients prefer surgery to chemotherapy and laparoscopy to open surgery. Laparoscopic RPLND is also feasible after chemotherapy, and the results are as good as those achieved in clinical stage I disease. Patients with stage IIb lesions can be spared the third and fourth cycle of chemotherapy if diagnostic laparoscopic RPLND is performed to exclude active tumor or remove mature teratoma. Laparoscopic removal of residual tumors following conventional chemotherapy for stage IIb lesions can be performed with minimal morbidity. The long and steep learning curve remains the biggest obstacle in laparoscopic RPLND. Most centers specializing in the treatment of testicular cancer are not trained in laparoscopic surgery and vice versa; however, the growing importance of laparoscopy for oncologic indications should help to overcome this problem in the near future.

Laparoscopic surgery for pheochromocytoma.

Because of the excessive production of catecholamines, surgery for pheochromocytoma carries a certain risk that can be reduced by accurate preoperative evaluation and by pretreatment with alpha-blockers. The authors' experience and that of other groups suggests that this inherent risk is not enhanced by the laparoscopic approach, and that, following successful surgery, patients benefit from the minimal invasiveness of this technique. Most surgeons recommend the transperitoneal approach that allows direct access to the adrenal vein, facilitating early ligation. This recommendation does not apply to other pathologies of the adrenal gland. Bilateral adrenal tumors are only seen in patients with familial pheochromocytomas. In this setting, adrenal-sparing surgery should be considered, which can also be performed laparoscopically. Previous adrenal surgery is not a contraindication but will render the procedure more difficult. Laparoscopic excision of paragangliomas is also technically feasible. Laparoscopic adrenal surgery for pheochromocytoma is a difficult and demanding task that must be performed by an experienced surgeon in cooperation with a team of specialists including an internist, endocrinologist, and anesthesiologist.

Laparoscopic pyeloplasty.

Laparoscopic pyeloplasty must be compared with open surgery in terms of efficacy and with endopyelotomy in terms of morbidity. All of the series published so far show that the results of laparoscopic pyeloplasty equal those of open surgery. Laparoscopy is associated with a lower morbidity; therefore, it is preferable to open surgery. The morbidity of endopyelotomy is also low, at least when it is performed in a retrograde fashion. The results of endopyelotomy are poor if UPJ obstruction is caused by crossing vessels. In addition, endopyelotomy in this clinical setting carries the risk of hemorrhage. Most adults with symptomatic UPJ obstruction present with crossing vessels at the UPJ. These patients benefit from laparoscopy, and endopyelotomy should be reserved for patients with true intrinsic stenoses. For this reason, preoperative investigation using contemporary imaging techniques is of crucial importance to be able to select the most appropriate surgical method for a given patient. Laparoscopic dismembered pyeloplasty is technically feasible but difficult. The authors prefer nondismembered techniques that yield equally good results in selected patients. Nondismembered pyeloplasty as described by Fenger is easy to perform and well suited for laparoscopy.