Objective: To report the first single port access (SPA) adrenalectomy to minimize patient discomfort through a less invasive procedure. Methods/Results: We performed the first SPA in a 63-year-old, otherwise healthy Caucasian female who had a 4.5-cm left adrenal mass that was incidentally discovered on computed tomography scan of the abdomen and pelvis. Through a 2-cm single longitudinal supraumbilical incision extended down to the abdominal fascia, three 5-mm ports were placed through separate facial entry points, to make a triangular port arrangement. The adrenal vein was identified and ligated using hemoclips. The remainder of the dissection was done using hemocoagulation. The adrenal gland was extracted via an EndoCatch bag device by removing one 5-mm port and upsizing to a 12-mm port. Conclusion: We report on the first SPA adrenalectomy. Although this technology is still in its infancy, the use of a single port for surgery provides a means to provide a potentially better patient outcome with a less invasive procedure.

To evaluate the pathological stage and margin status of patients undergoing radical retropubic prostatectomy (RRP), radical perineal prostatectomy (RPP) and robot-assisted laparoscopic prostatectomy (RALP). We performed a retrospective analysis of 196 patients who underwent RRP, RPP, and RALP as part of our multi-institution program. Fifty-seven patients underwent RRP, 41 RPP, and 98 RALP. Patient age, preoperative prostate specific antigen (PSA), preoperative Gleason score, preoperative clinical stage, pathological stage, postoperative Gleason score, and margin status were reviewed. The three groups had similar preoperative characteristics, except for PSA (8.4, 6.5, and 6.2 ng/ml) for the retropubic, robotic, and perineal approaches. Margins were positive in 12, 24, and 36% of the specimens from RALP, RRP, and RPP, respectively (P = 0.004). The positive margin rates in patients with pT2 tumors were 4, 14, and 19% in the RALP, RRP, and the RPP groups, respectively (P = 0.03). Controlling for age and pre-operative PSA and Gleason score, the rate of positive margins was statistically lower in the RALP versus both the RRP (P = 0.046) and the RPP groups (P = 0.02). In the patients with pT3 tumors, positive margins were observed in 36% of patients undergoing the RALP and 53 and 90% of those patients undergoing the RRP and RPP, respectively (P = 0.015). Controlling for the same factors, the rate of positive margins was statistically lower in the RALP versus the RPP (P = 0.01) but not compared with the RRP patients (P = 0.32). The percentage of positive margins was lower in RALP than in RPP for both pT2 and pT3 tumors. RRP had a higher percentage of positive margins than RALP in the pT2 tumors but not in the pT3 tumors.

OBJECTIVES To evaluate the results of robot-assisted laparoscopic prostatectomy (RALP) at a high-volume conventional laparoscopic radical prostatectomy (LRP) center, to determine whether a learning Curve still exists.MATERIAL AND METHODS A total of 293 consecutive men underwent RALP between May 2000 and November 2006. We prospectively collected and reviewed patient data including the preoperative prostate-specific antigen (PSA) and Gleason score, operative duration, and blood loss, duration of hospitalization, and pathologic Gleason score and margin status.RESULTS Mean operative duration for the entire group was 158 +/- 50 minutes, blood loss was 533 +/- 416 mL, hospital duration was 5 days, and mean age was 61 years. Operative time showed a statistically significant decline at 2 different breakpoints: after the first 12 cases, and after 189 cases, dividing the patients into 3 groups. Operative times were 242 +/- 64, 165 +/- 43, and 134 +/- 45 minutes, respectively, for each group. We also evaluated margin Status in the 3 groups. The positive margin rate in each group was 7/12 (58%), 41/180 (23%), and 10/89 (9%), which was statistically significant. Foley catheter duration was also statistically significant among groups. Age, preoperative Gleason score, and PSA were statistically significant between the second and third groups. There was no statistical significance demonstrated in blood loss, postoperative Gleason score, and length of hospital stay.CONCLUSIONS Urologists who are proficient in laparoscopic radical prostatectomy will still have a learning Curve when first performing an RALP. Experienced laparoscopic surgeons demonstrated continued improvement in operative and pathologic parameters with regard to operative duration and positive margin rate as their experience grew. UROLOGY 73: 127-133, 2009. (C) 2009 Published by Elsevier Inc.

OBJECTIVE:To determine the surgical feasibility and early oncological outcomes of laparoscopic distal ureterectomy in patients with low-grade upper urinary tract transitional cell carcinoma (UUT-TCC).PATIENTS AND METHODS:We retrospectively reviewed patients treated laparoscopically with conservative management for a UUT-TCC between 2001 and 2005. We collected data on gender, age, mode of diagnosis, smoking, history of bladder cancer, complications, tumour site, size, stage, grade, hospital stay, recurrence and progression.RESULTS:Data were analysed for six patients with a mean (range) age of 68.5 (54-76) years. Four patients had a diagnostic ureteroscopy with biopsy. The operative duration was 173.3 (120-240) min, the estimated blood loss was 75 (50-200) mL and the length of ureteric resection was 5.23 cm. Two patients required a psoas hitch. JJ stents were maintained for 25.8 (15-30) days. The hospital stay was 6 (5-8) days. There were minor complications in three patients after surgery. The follow-up was 32 (17-46) months. The tumour size was 1.7 (0.8-2.6) cm. There were low-grade tumours in four patients and pTa in five. All patients are alive and free of disease; there were no anastomotic strictures. Two patients developed a recurrence, one in the ipsilateral renal pelvis and one in the bladder.CONCLUSION:Laparoscopic distal ureterectomy with direct re-implantation is technically feasible for low-risk UUT-TCC (i.e. low-grade, noninvasive), in the properly selected patient. Early oncological outcomes are promising but strict surveillance protocols must be followed.

The robotic-assisted laparoscopic prostatectomy (RALP) has gained rapid acceptance in the urological community due to its documented advantages over standard laparoscopy radical prostatectomy (LRP)1,2 and open prostatectomy.3–5 This advantage has been most appreciated with regards to the learning curve due to enhanced three-dimensional visualization and instruments that allow six degrees of freedom of motion.6 These benefits to the surgeon must, however, translate to improved overall outcomes to justify the increased economic burden placed by the robot.7–9 In this chapter, we will review the current literature for the peri-operative morbidities of RALP. Due to our extensive experience with pure LRP at Montsouris,10,11 the minimally invasive standard to which the RALP must be compared, we will reference the current literature and our own series of both RALP and LRP to make the necessary comparisons for this developing technology.

OBJECTIVES:To determine the surgical and oncologic outcomes in patients who underwent either open nephroureterectomy (ONU) or laparoscopic nephroureterectomy (LNU) for upper urinary tract transitional cell carcinoma.METHODS:We performed a retrospective review of data for patients who underwent ONU or LNU for upper urinary tract transitional cell carcinoma from 1994 to 2004 at one institution. The recorded data included sex, age, mode of diagnosis, smoking, history of bladder cancer, type of surgery, complications, tumor site, tumor size, tumor stage, tumor grade, length of hospital stay, recurrence, and progression. We also determined the recurrence and survival rates.RESULTS:We reviewed the data for 46 patients. The median age was 70 years. Seven patients had a history of bladder cancer. Overall, 26 patients underwent ONU and 20 LNU. No differences in the complication rate (15% versus 15%) were observed. The median hospital stay was 4 days (range 3 to 6) after LNU and 9 (range 7 to 12) after ONU (P <0.001). The tumor stage and grade were independent prognostic factors for survival on multivariate analysis (P <0.05). The 5-year disease-specific survival rate was 89.4% for low-grade tumors and 63.1% for high-grade tumors (P = 0.04). ONU was associated with high-grade (P = 0.02) or invasive (P = 0.001) tumors. The 5-year tumor-free survival rate after ONU and LNU was 51.2% and 71.6%, respectively (P = 0.59).CONCLUSIONS:LNU does not affect the mid-term oncologic control and enables a shorter hospital stay. It can be recommended as an alternative to ONU in the management of low-risk upper urinary tract transitional cell carcinoma (Stage T1-T2 and/or low-grade disease). However, long-term follow-up is necessary to recommend it for highly invasive tumors (Stage T3-T4 or N+).

PURPOSE:We compared a single institution experience with radical prostatectomy using a pure laparoscopic technique vs a robotically assisted technique with regard to preoperative, intraoperative or postoperative parameters. MATERIALS AND METHODS:From May 2003 to May 2005 we reviewed 133 consecutive patients who underwent extraperitoneal robot assisted radical prostatectomy and compared them to 133 match-paired patients treated with a pure extraperitoneal laparoscopic approach. The patients were matched for age, body mass index, previous abdominopelvic surgery, American Society of Anesthesiologists score, prostate specific antigen, pathological stage and Gleason score. Preoperative, perioperative and postoperative data, including complications and oncological results, were analyzed between the 2 groups. RESULTS:The 2 groups were statistically similar with respect to age, body mass index, prostate specific antigen, Gleason score and clinical stage. No statistical differences were observed regarding operative time, estimated blood loss, hospital stay or bladder catheterization between the 2 groups. The transfusion rate was 3% and 9.8% for laparoscopic radical prostatectomy and robotic assisted laparoscopic prostatectomy, respectively (p = 0.03). Conversion from robotic assisted laparoscopic prostatectomy to laparoscopic radical prostatectomy was necessary in 4 cases. None of the laparoscopic radical prostatectomy cases required conversion to an open technique. The percentage of major complications was 6.0% vs 6.8%, respectively (p = 0.80). The overall positive margin rate was 15.8% vs 19.5% for laparoscopic radical prostatectomy and robotic assisted laparoscopic prostatectomy, respectively (p = 0.43). CONCLUSIONS:We demonstrated that the laparoscopic extraperitoneal radical prostatectomy is equivalent to the robotic assisted laparoscopic prostatectomy in the hands of skilled laparoscopic urological surgeons at our institution with respect to operative time, operative blood loss, hospital stay, length of bladder catheterization and positive margin rate.

You have accessJournal of UrologyDiscussed Poster, Tuesday, May 23, 2006, 9:00 am - 12:00 pm1 Apr 20061077: Laparoscopic Distal Ureterectomy for Low Grade Urothelial Malignancy: Technical Considerations and Intermediate Oncologic Outcomes Justin D. Harmon, Francois Rozet, Pascal Hajj, Xavier Cathelineau, Eric Barret, and Guy Vallancien Justin D. HarmonJustin D. Harmon More articles by this author , Francois RozetFrancois Rozet More articles by this author , Pascal HajjPascal Hajj More articles by this author , Xavier CathelineauXavier Cathelineau More articles by this author , Eric BarretEric Barret More articles by this author , and Guy VallancienGuy Vallancien More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)33302-0AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "1077: Laparoscopic Distal Ureterectomy for Low Grade Urothelial Malignancy: Technical Considerations and Intermediate Oncologic Outcomes." The Journal of Urology, 175(4S), p. 346 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 175Issue 4SApril 2006Page: 346 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Justin D. Harmon More articles by this author Francois Rozet More articles by this author Pascal Hajj More articles by this author Xavier Cathelineau More articles by this author Eric Barret More articles by this author Guy Vallancien More articles by this author Expand All Advertisement PDF DownloadLoading ...

Purpose: Prostate-sparing radical cystectomy has been described in the literature and has proven to be a promising procedure owing to the continence and erectile function results without necessarily compromising the oncologic outcome in selected patients. Technique points: A transperitoneal approach is used. Lymph node dissection is performed with frozen section, and then the ureters are ligated and biopsied. The seminal vesicles are dissected, followed by complete mobilization of the bladder. Incision of the bladder neck is performed, followed by simple prostatectomy. Finally, bowel reconstruction is carried out via a small infra-umbilical incision that also permits the extraction of the surgical specimen and the anastomosis of neobladder to the prostate capsule. A total of 25 patients have undergone this procedure, with average surgical times of 285 min and blood loss of 640 ml. The complications encountered included: one bowel incarceration, one urinary leak, one lymphocele and one port hernia. At median 9 months follow-up, no patient presented with daytime incontinence, although seven complained of nocturia. A total of 20 patients maintained their preoperative sexual potency, and four reported a postoperative decrease in their erectile function. Conclusions: Laparoscopic prostate-sparing radical cystectomy appears to be oncologically safe, reproducible and has promising functional benefits. The authors believe this procedure presents a good option in very select patients.

The current reference treatment for upper urinary tract transitional cell carcinoma is open nephroureterectomy via a lumbar incision and an iliac incision with resection of a large bladder cuff: Since the first laparoscopic nephroureterectomy performed in 1991, several teams have studied this approach for the treatment of urinary tract tumours. Laparoscopy has the advantage of decreased morbidity for the patient and allows early return to work. Recent published series do not demonstrate any difference in terms of cancer control between open and laparoscopic nephroureterectomy. However, the follow-up of laparoscopic nephroureterectomy is still limited and the safety of this technique has not been fully demonstrated. It therefore appears preferable to limit the indications for laparoscopic nephroureterectomy to small and/or low-grade tumours to avoid excessive manipulation of large transitional cell carcinomas in a gaseous atmosphere that can predispose to dissemination during dissection. Diagnostic ureteroscopy has therefore become a useful tool in the preoperative assessment. Biopsies can determine the tumour grade and guide the surgeon's choice of surgical approach.

The aim of this study is to report the relative advantages and disadvantages of the radical prostatectomy with a laparoscopic (LRP) and a robotic (RALP) approach. A medline search was performed. Published data regarding perioperative parameters, complications, oncological results, functional results were analyzed. Shorter learning curves have been reported with the RALP. Intra-operative and post-operative outcomes appear to be comparable between the two approaches. The average time for LRP is 234 min (151–453) versus 182 min (141–250) for RALP. Estimated blood loss for the LRP averages 482 ml (185–850) versus 234 ml (75–500) for the RALP. Complication rates in single institution studies are similar. Long-term outcomes data on PSA progression is not yet available for LRP or RALP due to their relatively short existence. RALP appears to offer a significant benefit to the laparoscopically naïve surgeon with respect to learning curve when compared to LRP. This, however, comes at an increased cost. Intra-operative and post-operative outcomes appear to be similar. Longer follow-up data is necessary to compare oncological and functional outcomes.

OBJECTIVES:To determine if placement of urethral suspension stitches during radical retropubic prostatectomy improves postoperative urinary continence. METHODS:Between January 1997 and January 1998 we performed radical retropubic prostatectomy on 50 men. The first 25 consecutive men had their surgery without urethral suspension stitches while the next 25 received placement of two anastomotic urethral suspension stitches anchored to the lower portion of the pubic bone. Patients were interviewed six months postoperatively and each underwent valsalva leak-point pressure measurement. Patients were categorized as either completely continent (requiring no pads and having no measurable valsalva leak point), socially continent (zero or one pad per day), or incontinent (two or more pads per day). RESULTS:In the urethral suspension group, 8/25 (32%) patients were completely continent and did not have a measurable valsalva leak-point pressure while 3/25 (12%) without urethral suspension were completely continent. Of the remaining patients in the urethral suspension group, 13/17 (76%) patients were socially continent while 4/17 (24%) were incontinent. The mean valsalva leak-point pressure in the 17 patients with suspension stitches was 89.6 +/- 21.6 cm H2O. In the patients without urethral suspension, there were 22 patients who had some degree of incontinence. Among non-stitch patients, 13/22 (59%) were socially continent while 9/22 (41%) were incontinent. The average valsalva leak-point pressure in these patients was 74.0 +/- 16.7 cm H2O, which was significantly lower than those with the suspension (p = 0.015). CONCLUSIONS:Placement of anastomotic urethral suspension stitches during radical retropubic prostatectomy may increase the likelihood of complete postoperative urinary continence. The urethral suspension stitches also increase valsalva leak-point pressure, which may improve the percentage of patients with socially acceptable incontinence.

Objectives. The efficacy of finasteride in the treatment of gross hematuria associated with benign prostatic hyperplasia is well established. We evaluated a regimen of pretreatment with finasteride in decreasing perioperative bleeding associated with transurethral resection of the prostate (TURP). Methods. A prospective analysis compared 25 patients pretreated with finasteride for 2 to 4 months before TURP with 50 patients without pretreatment. Patients in each group were further separated by the amount of prostate tissue resected. Patients were then followed up for perioperative bleeding, defined as a perioperative blood transfusion requirement or a return visit to the emergency room with gross hematuria or clot retention. Results. None of the patients with less than 30 g of prostate tissue resected experienced perioperative bleeding. In patients with 30 g or more resected, several episodes of bleeding occurred. In the patients pretreated with finasteride, 1 (8.3%) of 12 experienced perioperative bleeding; in the control group, 7 (36.8%) of 19 had an episode of bleeding. Conclusions. In patients with large prostate glands undergoing TURP, pretreatment with finasteride appears useful in reducing perioperative bleeding.

Arterial infusion 245 Aspergillosis radiography 110 Benign fibromatous tumor 34 -prostatic hyperplasia 155 -tumor 37 Bladder 93, 122 -augmentation 117 -cancer, diagnosis 26 -carcinoma 51, 213 -neck suspension 17, 57 -neoplasms 69 -substitution 99 -tumor 150 Body fluids 139 Bone metastasis 44 Bone-anchor suture fixation 57 N-Butyl-N-(4-hydroxybutyl)nitrosamine 150 C57BL/6 mice 150 Calcification 122 Calcium 87 Calculus 127 Captopril renography 1