Extraperitoneal endosurgical lymphadenectomy with insufflation in the staging of bladder and prostate cancer

Arterial blood gases in extraperitoneal laparoscopic urethrocystopexy

BACKGROUND

The aim of this study was to investigate the effects of extraperitoneal laparoscopy and carbon dioxide insufflation on hemodynamic parameters, arterial blood gases and complications in urethrocystopexy operations.

METHODS

Twenty-five female patients who underwent extraperitoneal laparoscopic mesh urethrocystopexy operation for the correction of urinary incontinence were allocated to the study. Hemodynamic parameters were noted and blood gas analyzes were performed before the induction of anesthesia, 10 min after induction, 5 and 10 min after the beginning of carbon dioxide insufflation, at the end of carbon dioxide insufflation and 30 min after exsufflation.

RESULTS

There was no significant change in mean arterial pressure, peripheral oxygen saturation, arterial carbon dioxide pressure, and arterial oxygen saturation compared to preinsufflation and preinduction values. End-tidal carbon dioxide pressure did not increase above 45 mm/Hg during carbon dioxide insufflation. Arterial oxygen saturation and partial oxygen pressure did not decrease. Subcutaneous emphysema, pneumothorax, pneumomediastinum and pleural effusion were not noted in any patient.

CONCLUSION

We conclude that, extraperitoneal laparoscopic urethrocystopexy is not associated with hemodynamic and respiratory impairment.

Indications, technique, and results of laparoscopic pelvic lymphadenectomy

Despite considerable clinical research, there is still controversy about the optimal management of the pelvic lymph nodes in men with prostate cancer. This article reviews the creation and application of selection criteria for laparoscopic pelvic lymphadenectomy and describes the various techniques.

Lymphoceles after laparoscopic pelvic node dissection

OBJECTIVE

Lymphocele formation has been infrequently reported as a complication of laparoscopic pelvic lymph node dissection (LPLND). We determined the incidence of clinical and subclinical lymphocele formation in patients undergoing transperitoneal LPLND.

METHODS

Charts and radiological records of 111 patients undergoing transperitoneal LPLND at this institution between January 1991 and December 1995 were reviewed to determine the incidence of lymphocele formation.

RESULTS

Of 111 patients undergoing LPLND, 12.6% had positive lymph nodes and received hormonal therapy. Radical retropubic (12) or perineal (28) prostatectomy was performed either simultaneously or within 2 weeks in 41% of the node-negative patients. Radiation therapy was the treatment modality in the remaining node negative patients (N = 57). Twenty-three patients undergoing radiation therapy had preplanning pelvic computed tomography (CT) scans 2 to 16 weeks (mean 8.2 weeks) after LPLND. These were reviewed by a single radiologist to determine the presence of subclinical lymphoceles. Seven patients (30.4%) had lymphoceles of varying sizes (3 large and 4 small). Although most were identified on CT scans 4 weeks after the procedure, two were identified on scans 12 and 16 weeks after the procedure (mean 6.5 weeks). None of these patients developed symptoms referable to or had treatment for the lymphocele during a 2 to 37 month follow-up (mean 20 months). Only two patients (3.5%) undergoing LPLND as an isolated procedure had clinical evidence of lymphocele formation, both of which were subsequently confirmed with CT scans (1 large, 1 small). One was treated with CT-guided drainage and sclerosis and the other resolved spontaneously.

CONCLUSION

The clinical incidence of lymphocele formation following LPLND remains relatively low. Only a portion of these patients requires intervention. Subclinical lymphoceles, as detected on follow-up CT scans, occur with a much greater frequency. These seldom become symptomatic requiring treatment. Rather, they appear to resolve spontaneously. Nevertheless, clinical suspicion should remain high in order to detect and properly treat symptomatic lymphoceles when they occur.

Laparoscopic staging of bladder tumor: concerns about port site metastases

Since the first laparoscopic pelvic lymph node dissection (LPLND) was performed for prostate cancer, only one case of port site metastasis has been reported, an incidence of 0.1%. On the other hand, three cases of port site metastasis have been reported after laparoscopic staging of transitional-cell carcinoma (TCC) of the bladder, a reported incidence of almost 4%. Herein, we review the circumstances of these three cases and address the potential risk factors and possible preventive measures regarding LPLND and port site metastasis in patients with TCC of the bladder.

Retroperitoneoscopic bilateral spermatic vein ligation

An alternative method for bilateral spermatic vein ligation is presented. With a retroperitoneoscopic approach, the vascular structures are clearly identified, and damage to the intraperitoneal organs, spermatic arteries and lymphatics is minimized. We believe that the potential complications of transperitoneal laparoscopic techniques may be decreased with a retroperitoneoscopic approach.

Laparoscopic staging of prostatic carcinoma

Current treatment of prostate cancer is highly controversial, however accurate assessment of pelvic lymph node status is important to determine early in the course of therapy if adjuvant hormonal ablation is necessary. Indications for laparoscopic assessment of pelvic lymph nodes are now better defined and the technique requires a high degree of technical skill and expertise. A series of 50 patients who underwent laparoscopic pelvic lymphadenectomy is presented. A greater than 40% chance of node positivity was found in a group of patients who had either a clinical stage B2, C, DO, or a prostate-specific antigen level greater than 40 ng/dl, or a total Gleason score of 7, 8, 9, or 10. Laparoscopic pelvic lymphadenectomy remains the current method to accurately stage lymph node involvement in prostate carcinoma.