RESUMEN
The objectives of this work were to evaluate the efficacy of controlled close step-sectioned and whole-mounted radical prostatectomy specimen processing in prediction of clinical outcome as compared to the traditional processing techniques. Two-hundred and forty nine radical prostatectomy (RP) specimens were whole-mounted and close step-sectioned at caliper-measured 2.2-2.3 mm intervals. A group of 682 radical prostatectomy specimens were partially sampled as control. The RPs were performed during 1993-1999 with a mean follow-up of 29.3 months, pretreatment PSA of 0.1-40, and biopsy Gleason sums of 5-8. Disease-free survival based on biochemical or clinical recurrence and secondary intervention were computed using a Kaplan-Meier analysis. There were no significant differences in age at diagnosis, age at surgery, PSA at diagnosis, or biopsy Gleason between the two groups (P<0.05). Compared with the non-close step-sectioned group, the close step-sectioned group showed higher detection rates of extra-prostatic extension (215 (34.1%) vs, 128 (55.4%), P<0.01), and seminal vesicle invasion (50 (7.6%) vs 35 (14.7%), P<0.01). The close step-sectioned group correlated with greater 3-y disease-free survival in organ-confined (P<0.01) and specimen-confined (P<0.01) cases, over the non-uniform group. The close step-sectioned group showed significantly higher disease-free survival for cases with seminal vesicle invasion (P=0.046). No significant difference in disease-free survival was found for the positive margin group (P=0.39) between the close step-sectioned and non-uniform groups. The close step-sectioned technique correlates with increased disease-free survival rates for organ and specimen confined cases, possibly due to higher detection rates of extra-prostatic extension and seminal vesicle invasion. Close step-sectioning provides better assurance of organ-confined disease, resulting in enhanced prediction of outcome by pathological (TNM) stage.
Asunto(s)
Prostatectomía , Neoplasias de la Próstata/cirugía , Adhesión del Tejido/métodos , Adulto , Anciano , Anciano de 80 o más Años , Supervivencia sin Enfermedad , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias de la Próstata/mortalidad , Neoplasias de la Próstata/patologíaRESUMEN
OBJECTIVES: To determine whether a 1-cm margin is necessary for cancer control during nephron-sparing surgery (NSS) for renal cell carcinoma (RCC). METHODS: A retrospective review of 67 patients who underwent NSS for RCC between 1990 and 2000 was conducted. The data collected included patient demographics, tumor size and location, histologic type and grade, margin status (positive or negative), and the shortest distance of normal parenchyma (in millimeters) around the tumor in the final pathologic specimen. Recurrence was determined from the clinical follow-up, which included physical examination, ultrasonography or computed tomography, and various laboratory tests. RESULTS: Fifty-five cases were performed open and 12 laparoscopically. The mean follow-up was 60 months (range 5 to 124). The mean tumor size was 3.0 cm (range 0.9 to 11.0). Seven patients were found to have a positive margin; 1 died of metastatic RCC, 1 was alive with systemic recurrence, and 5 had no evidence of disease. Of 11 patients with a negative margin distance of less than 1 mm, 9 were recurrence free, 1 had simultaneous local and pulmonary relapse, and the other had pulmonary recurrence only. The remainder of the study patients (n = 49) had negative margins greater than 1 mm, and all were alive without evidence of disease at the last follow-up. CONCLUSIONS: This review questions the necessity of a 1-cm margin to prevent recurrence after NSS for RCC. Additional studies to determine the optimal margin distance should be conducted.
Asunto(s)
Carcinoma de Células Renales/cirugía , Neoplasias Renales/cirugía , Riñón/cirugía , Recurrencia Local de Neoplasia/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Renales/mortalidad , Carcinoma de Células Renales/patología , Femenino , Estudios de Seguimiento , Humanos , Riñón/patología , Neoplasias Renales/mortalidad , Neoplasias Renales/patología , Masculino , Persona de Mediana Edad , Nefronas , Proyectos Piloto , Complicaciones Posoperatorias , PronósticoRESUMEN
PURPOSE: To increase the safety and efficiency of laparoscopic surgery clinical training programs have been developed to increase the skill and efficiency of urological trainees. We evaluated the impact of dedicated laparoscopy training on the rate and type of complications after trainees entered clinical practice. MATERIALS AND METHODS: Data were obtained from 13 centers where laparoscopy was performed by a single surgeon with at least 12 months of training in urological laparoscopy before clinical practice. Data included training experience, laparoscopic procedures performed after commencing clinical practice and associated complications. Procedures were classified as easy, moderate and difficult. RESULTS: During training each surgeon participated in a mean of 71 cases. In clinical practice a total of 738 laparoscopic cases were performed with the group reporting an overall complication rate of 11.9%. The rate was unchanged when the initial 20, 30 and 40 cases per surgeon were compared with all subsequent cases (12%, 11.9% and 12% versus 11.8 to 12%, respectively). The re-intervention rate was 1.1%. The complication rate increased with case difficulty. Overall and early complication rates attributable to laparoscopic technique in the initial 20, 30 and 40 cases were identical. The most common complications were neuropathy in 13 patients, urine leakage/urinoma in 9, transfusion in 7 and ileus in 5. CONCLUSIONS: The complication rate of surgeons who completed at least 12 months of laparoscopy training did not differ according to initial versus subsequent surgical experience. Intensive training seems to decrease the impact of the learning curve for laparoscopy.
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Laparoscopía/efectos adversos , Urología/educación , Humanos , Complicaciones Posoperatorias/epidemiologíaRESUMEN
PURPOSE: We compare postoperative pain, stone-free rates and complications after ureteroscopic treatment of distal ureteral calculi with or without the use of ureteral stents. MATERIALS AND METHODS: A total of 113 patients with distal ureteral calculi amenable to ureteroscopic treatment were prospectively randomized into stented (53) and unstented (60) groups. Stones were managed with semirigid ureteroscopes with or without distal ureteral dilation and/or intracorporeal lithotripsy. Preoperative and postoperative pain questionnaires were obtained from each patient. Patients with stents had them removed 3 to 10 days postoperatively. Radiographic followup was performed postoperatively to assess stone-free rates and evidence of obstruction. RESULTS: Six patients randomized to the unstented group were withdrawn from the study after significant intraoperative ureteral trauma was recognized, including 3 ureteral perforations, that required ureteral stent placement, leaving 53 with stents and 54 without for analysis. Patients with stents had statistically significantly more postoperative flank pain (p = 0.005), bladder pain (p <0.001), urinary symptoms (p = 0.002), overall pain (p <0.001) and total narcotic use (p <0.001) compared to the unstented group. Intraoperative ureteral dilation or intracorporeal lithotripsy did not statistically significantly affect postoperative pain or narcotic use in either group (p >0.05 in all cases). Overall mean stone size in our study was 6.6 mm. There were 4 (7.4%) patients without stents who required postoperative readmission to the hospital secondary to flank pain. All patients (85%) who underwent imaging postoperatively were without evidence of obstruction or ureteral stricture on followup imaging (mean followup plus or minus standard deviation 1.8 +/- 1.5 months), and the stone-free rate was 99.1%. CONCLUSIONS: Uncomplicated ureteroscopy for distal ureteral calculi with or without intraoperative ureteral dilation can safely be performed without placement of a ureteral stent. Patients without stents had significantly less pain, fewer urinary symptoms and decreased narcotic use postoperatively.
Asunto(s)
Dolor Postoperatorio , Stents , Cálculos Ureterales/cirugía , Ureteroscopía , Humanos , Litotricia , Estudios ProspectivosRESUMEN
OBJECTIVES: The techniques for hemostasis after renal tumor excision have limited the widespread application of laparoscopic partial nephrectomy (LPN). To improve hemostasis and aid visualization, we report our experience with a novel radiofrequency coagulation (RFC) technique for LPN. METHODS: Ten patients underwent RFC-assisted LPN. The demographic and perioperative data were tabulated. Patients were positioned as for laparoscopic nephrectomy, and laparoscopic ports were placed. The kidney within Gerota's fascia was mobilized, and the fat overlying the tumor was carefully removed for pathologic evaluation. Under laparoscopic guidance, a radiofrequency probe was percutaneously inserted into the lesion and deployed to coagulate the lesion and a margin of normal parenchyma. Laparoscopic scissors were used to excise the lesion; additional hemostatic maneuvers were used selectively. RESULTS: The mean renal tumor size was 2.1 cm (range 1.0 to 3.2). The median operative time was 170 minutes and the median blood loss was 125 mL. The RFC technique resulted in complete tissue coagulation within the treated volume, thereby facilitating intraoperative visualization, minimizing blood loss, and permitting rapid and controlled tumor resection. The renal architecture was preserved, allowing accurate diagnosis of renal cell carcinoma and angiomyolipoma in 9 and 1 cases, respectively. No perioperative complications occurred. CONCLUSIONS: The use of RFC is an effective method to facilitate LPN of both exophytic and endophytic masses. By coagulating a margin of normal parenchyma, the technique minimizes blood loss and improves visualization during LPN. We anticipate this technique will broaden the clinical application for LPN.
Asunto(s)
Ablación por Catéter , Técnicas Hemostáticas , Laparoscopía , Nefrectomía/métodos , Adulto , Anciano , Femenino , Humanos , Neoplasias Renales/patología , Neoplasias Renales/cirugía , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVES: To evaluate the laparoscopic and percutaneous delivery of impedance-based radiofrequency ablation (RFA) of the kidney by studying the acute and chronic clinical, radiographic, and histopathologic effects in the porcine model. METHODS: Eight kidneys from 4 pigs underwent laparoscopic RFA. Six kidneys from 3 additional pigs received computed tomography (CT)-guided, percutaneous RFA. CT scans were performed immediately after RFA and before harvest at 2 hours, 24 hours, 3 weeks, and 13 weeks. The gross, radiographic, and histopathologic changes were recorded for each period. RESULTS: Grossly, the RFA lesions were sharply demarcated, measuring 3 to 5 cm. Two major complications (14%) occurred (one urinoma, one psoas muscle injury) in 14 ablations. No deaths or significant blood loss occurred as a result of RFA. Radiographically, the immediate CT scanning demonstrated small perinephric hematomas and wedge-shaped defects. Delayed CT showed nonenhancing defects up to 5 cm. Color-flow and power Doppler were unable to distinguish significant tissue changes during RFA. The histopathologic evaluation revealed marked inflammation surrounding the necrotic regions in the early lesions; chronic lesions were characterized by dense fibrosis. The tissue temperatures ranged from 62 degrees to 118 degrees C in the area of ablation. CONCLUSIONS: RFA is readily delivered laparoscopically or percutaneously with minimal morbidity. Impedance-based application of radiofrequency energy allows monitoring and control of ablation. Using a multi-antenna probe, areas of tissue up to 5 cm can be completely destroyed. The RFA lesion can be monitored as a nonenhancing cortical defect on CT.
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Ablación por Catéter/métodos , Riñón/cirugía , Laparoscopía/métodos , Tomografía Computarizada por Rayos X/métodos , Animales , Ablación por Catéter/efectos adversos , Estudios de Factibilidad , Hematoma/etiología , Riñón/diagnóstico por imagen , Riñón/patología , Necrosis de la Corteza Renal/etiología , Necrosis de la Corteza Renal/patología , Enfermedades Renales/etiología , Monitoreo Intraoperatorio/métodos , PorcinosRESUMEN
Previous clinical application of remote telesurgery has been the use of a novel system of video teleconferencing equipment along with remote control of a laparoscopic camera at distances over 11,000 miles. Recently, a robotic system has been developed to assist with percutaneous renal surgery. This robot has been incorporated into the telesurgical system to allow remote needle placement into the renal collecting system under radiological guidance. The main component of the telesurgical system is a low degree of freedom robot called "PAKY" (percutaneous access of the kidney). It is custom designed for fluoroscopic guided percutaneous needle insertion into the renal collecting system. The robot is a six-degrees of freedom device. However, when the skin entry site is fixed and held in position, only two degrees of freedom are required to orient the needle in the correct plane for accurate insertion. Remote control of the robot was accomplished over a plain old telephone system (POTS) line. On June 17, 1998, the first remote telerobotic percutaneous renal access procedure was performed between the Johns Hopkins Hospital, Baltimore, Maryland, and Tor Vergata University, Rome, Italy. This new telesurgical robot was successful in term of obtaining percutaneous access within 20 min, with two attempts to obtain entry into the collecting system. This robot represents the first system for performing remote telesurgical interventions in the kidney and demonstrates the feasibility and safety of assisting accurate and rapid needle access to the kidney during percutaneous procedures.
Asunto(s)
Nefrostomía Percutánea/instrumentación , Robótica/tendencias , Telemedicina/instrumentación , Anciano , Humanos , Masculino , Telemedicina/tendenciasRESUMEN
PURPOSE: We investigated the ease of breakage of endoscopic stone baskets with the holmium:yttrium-aluminum-garnet (YAG) laser and their resultant configuration. More importantly, possible safe methods of retrieval were evaluated. MATERIALS AND METHODS: Endoscopic stone baskets from Bard (Platinum Class 2.4F Flat and 3.0F Helical Wire), Cook (3.2F Captura, 3.2F Atlas, 3.0F N-Circle, 4.5F N-Force), and Microvasive (2.4F Zero Tip, 3.0F Gemini, 3.0F Segura) were broken once using the holmium:YAG laser. The energy (kJ) required to break one of the wires was recorded. Configuration was documented using photographs. Baskets were disassembled and assessed for extraction through a 7F open-ended catheter, an 8F/10F set, and a 20F peel-away sheath. RESULTS: Tipless baskets (N-Circle, Zero Tip) broke the easiest (range 0.02-0.03 kJ). Tipped baskets (Segura, Platinum Class Flat and Helical, Gemini, Captura, N-Force, Atlas) were more resistant, but all broke within the range (0.06-0.78 kJ) typically used for intracorporeal lithotripsy. Broken segments of wire tended to protrude outward, with tipless baskets having less change in configuration than tipped baskets. Tipless baskets could easily be pulled into any of the extracting devices, whereas tipped baskets could not. CONCLUSIONS: Baskets break at typical holmium:YAG intracorporeal lithotripsy energy settings. Tipless baskets break easiest and assume a safer configuration. Tipless baskets are extracted easily through a 7F open-ended catheter, 8F/10F set, or 20F sheath, while tipped baskets are unable to be extracted through any of these.
Asunto(s)
Terapia por Láser/instrumentación , Ureteroscopios/efectos adversos , Ureteroscopía/métodos , Cálculos Urinarios/cirugía , Diseño de Equipo , Falla de Equipo , Humanos , Ensayo de MaterialesRESUMEN
OBJECTIVES: To report our experience with laparoscopic nephron-sparing surgery (NSS) for solid renal masses. METHODS: Between August 1998 and December 1999, 15 patients with solid renal masses underwent laparoscopic NSS at our institutions. Seven patients underwent a transperitoneal approach and eight a retroperitoneal approach. The kidneys were fully mobilized to allow inspection of all renal parenchyma. The ultrasonic shears were used to divide the renal parenchyma around the tumor in all cases. Renal surface hemostasis was then accomplished by welding a piece of oxidized regenerated cellulose gauze to the transected renal surface with the argon beam coagulator. Tumors were removed intact and sent for analysis of frozen section margin status. RESULTS: Laparoscopic NSS was successfully completed without complications in all patients. The mean tumor size was 2.3 cm (range 0.8 to 3.5), mean operative time was 170 minutes (range 105 to 240), and mean estimated blood loss was 368 mL (range 75 to 1000). The final pathologic finding was renal cell carcinoma in 12 patients and oncocytoma in 3 patients. All final surgical margins were negative. Patients were hospitalized for a mean of 2.6 days (range 2 to 4). CONCLUSIONS: Laparoscopic NSS for small, solid renal masses can be performed safely with a combination of the ultrasonic shears for renal parenchymal transection and argon beam coagulation and oxidized regenerated cellulose gauze for renal surface hemostasis.
Asunto(s)
Adenoma Oxifílico/cirugía , Carcinoma de Células Renales/cirugía , Neoplasias Renales/cirugía , Laparoscopía/métodos , Terapia por Ultrasonido/instrumentación , Adenoma Oxifílico/patología , Adulto , Anciano , Carcinoma de Células Renales/patología , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Renales/patología , Tiempo de Internación , Masculino , Persona de Mediana Edad , Stents , Resultado del Tratamiento , Terapia por Ultrasonido/métodosRESUMEN
PURPOSE: We describe the use of fibrin sealant for rapid and definitive hemostasis of splenic injuries incurred during open and laparoscopic left nephrectomy. MATERIALS AND METHODS: In 2 patients undergoing left nephrectomy for a suspicious renal mass splenic laceration occurred during mobilization of the colonic splenic flexure at open nephrectomy and laparoscopic upper pole dissection, respectively. Fibrin sealant was applied topically in each case. RESULTS: In each patient fibrin sealant achieved immediate hemostasis and each recovered without further splenic bleeding. CONCLUSIONS: The topical application of fibrin sealant safely, rapidly and reliably achieves definitive hemostasis of splenic injuries. It is simple to use in the open and laparoscopic approaches.
Asunto(s)
Adhesivo de Tejido de Fibrina/administración & dosificación , Hemostasis Quirúrgica , Hemostáticos/administración & dosificación , Laparoscopía , Nefrectomía/efectos adversos , Bazo/lesiones , Administración Tópica , Anciano , Humanos , Complicaciones Intraoperatorias , Masculino , Persona de Mediana EdadRESUMEN
PURPOSE: Controlled ligation and division of the renal hilum are critical steps during any nephrectomy procedure. The use of the endovascular gastrointestinal anastomosis (GIA) stapling device for control of the renal vessels during laparoscopic nephrectomy has become standard practice. However, malfunction can lead to serious consequences which require emergency conversion to an open procedure. We report our experience with GIA malfunction during laparoscopic nephrectomy. MATERIALS AND METHODS: From July 1993 to September 1999, 565 patients underwent laparoscopic nephrectomy at 2 institutions for benign and malignant diseases, and for live renal donation. Retrospective chart reviews and primary surgeon interviews were conducted to determine etiology of failure, intraoperative management and possible future prevention. RESULTS: Malfunction occurred in 10 cases (1.7%). In 8 cases the renal vein was involved and malfunctions affected the renal artery in 2. The estimated blood loss ranged from 200 to 1,200 cc. Open conversions were necessary in 2 cases (20%). The etiology of the failure included primary instrument failure in 3 cases and preventable causes in 7. Open surgery was required in 2 patients and laparoscopic management was possible in 8. CONCLUSIONS: The endovascular GIA stapler is useful in performing laparoscopic nephrectomy. However, malfunctions may occur, and can be associated with significant blood loss and subsequent need for conversion to an open procedure. The majority of errors could be avoided with careful application and recognition. Many failures, especially when recognized before release of the device, can be managed without conversion to an open procedure.
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Anastomosis Quirúrgica/instrumentación , Laparoscopía , Nefrectomía/métodos , Engrapadoras Quirúrgicas , Pérdida de Sangre Quirúrgica , Procedimientos Quirúrgicos del Sistema Digestivo , Servicios Médicos de Urgencia , Falla de Equipo , Humanos , Arteria Renal/cirugía , Venas Renales/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND AND PURPOSE: Holmium:YAG lithotripsy of uric acid calculi produces cyanide. The laser and stone parameters required to produce cyanide are poorly defined. In this study, we tested the hypotheses that cyanide production: (1) varies with holmium:YAG power settings; (2) varies among holmium:YAG, pulsed-dye, and alexandrite lasers; and (3) occurs during holmium:YAG lithotripsy of all purine calculi. MATERIALS AND METHODS: Holmium:YAG lithotripsy of uric acid calculi was done using various optical fiber diameters (272-940 microm) and pulse energies (0.5-1.5 J) for constant irradiation (0.25 kJ). Fragmentation and cyanide were quantified. Cyanide values were divided by fragmentation values, and fragment sizes were characterized. To test the second hypothesis, uric acid calculi were irradiated with Ho:YAG, pulsed-dye, and alexandrite lasers. Fragmentation and cyanide were measured, and cyanide per fragmentation was calculated. Fragment sizes were characterized. Finally, Ho:YAG lithotripsy (0.25 kJ) of purine and nonpurine calculi was done, and cyanide production was measured. RESULTS: Fragmentation increased as pulse energy increased for the 550- and 940-microm optical fibers (P < 0.05). Cyanide increased as pulse energy increased for all optical fibers (P < 0.002). Cyanide per fragmentation increased as pulse energy increased for the 272-microm optical fiber (P = 0.03). Fragment size increased as pulse energy increased for the 272-microm, 550-microm, and 940-microm optical fibers (P < 0.001). The mean cyanide production from 0.25 kJ of optical energy was Ho:YAG laser 106 microg, pulsed-dye 55 microm, and alexandrite 1 microg (P < 0.001). The mean cyanide normalized for fragmentation (microg/mg) was 1.18, 0.85, and 0.02, respectively (P < 0.001). The mean fragment size was 0.6, 1.1, and 1.9 mm, respectively (P < 0.001). After 0.25 kJ, the mean amount of cyanide produced was monosodium urate stones 85 microg, uric acid 78 microg, xanthine 17 microg, ammonium acid urate 16 microg, calcium phosphate 8 microg, cystine 7 microg, and struvite 4 microg (P < 0.001). CONCLUSIONS: Cyanide production varies with Ho:YAG pulse energy. To minimize cyanide and fragment size, Ho:YAG lasertripsy is best done at a pulse energy < or = 1.0 J. Cyanide production from laser lithotripsy of uric acid calculi varies among Ho:YAG, pulsed-dye, and alexandrite lasers and is related to pulse duration. Cyanide is produced by Ho:YAG lasertripsy of all purine calculi.
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Cianuros/metabolismo , Terapia por Láser , Cálculos Urinarios/metabolismo , Cálculos Urinarios/terapia , Relación Dosis-Respuesta en la Radiación , Humanos , Litotricia , Purinas/análisis , Ácido Úrico/análisisRESUMEN
OBJECTIVES: To present the preliminary results of renal ablative cryosurgery in selected patients. METHODS: Seven patients were treated, all of whom had small peripheral tumors and chose not to undergo partial or radical nephrectomy. Four patients underwent a rib-sparing flank incision; the remaining three underwent laparoscopy. All tumors were biopsied before cryoablation. Intraoperative ultrasound was used to monitor the cryolesion. RESULTS: There were no intraoperative complications. The estimated blood loss averaged 111 mL. To date, 6 of the 7 patients have undergone at least one follow-up computed tomography scan (14.2 months average follow-up); all these scans demonstrated partial resolution of the lesion. Clinically, the patients tolerated the procedure without any renal complications or significant changes in creatinine. CONCLUSIONS: This limited clinical trial has demonstrated the feasibility of treating small peripherally located renal tumors with cryosurgery with minimal morbidity and a favorable outcome. Further studies are necessary to determine the long-term efficacy of this treatment modality.
Asunto(s)
Criocirugía , Neoplasias Renales/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Neoplasias Renales/diagnóstico , Masculino , Persona de Mediana EdadRESUMEN
Histologic information can be pivotal in making treatment decisions. Ultrasound-guided percutaneous biopsy is the current standard, but if this procedure fails or is considered to be high risk, laparoscopic biopsy may be appropriate. A CT or ultrasound scan is obtained to determine whether there is any condition that would mandate biopsy of a particular kidney. The retroperitoneal space is entered with a visual obturator, and, after CO2 insufflation to 15 to 20 mm Hg, the space is enlarged initially by blunt dissection with the laparoscope. Two-tooth biopsy forceps are used to obtain tissue, and hemostasis is achieved with the argon beam coagulator with care to vent the increased pressure created by the flow of gas. Postoperatively, specific attention is given to blood pressure control. Hemorrhage is the most common serious complication, so any anticoagulation regimen must be reinstituted cautiously.
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Biopsia/métodos , Enfermedades Renales/patología , Laparoscopía , Humanos , Enfermedades Renales/diagnóstico por imagen , Tiempo de Internación , Selección de Paciente , Postura , Reproducibilidad de los Resultados , Espacio Retroperitoneal , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
OBJECTIVES: To assess retrospectively whether laparoscopic retroperitoneal lymph node dissection (RPLND) in patients with clinical Stage I nonseminomatous germ cell testicular tumor (NSGCT) provides useful pathologic staging information on which subsequent management can be based. Approximately 30% of patients with clinical Stage I NSGCT will have pathologic Stage II disease. METHODS: A retrospective review of 29 patients with clinical Stage I NSGCT who underwent transperitoneal laparoscopic RPLND by a single surgeon was performed. Selection criteria included the presence of embryonal carcinoma in the primary tumor or vascular invasion. A modified left (n = 18) or right (n = 11) template was used. RESULTS: Positive retroperitoneal nodes were detected in 12 (41%) of 29 patients. Ten of these patients received immediate adjuvant platinum-based chemotherapy, and 2 patients refused chemotherapy. The nodes were negative in 1 7 (59%) of 29 patients; all but 2 patients (one with recurrence in the chest, the other with biochemical recurrence) have undergone observation. No evidence of disease recurrence has been found in the retroperitoneum of any patient (follow-up range 1 to 65 months). Prospectively, the dissection was limited if grossly positive nodes were encountered; therefore, the total number of nodes removed was significantly different if the nodes were positive or negative (14 +/- 2 and 25 +/- 3, respectively; P <0.004). Two patients required an open conversion because of hemorrhage. Complications included lymphocele (n = 1) and flank compartment syndrome (n = 1). CONCLUSIONS: Laparoscopic RPLND is a feasible, minimally invasive surgical alternative to observation or open RPLND for Stage I NSGCT. Disease outcomes are favorable to date. Longer follow-up in a larger series is necessary to determine therapeutic efficacy.
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Germinoma/secundario , Germinoma/cirugía , Laparoscopía , Escisión del Ganglio Linfático/métodos , Neoplasias Testiculares/patología , Neoplasias Testiculares/cirugía , Adulto , Humanos , Metástasis Linfática , Masculino , Estadificación de Neoplasias , Espacio Retroperitoneal , Estudios RetrospectivosRESUMEN
PURPOSE: We determine the subjective and objective durability of laparoscopic versus open pyeloplasty. MATERIALS AND METHODS: From August 1993 to April 1997, 42 patients underwent laparoscopic pyeloplasty (laparoscopy group) with a minimum clinical followup of 12 months (mean 22). Subjective outcomes and objective findings were compared to those of 35 patients who underwent open pyeloplasty (open surgery group) from August 1986 to April 1997 with a minimum clinical followup of 12 months (mean 58). We assessed clinical outcome based on responses to a subjective analog pain and activity scale. In addition, radiographic outcome was assessed based on the results of the most recent radiographic study. RESULTS: Of the 42 laparoscopy group patients 90% (38) were pain-free (26, 62%) or had significant improvement in flank pain (12, 29%) after surgery. Two patients had only minor improvement and 2 had no improvement in pain. Surgery failed in only 1 patient with complete obstruction. A patent ureteropelvic junction was demonstrated in 98% (41 of 42 patients) of the laparoscopy group on the most recent radiographic study (mean radiographic followup 15 months). Of the 35 open surgery group patients 91% were pain-free (21, 60%) or significantly improved (11, 31%) after surgery. One patient had only minor improvement and 2 were worse. CONCLUSIONS: Pain relief, improved activity level and relief of obstruction outcomes are equivalent for laparoscopic and open pyeloplasty.
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Pelvis Renal/cirugía , Laparoscopía , Obstrucción Ureteral/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Dimensión del Dolor , Resultado del TratamientoRESUMEN
PURPOSE: No specific cause is identified in most cases of chronic orchialgia. Nonsurgical therapies, including management at a chronic pain clinic, are generally recommended. Only when multiple conservative measures fail are patients offered surgical intervention, such as orchiectomy. We evaluate laparoscopic testicular denervation as an organ preserving and minimally invasive surgical alternative. MATERIALS AND METHODS: Since 1993, 9 patients with chronic orchialgia have undergone transperitoneal laparoscopic testicular denervation after nonsurgical modalities failed. Using 1, 10 mm. and 1 or 2, 5 mm. ports, the gonadal vessels were isolated circumferentially and divided cephalad to the vas deferens and its vasculature. Preoperative treatment modalities, morbidity and outcome were documented. A cord block provided temporary relief in all 9 patients. Analog scales were used to assess long-term pain relief (0 no pain to 100 worst pain) and activity levels (0 bedrest to 100 no restrictions). RESULTS: Average symptom duration before laparoscopic testicular denervation was 4.1 years. Of 9 patients 8 had undergone prior scrotal surgery. Failed nonsurgical modalities included anti-inflammatory drugs in 7 patients, antibiotics in 6, pain clinic consultations in 4 and antidepressant medications in 2. Mean pain score decreased from 69.4 (range 35 to 90) preoperatively to 30.6 at a mean followup of 25.1 months. Excluding the 2 cases that had no pain relief (less than 10-point reduction), average pain score decreased from 69 to 19 postoperatively (mean reduction 71%). Activity levels improved in all cases. There were no significant complications, including testis atrophy. One patient who had no pain relief underwent subsequent hydrocelectomy for pain, which also failed. CONCLUSIONS: Laparoscopic testicular denervation can provide significant long-term pain relief and appears to be a reasonable alternative in select cases with chronic orchialgia refractory to medical therapy. Larger series and prospective evaluations are necessary.
Asunto(s)
Desnervación , Laparoscopía , Dolor/cirugía , Enfermedades Testiculares/cirugía , Testículo/inervación , Testículo/cirugía , Adulto , Enfermedad Crónica , Humanos , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVES: To evaluate renal cryosurgery by studying the feasibility of laparoscopic delivery and the radiographic characteristics and histopathologic effects in a porcine model using different freeze cycles. On the basis of the results, a clinical trial of laparoscopic cryosurgical ablation in select patients with clinical stage T1 renal tumors was started. MATERIALS AND METHODS: Twelve kidneys from six farm pigs underwent cryosurgery. Each kidney was treated with two freeze cycles to -180 degrees C. Six kidneys were retroperitonealized, and six were not. An abdominal CT scan was performed at various times to evaluate for the presence of urinoma or hematoma and to monitor lesion changes. Organs were harvested at times ranging from 24 hours to 13 weeks. Radiographic and histopathologic changes were recorded for each time period. Eight patients with small (average 2-cm) exophytic renal masses underwent laparoscopic biopsy and cryosurgical ablation using a 3- or 4.8-mm probe (Cryomedical Sciences Inc., Rockville, MD) for one 15-minute or two 5-minute freeze cycles to a temperature of -180 degrees C to extend the ice ball at least 7 mm beyond the tumor margin. RESULTS: Dense adhesions between the bowel and cryoablated renal tissue were encountered in all non-retroperitonealized kidneys, but no fistula formation was present. The retroperitonealized kidneys had minimal adhesion formation. None of the animals developed a urinary fistula. At 24 hours and 1 week, CT scanning demonstrated an enhancement defect corresponding to the region of the ice ball with no urinoma or hematoma. At 13 weeks, only a nonenhancing cortical defect was seen. At immediate harvest, hemorrhage was noted in the area of the ice ball with a sharp demarcation at the edge of the freeze zone. At 1 week, four distinct zones were seen: central necrosis, inflammatory infiltrate, hemorrhage, and fibrosis with regeneration. At 13 weeks, the necrotic tissue had been replaced with a circumscribed area of fibrosis. There were no intraoperative or postoperative complications in the eight patients. The estimated blood loss was 140 mL, and the mean hospital stay was 3.5 days. At a mean clinical follow-up of 7.7 (range 1-18) months and radiographic follow-up of 5 months; there have been no tumor recurrences or significant changes in the serum creatinine concentration. At 24 hours, there was an enhancement defect in the area of the ice ball. The CT images at 13 weeks showed a nonenhancing cortical defect in the area of the ice ball. CONCLUSIONS: Cryosurgery can be readily delivered laparoscopically, creating a discrete lesion at the time of treatment that appears to be consistent over time. In the animal studies, complete tissue necrosis developed in the freeze zone, followed by reabsorption, and by 13 weeks, fibrous tissue had replaced the defect. In the animal and human trials, there were no operative complications, urinomas, hematomas, or bowel or urinary fistulas. Follow-up imaging in human trials revealed a persistent nonenhancing defect in the area of the freeze zone. Long-term clinical follow-up will be necessary to determine the cancer-free survival rate.
Asunto(s)
Carcinoma de Células Renales/cirugía , Criocirugía/métodos , Neoplasias Renales/cirugía , Riñón/cirugía , Laparoscopía , Tomografía Computarizada por Rayos X , Anciano , Anciano de 80 o más Años , Animales , Biopsia , Carcinoma de Células Renales/diagnóstico por imagen , Carcinoma de Células Renales/patología , Estudios de Factibilidad , Estudios de Seguimiento , Humanos , Riñón/diagnóstico por imagen , Riñón/patología , Neoplasias Renales/diagnóstico por imagen , Neoplasias Renales/patología , Tiempo de Internación , Persona de Mediana Edad , Estadificación de Neoplasias , Resultado del Tratamiento , Ultrasonografía DopplerRESUMEN
PURPOSE: Bowel injury is a potential complication of any abdominal or retroperitoneal surgical procedure. We determine the incidence and assess the sequelae of laparoscopic bowel injury, and identify signs and symptoms of an unrecognized injury. MATERIALS AND METHODS: Between July 1991 and June 1998 laparoscopic urological procedures were performed in 915 patients, of whom 8 had intraoperative bowel perforation or abrasion injuries. In addition, 2 cases of unrecognized bowel perforation referred from elsewhere were reviewed. A survey of the surgical and gynecological literature revealed 266 laparoscopic bowel perforation injuries in 205,969 laparoscopic cases. RESULTS: In our series laparoscopic bowel perforation occurred in 0.2% of cases (2) and bowel abrasion occurred in 0.6% (6). The 6 bowel abrasion injuries were recognized intraoperatively and 5 were repaired immediately. In 4 cases, including 2 referred from elsewhere, perforation injuries were not recognized intraoperatively and they had an unusual presentation postoperatively. These patients had severe, single trocar site pain, abdominal distention, diarrhea and leukopenia followed by acute cardiopulmonary collapse secondary to sepsis within 96 hours of surgery. The combined incidence of bowel complications in the literature was 1.3/1,000 cases. Most injuries (69%) were not recognized at surgery. Of the injuries 58% were of small bowel, 32% were of colon and 50% were caused by electrocautery. Of the patients 80% required laparotomy to repair the bowel injuries. CONCLUSIONS: Bowel injury following laparoscopic surgery is a rare complication that may have an unusual presentation and devastating sequelae. Any bowel injury, including serosal abrasions, should be treated at the time of recognition. Persistent focal pain in a trocar site with abdominal distention, diarrhea and leukopenia may be the first presenting signs and symptoms of an unrecognized laparoscopic bowel injury.
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Perforación Intestinal/diagnóstico , Perforación Intestinal/epidemiología , Complicaciones Intraoperatorias/diagnóstico , Complicaciones Intraoperatorias/epidemiología , Laparoscopía , Humanos , IncidenciaRESUMEN
OBJECTIVE: Using a personal computer-based teleradiology system, we compared accuracy, confidence, and diagnostic ability in the interpretation of digitized radiographs to determine if teleradiology-imported studies convey sufficient information to make relevant clinical decisions involving urology. Variables of diagnostic accuracy, confidence, image quality, interpretation, and the impact of clinical decisions made after viewing digitized radiographs were compared with those of original radiographs. MATERIALS AND METHODS: We evaluated 956 radiographs that included 94 IV pyelograms, four voiding cystourethrograms, and two nephrostograms. The radiographs were digitized and transferred over an Ethernet network to a remote personal computer-based viewing station. The digitized images were viewed by urologists and graded according to confidence in making a diagnosis, image quality, diagnostic difficulty, clinical management based on the image itself, and brief patient history. The hard-copy radiographs were then interpreted immediately afterward, and diagnostic decisions were reassessed. All analog radiographs were reviewed by an attending radiologist. RESULTS: Ninety-seven percent of the decisions made from the digitized radiographs did not change after reviewing conventional radiographs of the same case. When comparing the variables of clinical confidence, quality of the film on the teleradiology system versus analog films, and diagnostic difficulty, we found no statistical difference (p > .05) between the two techniques. Overall accuracy in interpreting the digitized images on the teleradiology system was 88% by urologists compared with that of the attending radiologist's interpretation of the analog radiographs. However, urologists detected findings on five (5%) analog radiographs that had been previously unreported by the radiologist. CONCLUSION: Viewing radiographs transmitted to a personal computer-based viewing station is an appropriate means of reviewing films with sufficient quality on which to base clinical decisions. Our focus was whether decisions made after viewing the transmitted radiographs would change after viewing the hard-copy images of the same case. In 97% of the cases, the decision did not change. In those cases in which management was altered, recommendation of further imaging studies was the most common factor.