American Confederation of Urology (CAU) experience in minimally invasive partial nephrectomy.

PURPOSE: To describe the perioperative and oncology outcomes in a series of laparoscopic or robotic partial nephrectomies (PN) for renal tumors treated in diverse institutions of Hispanic America from the beginning of their minimally invasive (MI) PN experience through December 2014. METHODS: Seventeen institutions participated in the CAU generated a MI PN database. We estimated proportions, medians, 95 % confidence intervals, Kaplan-Meier curves, multivariate logistic and Cox regression analyses. Clavien-Dindo classification was used. RESULTS: We evaluated 1501 laparoscopic (98 %) or robotic (2 %) PNs. Median age: 58 years. Median surgical time, warm ischemia and intraoperative bleeding were 150, 20 min and 200 cc. 81 % of the lesions were malignant, with clear cell histology being 65 % of the total. Median maximum tumor diameter is 2.7 cm, positive margin is 8.2 %, and median hospitalization is 3 days. One or more postoperative complication was recorded in 19.8 % of the patients: Clavien 1: 5.6 %; Clavien 2: 8.4 %; Clavien 3A: 1.5 %; Clavien 3B: 3.2 %; Clavien 4A: 1 %; Clavien 4B: 0.1 %; Clavien 5: 0 %. Bleeding was the main cause of a reoperation (5.5 %), conversion to radical nephrectomy (3 %) or open partial nephrectomy (6 %). Transfusion rate is 10 %. In multivariate analysis, RENAL nephrometry score was the only variable associated with complications (OR 1.1; 95 % CI 1.02-1.2; p = 0.02). Nineteen patients presented disease progression or died of disease in a median follow-up of 1.37 years. The 5-year progression or kidney cancer mortality-free rate was 94 % (95 % CI 90, 97). Positive margins (HR 4.98; 95 % CI 1.3-19; p = 0.02) and females (HR 5.6; 95 % CI 1.7-19; p = 0.005) were associated with disease progression or kidney cancer mortality after adjusting for maximum tumor diameter. CONCLUSION: Laparoscopic PN in these centers of Hispanic America seem to have acceptable perioperative complications and short-term oncologic outcomes.

Renal cancer from laparoscopic to robotic: How to proceed.

The benefits laparoscopic surgery brings to the table are well established in the literature. In our environment however, still most of the reconstructive/oncologic procedures are performed as open surgery. This can be explained by the multiple challenges this technique involves, as well as a demanding learning curve. Technology has provided means to improve precision and usefulness of laparoscopy, as well as broaden its use amongst the medical community by shortening its learning curve. Renal tumors have been managed by laparoscopic approach for the past 20 years. During this time, many studies appeared in the literature comparing this procedure with open surgery. In the vast majority, laparoscopic surgery has the upper hand in regards of perioperative events. A number of series are available regarding the feasibility of robotic radical nephrectomy, however there is no literature available that demonstrates better outcome of robotic radical nephrectomy compared to standard laparoscopy. Laparoscopic partial nephrectomy is technically difficult, which has prevented its massive spread through the urologist community, even amongst trained laparoscopists. Current reports are starting to favor robotic partial nephrectomy over standard laparoscopy regarding perioperative outcomes, with similar oncologic results. More studies have to be performed in order to elucidate the importance of NOTES and LESS in the treatment on localized renal cancer, but the use of the robot will lower their learning curve and probably make them attractive in the short term. Even though this technology has brought laparoscopy closer to a greater number of surgeons, physicians should become familiar and proficient in conventional laparoscopic procedures before embarking into robotics.

[Renal cell carcinoma of the collecting ducts of bellini with retroperitoneal recurrence by another histological subtype Of renal tumor]. / Carcinoma renal de los conductos colectores de bellini con recidiva retroperitoneal por otro tipo histológico de tumor renal.

OBJECTIVE: Collecting Duct Carcinoma or Bellini Carcinoma (CDC) is a rare aggressive histological subtype. We present a case of CDC with retroperitoneal recurrence by another histological subtype of renal tumor and review of the literature. METHODS: A 59-year-old man with no relevant clinical history presented gross hematuria. At the time of diagnosis, a computed tomography ( CT) showed a tumor mass occupying the left renal pelvis. Left Laparoscopic radical nephroureterectomy was performed with endoscopic intramural ipsilateral ureter disinsertion. RESULTS: The pathological diagnosis was CDC with negative surgical margins. A CT scan control was performed 10 months later, showed a left retroperitoneal tumor compatible with a local recurrence. We performed a left subcostal laparotomy with complete resection of the mass. Histological diagnosis was large cell carcinoma with components of granular cells and clear cell. CONCLUSIONS: The CDC is a rare subtype of renal cell carcinoma (RCC) and has an aggressive behavior that is associated with poor prognosis. Surgical resection remains the treatment of choice. We present the first reported case of CDC with retroperitoneal recurrence by another histological subtype of renal tumor.

Histological changes due to intravesical instillation of mitomycin C.

OBJECTIVE: Transurethral resection (TUR) is highly effective in the local control of superficial bladder cancer. However, the recurrence rate can reach 80% of the cases. Adjuvant intravesical chemotherapy may decrease significantly tumor recurrence. We describe a bladder adverse reaction to mitomycin C as adjuvant therapy for non-invasive bladder cancer METHODS: Three patients with diagnosis of pTa G1 urothelial carcinoma were treated by TUR plus an instillation of 40 mg. of mitomicin C. A month later, the patients were attended for dysuria and hematuria. Cystoscopy and bladder biopsy were performed in all cases. RESULTS: Multiple sessile lesions suspicious of tumor recurrence were found on cystoscopy. The histopathological diagnosis disclosed the existence of severe atypia of the urothelium and stromal changes similar to those observed after radiotherapy CONCLUSIONS: Adjuvant intravesical chemotherapy with mitomycin C may cause local reactions with macroscopic patterns similar to tumoral recurrences.

Retroperitoneal laparoscopic lymph node dissection (RPLND) in testicular cancer.

Retroperitoneal Laparoscopic Lymph node Dissection (RPLND) seems to offer similar staging accuracy and long term outcomes to Open RPLND. It is also a reasonable option in terms of morbidity. However, solid laparoscopic skills are necessary to safely perform this surgery. In the following article, we assess indications, access, surgical technique, complications and controversies of the laparoscopic RPLND.

[Laparoscopic simple nephrectomy with transvaginal notes assistance and the use of standard laparoscopic instruments]. / Nefrectomía laparoscópica simple con asistencia de notes transvaginal y uso de instrumentos laparoscópicos estándar.

INTRODUCTION: Natural orifice transluminal endoscopic surgery (NOTES) is an emerging technique, which allows to performed surgical procedures avoiding any surgical scars. However there are some problems due to the lack of equipment available for these procedures. The aim of these study is to present our initial experience with the transvaginal nephrectomy NOTES using standard laparoscopic instruments. MATERIAL AND METHODS: Two female patients 23 and 29 years old, both of them with diagnosis of recurrent urinary tract infection and renal atrophy. A transvaginal simple nephrectomy was performed using a transvaginal Access for the camera port and two abdominal work ports of 10 and 3 mm. RESULTS: Total operation room time was 120 min in the first case and 40 min. in the second with an average blood loss of 200 cc. There were no perioperative complications, and both patients was discharged 36 hours after the surgery CONCLUSION: Laparoscopic nephrectomy with transvaginal NOTES assistance is technically feasible with the use of standard laparoscopic instruments. Special Access trocars and instruments development for this procedure will allow to perform a pure technique without the use of abdominal incisions.

[Laparoscopic radical cystectomy. The new gold standard for bladder carcinoma?]. / Es la cistectomía radical laparoscópica el nuevo standard de oro para el cáncer de vejiga?

SUMMARY OBJECTIVES: The experience of a renowned Latin American laparoscopic center is reported and the differences with the open technique are thoroughly discussed. METHODS: During a 7 year period a total of 85 laparoscopic cystectomies were performed; in 92%of the cases urinary diversion was performed extracorporeally. This accounted for: 14 anterior exanterations, 50 radical cystoprostatectomies, 7 radical cystectomies and 14 simple cystectomies. Male to female ratio was 3:1. Mean patient age was 63 years (range 29 to 83). Mean Body Mass Index (BMI) was 28 kg/m2(range 20 to 47). Operative data and long term results are analyzed. RESULTS: All 85 procedures were completed laparoscopically without need for conversion to open surgery. Orthotopic neobladder, Santiago pouch, Studer, Fontana and Le Bag were performed in 42, 13, 16, 12 and 1 case respectively. Ileal conduit, Indiana pouch and Mainz II were employed in 24, 10 and 9 cases respectively. All Mainz II were performed intracorporeally. Mean operative time and blood loss were 279 minutes (range 180 to 375) and 436 ml (range 50 to 1.500) respectively. A total of 8 patients (11%) presented perioperative complications: 5 vascular lesions, 2 eviscerations and 2 septicemias. Delayed complications were observed in 7 cases (9%); 3 urinary sepsis, 1 ureteral stenosis, 2 spontaneous ruptures and 1 mesenteric ischemia. Mean hospital stay was 8.8 days (range de 4 to 28). There was no operative mortality. Mean follow-up was 18 months (range 2 to 68 months). Ten patients (13%) presented disease progression and death. CONCLUSIONS: Laparoscopic radical cystectomy is associated with diminished operative bleeding, time to oral intake and hospital stay. Though this is a reproducible technique it demands a very long learning curve.

Corrigendum to "Modified urethrovesical anastomosis during robot-assisted simple prostatectomy: Technique and results" [Prostate Int 4 (2016) 61-64].

[This corrects the article DOI: 10.1016/j.prnil.2016.04.001.].

Modified urethrovesical anastomosis during robot-assisted simple prostatectomy: Technique and results.

BACKGROUND: Despite significant developments in transurethral surgery for benign prostatic hyperplasia, simple prostatectomy remains an excellent option for patients with severely enlarged glands. The objective is to describe our results of robot-assisted simple prostatectomy (RASP) with a modified urethrovesical anastomosis (UVA). METHODS: From May 2011 to February 2014, RASP with UVA was performed in 34 patients by a single surgeon (O.C.) using the da Vinci S-HD surgical system. The UVA was performed between the bladder neck and urethral margin using the Van Velthoven technique. Demographic, perioperative, and outcome data were recorded. Complications were recorded with the Clavien-Dindo system. RESULTS: The mean (standard deviation) age was 68 years (62-74 years). The median preoperative prostate volume (interquartile range) was 117 cc (99-146 cc). Operative time was 96 minutes (78-126 minutes), estimate blood loss was 200 mL (100-300 mL), and two (5.8%) patients required a blood transfusion. No conversion to open surgery was needed. The median specimen weight on pathological examination was 76 g (58-100 g). The average hospital stay was 2.2 days (1-4 days) and average Foley catheter time was 4.6 days (4-6 days). No intraoperative complications were recorded. There were seven (20.5%) postoperative complications, most of them Clavien less than or equal to Grade II. CONCLUSION: The results of our study show that RASP with UVA is a feasible, secure, and reproducible procedure with low morbidity. Additional series with larger patient cohorts are needed to validate this approach.

[Testosterone replacement therapy and prostate cancer: the downfall of a paradigm?]. / Terapia de reemplazo con testosterona y cáncer de próstata: ¿la caída de un paradigma?

For six decades, it has been a part of the conventional medical wisdom that higher levels of testosterone increase the risk of prostate cancer. This belief is mostly derived from the well-documented regression of prostate cancer after surgical or pharmacological castration. However, there is an absence of scientific data supporting the concept that higher testosterone levels are associated with an increased risk of prostate cancer. Moreover, men with hypogonadism have substantial rates of prostate cancer in prostatic biopsies, suggesting that low testosterone has no protective effect against the development of prostate cancer. Moreover, prostate cancer rate is higher in elderly patients when hormonal levels are low. These results argue against an increased risk of prostate cancer with testosterone replacement therapy.

Por casi seis décadas ha sido parte de la cultura médica en general, que los niveles altos de testosterona incrementan el riesgo de padecer o agravar un cáncer de próstata. Esta creencia se ha derivado fundamentalmente de la bien documentada regresión del cáncer de próstata luego de la castración médica o quirúrgica. Sin embargo, no existe evidencia científica que apoye la idea de que niveles altos de testosterona están asociados con un incremento del riesgo de cáncer de próstata. Más aún, los hombres con hipogonadismo tienen una tasa substancialmente alta de cáncer de próstata detectado por biopsia, lo que sugiere que los niveles bajos de testosterona no tienen un efecto protector en el desarrollo de cáncer de próstata y, además, la tasa de cáncer de próstata es más alta en los pacientes de edades avanzadas cuando sus niveles hormonales son más bajos. Estos argumentos tienden a demostrar que no existiría un incremento del riesgo de padecer un cáncer de próstata asociado a la terapia de reemplazo con testosterona.

First Report: Robot-Assisted Total Pelvic Exenteration for Locally Advanced Prostate Cancer.

Pelvic exenteration is used in the treatment of several pelvic cancers, including those of the rectum, uterus, and bladder. We report the first case of robotic pelvic exenteration for the treatment of symptomatic prostate cancer involving the rectum and bladder. A six-port transperitoneal robotic approach was used. Bilateral extended lymphadenectomy up to the inferior mesenteric artery was performed. The rectum and bladder were removed en bloc, and a double-barrel anastomosis was then performed with both ureters being connected to the lower opening of the colostomy. Operative time was 249 minutes, and estimated blood loss was 600 mL. No intraoperative or postoperative complications were recorded. Biopsy of the rectum and bladder showed prostatic adenocarcinoma with a Gleason score of 9 (5+4), and 1 of 17 nodes was positive for cancer. Postoperative prostate-specific antigen level was 1.24 ng/mL. The patient is already 19 months after surgery with optimal quality of life. Thus pelvic exenteration is a feasible alternative for highly symptomatic prostate cancer involving adjacent pelvic organs.

Bilateral simultaneous laparoscopic adrenalectomy for congenital adrenal hyperplasia: initial experience.

OBJECTIVE: Congenital adrenal hyperplasia (CAH) is an uncommon syndrome which represents a therapeutic challenge. We analyzed the role of bilateral simultaneous laparoscopic adrenalectomy in the management of CAH. MATERIAL AND METHODS: : Between October 2004 and September 2006, three female patients underwent bilateral simultaneous laparoscopic adrenalectomy for CAH. Data were retrospectively collected. Variables analyzed were persistence of CAH clinical signs, variations in 17 OH progesterone level and corticoid medication, operative time, median blood loss, postoperative pain, hospital stay, and body image perception after surgery. RESULTS: Median age was 16.3 years. Complete regression of virilization signs, acne and hyperpigmentation was achieved in one case. The other two cases showed partial regression of signs. Levels of 17 OH progesterone reached normal parameters in all cases. Steroids doses were lowered and given only for replacement purposes. Mean operative time was 125, 65 and 60min for whole, right and left procedure, respectively. Median blood loss remained under 50ml in all cases and there were no complications. Median postoperative pain level was 5 according to visual analog pain scale. Median hospital stay was 4 days. CONCLUSION: Bilateral simultaneous laparoscopic adrenalectomy shows all the advantages of minimally invasive surgery, and appears a viable alternative to medical management, which is not exempt from complications.

[Urologic Notes: where are we and where we are going]. / Cirugía endoscópica transluminal por orificios naturales en Urologia: Dónde estamos y hacia dónde vamos.

BACKGROUND: The natural orifice translumenal endoscopic Surgery (NOTES) approach has been successfully reported by several surgical teams in different specialties. Urologic teams have recently presented several experimental and clinical experiences with the technique. Our aim is to review the initial experience with NOTES in minimal access urological surgery.

[Transumbilical laparoscopic simple nephrectomy using a flexible cystoscope and standard laparoscopic instruments]. / Nefrectomía simple laparocópica transumbilical con el uso de cistoscopio flexible e instrumentos laparsocópicos estándar.

OBJECTIVES: We present our initial experience with transumbilical surgery in a simple nephrectomy performed with a flexible cystoscope and standard laparoscopic instruments. METHODS: A 15 year-old child, with severe left renal parenchyma atrophy, secondary to recurrent urinary tract infection (UTI) complicated with left pyelonephritis. Decision for simple nephrectomy was taken and we planned to perform a single port laparoscopic nephrectomy. In the lumbotomy position, two 5mm ports were insertend through a 3 cm umbilical incision. One trocar permitted the progression of the flexible cystoscope (Olympus) and the other the entrance of the PKS Plasma Trissector. The latter was then changed for a 10mm port to allow the entrance of the Weck clips. A Maryland grasper for countertraction was placed without port in the lef-upper quadrant and progressed directly into de peritoneal cavity under direct vision. RESULTS: The standard laparoscopic steps were duplicated uneventfully. Mean operative time was 90 minutes and mean blood loss was 200 mL. Hospital stay was 18 hours. No transfusion was needed. CONCLUSION: Single port urologic surgery will expand in the future. There is lack of commercial availability of the ideal hardware needed for the procedures. Versatility of urologic instruments allow for its use in different settings.

[Upper urinary tract transitional cell carcinoma: current treatment options and minimally invasive approaches]. / Carcinoma de células transcionales del tracto urinario superior: opciones de tratamiento actual y abordajes minimamente invasivos.

OBJECTIVES: Upper urinary tract transitional cell carcinoma (UUT-TCC) is a rare disease. Open nephroure-terectomy remains the gold standard for surgical treatment. We aim to evaluate the standing of novel surgical treatment in UUT-TCC. METHODS: Extensive review of available literature on UUT-TCC, with emphasis in surgical treatment. English medical literature available in PubMed, Ovid, EMBASE y Science Direct was employed for the study. RESULTS: Laparoscopic nephroureterectomy, ureteroscopy and percutaneous treatment are the available surgical options that based on adequate patient selection offer acceptable cancer control. CONCLUSIONS: Indications for the treatment of UT-TCC are expanding and this allows clinicians to tailor treatment while preserving oncological results.

Cistectomía radical laparoscópica: técnica y resultados en 100 pacientes consecutivos / Radical laparoscopic cystectomy: experience in 100 patients

Background: Laparoscopic cystectomy is a less invasive alternative than traditional surgery. Aim: To report our experience with laparoscopic radical cystectomy, the technique, results and complications. Material and Methods: During a 10-year period, 100 consecutive laparoscopic cystectomies for bladder cancer were carried out. The procedures performed were 57 radical cystoprostatectomies, 27 pelvic exenterations, 14 cystectomies with prostate preservation and seven radical cystectomies. An extracorporeal urinary diversion was performed in 92 percent of cases. Results: The age of patients ranged from 29 to 83 years and the male/female ratio was 3:1. As urinary diversion, an orthotopic reservoir was used in 49 patients, and ileal conduit in 32, Indiana continent reservoir in 10 and intracorporeal Sigma-rectum pouch (Mainz pouch II) in 9 patients. All Mainz II pouches were constructed laparoscopically. Mean operative time and blood loss were 279 minutes (range 180 to 375) and 436 ml (range 50 to 1.500) respectively. Eight patients (11 percent) had perioperative complications: five had vascular lesions, two had eviscerations and two had septicemia. Delayed complications were observed in seven cases (9 percent). Three patients had a urinary sepsis, one had a ureteral stenosis, two had spontaneous ruptures of a continent reservoir and one had an intestinal fistula. Mean hospital stay was 8.8 days (range de 4 to 28). One patient died due to an intestinal fistula and secondary peritonitis. Mean follow-up was 18 months (range 2 to 68 months). Ten patients (13 percent) had disease progression and died in long-term follow up. Conclusions: Laparoscopic radical cystectomy is associated with a reduced operative bleeding, a short hospital stay and acceptable morbidity.

Objetivo: Presentar nuestra serie de cistectomía radical laparoscópica, su técnica, resultados y complicaciones. Material y Métodos: En un período de 10 años, se efectuaron un total de 100 cistectomías lapa-roscópicas en forma consecutiva por un solo cirujano, cuya indicación fue por cáncer vesical. Se realizaron 57 cistoprostatectomías radicales, 22 exanteraciones anteriores, 14 cistectomías con preservación prostática y 7 cistectomías radicales. La derivación urinaria fue efectuada por vía extracorpórea en el 92 por ciento de los casos. Se analizan los resultados peri operatorios y a largo plazo obtenidos con esta técnica. Resultados: Los 100 procedimientos se completaron por vía laparoscópica sin conversión. La relación hombre mujer fue de 3:1. La edad promedio fue de 63 años (29-83). El índice de masa corporal promedio (IMC) fue de 28 kg/m² (20-47). La derivación urinaria empleada fue una Neovejiga ortotópica en 49 pacientes, Conducto ileal incontinente en 32, Reservorios urinario-continente tipo Indiana en 10 y Neovejiga recto-sigmoidea (Mainz II) intracorpórea en 9 pacientes. El tiempo operatorio promedio fue de 271 min (180-375) y el sangrado estimado promedio de 459 ml (50-1.500). Hubo 8 pacientes (11 porciento) con complicaciones intra o peri operatorias. Hubo 7 complicaciones tardías (9 por ciento). El tiempo promedio de hospitalización fue de 8,8 días (4-28). Hubo un fallecido. El seguimiento promedio fue de 48 meses. Diez pacientes (13 por ciento) presentaron muerte por progresión de la enfermedad. Conclusión: Los resultados a mediano plazo son prometedores, se requiere de un seguimiento más prolongado para consolidar su validez oncológica.

Linfadenectomía aorto -iliaca robótica en cáncer de próstata / Aorto-iliac robotic lymphadenectomy in prostate cancer

Introducción. El beneficio de la linfadenectomía en el cáncer de próstata sigue siendo controversial. Es el único procedimiento que permite un estadiaje anatomopatológico más preciso. Antiguamente se indicaba en pacientes de riesgo intermedio o mayor. Actualmente utilizamos el Score de CAPRA sobre 2 para indicar el procedimiento con el fin de seleccionar de mejor manera los pacientes que se beneficiarían de este procedimiento. Objetivo. Analizar la utilidad de CAPRA-Score para indicar la linfadenectomía. Pacientes y Métodos. Estudio prospectivo de carácter descriptivo. De un universo de 155 Pacientes sometidos a prostatectomía radical laparoscópica entre 2003-2013 por un único cirujano, se analizaron 34 pacientes a los que se le realizó linfadenectomía . Los datos se recopilaron en el momento de la cirugía y controles postoperatorios. Se agruparon datos: edad, PSA, Estadio Clínico, Gleason y porcentaje de cilindros (+) en biopsia TR. Se agruparon según indicación por Riesgo o CAPRA-S y se compararon los resultados obtenidos en la histología de los ganglios extraídos (linfadenectomías +). Los datos se analizaron considerando p<0,05 estadísticamente significativo según prueba de T de Student. Resultados. Se incluyeron en total 34 pacientes. Hasta el año 2010 un total de 23 linfadenectomía indicadas a grupo de riesgo intermedio-alto, el 78 por ciento (18) indicado por Gleason. Se sacó en promedio 12 ganglios por paciente, 72 por ciento linfadenectomía ampliadas. Ningún paciente tuvo ganglios (+). Desde el año 2011 un total de 11 linfadenectomía por CAPRA-Score >2, sacándose promedio 15 ganglios, 9 fueron linfadenectomías ampliadas. Se obtuvo 18 ciento linfadenectomías (+) para compromiso metastásico. Conclusiones. De los pacientes previo a CAPRA-Score, un 17por ciento pacientes estarían sobreindicados según éste y coincide con la negatividad del resultado histológico. Hubo diferencia estadísticamente significativa en la aparición de ganglios (+) en pacientes que se aplicó CAPRA-Score. (P<0.05). Según la serie de pacientes presentados, CAPRA-Score seleccionaría mejor los pacientes que se beneficiarían con una linfadenectomía, sin embargo se requieren estudios de mayor cantidad de pacientes.AU

INTRODUCTION Despite the good oncological results of radical prostatectomy (PR) in the treatment of prostate cancer (PCa), more than 35 pertcent of patients will present with biochemical recurrence (RB) after surgery. In these patients, pelvic and / or distal nodes may represent the site of recurrence of the disease. Our objective is to present our surgical technique of aortoiliac robotic lymphadenectomy (LAO) in prostate cancer.AU

Prostatectomia radical laparoscópica / Radical laparoscopic prostatectomy

Radical laparosocpic prostatectomy (RLP) is an attractive therapeutic modality for localized prostate cancer. The results obtained with this technique are similar to those obtained with open radical prostatectomy, which continues to be the gold standard for the treatment of prostate cancer. The surgical access for RLP can be extra-peritoneal or trans-peritoneal. The advantages of laparoscopy are lower bleeding rates, less need for transfusion and shorter recuperation time and hospital stay. The oncological results of RLP are similar, but in any case better, that those obtained with open retropubic radical prostatectomy. Recent reports raised the concern that laparoscopic prostatectomy could have higher rates of relapse of cancer. However this opinion is questionable. RLP is a difficult technique and should be performed by experienced teams. Robot assistance facilitates the procedure and could improve functional and oncological results. Therefore RLP is nowadays an alternative to traditional retropubic prostatectomy.

La Prostatectomia radical laparoscópica (PRL) se ha convertido en una técnica atractiva para el tratamiento quirúrgico del cáncer de próstata localizado. Si bien, los resultados actuales son inicialmente comparables a la prostatectomia radical abierta, es importante mencionar que la tendencia quirúrgica en cáncer de próstata, se ha modificado a pesar de que no hay estudios que confirmen la superioridad del método endoscópico y hoy, el estándar dorado sigue siendo la prostatectomia radical abierta. Dos rutas de acceso quirúrgico pueden ser utilizadas para la realización de PRL, la vía extraperitoneal y la transperitoneal. Un menor sangrado y menor tasa de transfusión, así como, tiempo de hospitalización y recuperación más cortos, son ventajas incuestionables para los procedimientos laparoscópicos. Los resultados oncológicos y funcionales de la prostatectomia laparoscópica son hoy en día comparables, pero en ningún caso mejores que la técnica retropúbica abierta estándar. Recientemente, Hu y colaboradores, en base a una revisión de cerca de 3.000 pacientes tratados en los Estados Unidos, plantean la posibilidad de que los pacientes tratados con prostatectomia laparoscópica (pura o asistida por robot), pudiesen tener mayor riesgo de recurrencia de la enfermedad. Esta es una posición discutible, ya que el análisis, a pesar de ser extenso es limitado para establecer conclusiones finales en el tema. Es importante recordar que la PRL sigue siendo una intervención técnicamente difícil y debiera ser realizada en centros seleccionados con equipos experimentados. La prostatectomía laparoscópica asistida por Robot, facilita el procedimiento y en suma, pareciera mejorar los resultados oncológicos y funcionales. La PRL es hoy en día una alternativa válida a la prostatectomía retropúbica tradicional, con ciertas ventajas adicionales.

Prostatectomía radical asistida por robot da Vinci: experiencia inicial en 50 casos consecutivos / Da Vinci robot-assisted radical prostatectomy: initial experience in 50 consecutive cases

Objective: To report our initial experience in 50 cases submitted to a Robotic Radical Prostatectomy (RRP), evaluating results and the learning curve. Material and Methods: From January to October 2010 we performed 50 consecutives cases of RRP with the da Vinci S-HD Surgical System®. The database was performed prospectively, and was analyzed retrospectively. We evaluate demographic data (age, body mass index) and perioperative data such as clinical stage, preoperative PSA (Prostate Specific Antigen), Gleason Score, ASA, operative times, estimated blood loss, morbidity, hospital stay, time of bladder catheterization and positive margins. A statistical analysis of exponential regression was performed to estimate the learning curve. Results: The mean age was 62 years and the most frequent clinical stage was T1c (84 percent). The mean PSA was 6.36 ng/mL and in 50 percent of the patients the Gleason Score was 7. The median surgical time was 199 minutes. The mean blood loss was 666 mL (50-4.000 mL). The hospital stay and the average bladder catheterization time were 2 and 6 days, respectively. There were 2 conversions to a laparoscopic approach, none to open surgery, and 8 percent of postoperative complication (all Clavien 1). Inmediat urinary continence and potency rates were 88.3 percent and 33.3 percent, respectively. When comparing the 25 initial cases versus the last 25, there was a decrease in surgical time and estimated blood loss (254 minutes vs 189 minutes and 876 mL vs 467 mL, respectively). We also found a lower rate of positive margins (20 percent vs 12 percent). The learning curve statistically estimated is 40 procedures. Conclusion: The surgeon's experience determine a decrease in surgical time, intraoperative bleeding and especially in the rate of positive margins.

Objetivo: Comunicar nuestra experiencia inicial en 50 casos de Prostatectomía Radical Robótica (PRR), evaluando resultados y curva de aprendizaje. Material y Métodos: Desde enero a octubre de 2010 se realizaron 50 PRR con el sistema da Vinci S-HD®. La base de datos fue confeccionada en forma prospectiva y se evaluaron en forma retrospectiva los datos demográficos (edad, índice de masa corporal), estadio clínico, valor de Antígeno Prostático Específico (APE), Score de Gleason, ASA, tiempos quirúrgicos, sangrado estimado, complicaciones, estadía hospitalaria, tiempo de sonda vesical y tasa de márgenes positivos. Se realizó un análisis estadístico de regresión exponencial para estimar la curva de aprendizaje del método. Resultados: La edad media fue de 62 años y el estadio clínico más frecuente fue el T1c (84 por ciento). El valor medio de APE fue de 6,36 ng/mL. El score de Gleason en un 50 por ciento correspondió al 7 y la media del ASA a 2. La mediana del tiempo quirúrgico fue de 199 minutos. El sangrado medio estimado fue de 666 mL (50-4.000 mL). La media de la estadía hospitalaria y el tiempo de sonda fueron de 2 y 6 días, respectivamente. Hubo 2 conversiones a cirugía laparoscópica, ninguna a cirugía abierta y un 8 por ciento de complicaciones postoperatorias (todas Clavien 1). La tasa de continencia y de potencia inmediata fue de 88,3 por ciento y 33,3 por ciento, respectivamente. Cuando comparamos los 25 casos iniciales versus los 25 finales hubo un descenso significativo en el tiempo quirúrgico y sangrado estimado (254 minutos vs 189 minutos y 876 mL vs 467 mL, respectivamente). También encontramos una menor tasa de márgenes positivos en el grupo 2 (12 por ciento vs 20 por ciento). El análisis estadístico determinó la curva de aprendizaje en 40 procedimientos. Conclusión: Una mayor experiencia del cirujano, determina una disminución en los tiempos quirúrgicos, sangrado intraoperatorio y sobre todo en la tasa de márgenes positivos.

Respuesta inflamatoria al estrés quirúrgico: comparación entre nefrectomía laparoscópica, laparoscopia por puerto único y cirugía abierta / Inflamatory response to surgical stress: comparison of laparoscopic nephrectomy, single port nephrectomy and open surgery

Introducción: La cirugía laparoscópica ha demostrado inducir una menor supresión de la respuesta inmune que la cirugía abierta, presumiblemente debido a que existe un menor trauma de los tejidos, un factor que podría tener impacto en el control oncológico. La cirugía laparoendoscópica por sitio único (LESS) es una tecnología emergente, que permite realizar procedimientos quirúrgicos minimizando el uso de incisiones abdominales. El objetivo de este estudio es comparar la respuesta de citoquinas y de estrés, asociada con la nefrectomía abierta, por puerto único y con la técnica laparoscópica pura. Materiales y métodos: Dieciocho cerdos de sexo femenino (45-50 kg) fueron sometidos a nefrectomía laparoscópica transperitoneal, nefrectomía por puerto único y nefrectomía abierta (n =6 en cada grupo). Utilizando técnicas de ELISA, se obtuvieron muestras séricas y peritoneales de factor de necrosis tumoral alfa (FNT), interleukina 1 beta (IL-1) e interleukina 6 (IL-6) a la 1, 4, 24 y 48 horas posnefrectomía. También fue evaluada, la temperatura corporal, la glucosa sérica y el cortisol. Resultados: No se evidenció infección perioperatoria en ningún animal según el registro de la temperatura corporal y los niveles de glucosa. El tiempo operatorio y la pérdida sanguínea fue comparable entre los tres grupos. Las concentraciones séricas de cortisol fueron significativamente más altas en el grupo laparoscópico puro que en el grupo por puerto único a las 24 horas (p =0,02). Las concentraciones séricas de FNT fueron significativamente más bajas en el grupo por puerto único (40+/-6 pg/mL) que en los grupos laparoscópicos puros y abierto (81+/-6 pg/mL y 83+/-17 pg/mL, respectivamente; p <0,05), a pesar de que no existieron diferencias entre los grupos en las concentraciones séricas de IL-1 e IL-6. La IL-1 peritoneal fue significativamente más alta en el grupo laparoscópico puro que el grupo abierto (2.993+/-507 pg/mL y 733+/-185 pg/mL, respectivamente; p =0,05). La IL-6...

Introduction: Laparoscopic surgery has shown to induce less immune response suppression than open surgery, probably due to less tissue trauma; this factor may have a role in oncologic control.Single port laparo-endoscopic surgery (LESS) is an emerging technique, that allows to minimize abdominalincisions. The objective of this study is to compare citokine and stress responses associated with open nephrectomy, single port and pure laparoscopy.Materials and methods: 18 female pigs (45-50 kg) were submitted to laparoscopic, single port andopen nephrectomy (n=6 in each group). Using ELISA technique, seri can peritoneal samples were obtained for Alfa Tumor Necrosis Factor (FNT), interleukine 1 beta (IL-1) and interleukine 6 (IL-6) at 1, 4, 24 y 48 hours post nephrectomy. Body temperature, seric glucose and cortisol were also evaluated. Results: There was no evidence of perioperative infection in any animal when temperature or glucosewas considered. Surgical time and blood loss were comparable in the three groups. Seric cortisol was significantly higher in the pure laparoscopy group than in the single port group at 24 hours. (p = 0.02). Seric FNT concentrations were significantly lower in the single port group (40+/-6 pg/mL) than in thepure laparoscopy and open groups (81+/-6 pg/mL y 83+/-17 pg/mL, respectively; p <0.05), even thoughthere was no difference in the groups in the seric concentration of IL-1 and IL-6. Peritoneal IL-1 was significantly higher in the pure laparoscopy group than the open group (2993+/-507 pg/mL and 733+/-185 pg/mL, respectively; p = 0.05). Peritoneal IL-6 was significantly lower in the single port group (694 +/-234 pg/mL) than the open group (1688+/- 312 pg/mL) (p=0.04).Conclusion: Single port laparoscopic surgery in pigs produces a lower citokine response than pure laparoscopic or open nephrectomy, regarding seric concentrations of FNT and peritoneal concentrations of IL-6. These may reflect less injury to the immune...