Laparoscopic cystectomy and intracorporeal continent urinary diversion (Mainz II) in treatment for interstitial cystitis

INTRODUCTION

Interstitial cystitis (IC) is a difficult-to-manage chronic and insidious condition. We present a series of patients with IC who failed to respond to conservative treatment. The patients underwent total cystectomy with completely intracorporeally performed continent urinary diversion (Mainz II rectosigmoid pouch) as a radical alternative to the treatment of this condition.

MATERIAL AND METHODS

Eight patients who fulfilled the clinical criteria for IC according to the National Institute of Health and in whom all previous conservative treatments had failed between January 2001 and April 2009 were operated on. A descriptive analysis was made with the following variables: age, surgical risk according to the American Society of Anesthesiology (ASA), total surgical time (ST), ST of the cystectomy, ST of the urinary diversion, early and late complications, time of hospital stay, bleeding and need of transfusion, specimen extraction pathway and uterine sparing.

RESULTS

Mean age was 54.25 (±17.8) years, total mean ST 286.4 (±44.8) minutes, mean ST of the cystectomy 86.2 (±25.6) minutes, mean ST of the diversion 123.7 (±28.6) minutes, mean bleeding 321.4 (±242.9) cc, mean time of hospital stay 8.3 (±1.3) days. Fifty percent were ASA I, 37.5% ASA II and 12.5% ASA III. A hysterectomy was made in 50% of the cases. In 5 cases (62.5%) the bladder was extracted through the rectum and in 3 cases (37.5%) through the vagina. The only early complication was urinary sepsis in one patient. There was no conversion in the series.

CONCLUSIONS

Total cystectomy with urethrectomy and intracorporeal continent urinary diversion is an effective and definitive alternative for the treatment of treatment resistant IC. Their technical difficulty and its learning curve limit their application to centers with an extensive experience in laparoscopy.

Laparoscopic ureteral replacement by Boari flap: multi-institutional experience in 30 cases

INTRODUCTION

The Boari flap is an excellent technique for replacement of distal ureteral injuries. There are few reports with the use of laparoscopic surgery, especially with long term results. Our goal is to present the results of a multi-institutional study of 30 cases.

MATERIAL AND METHODS

We analyzed 30 patients treated between December 2001 and January 2009 who underwent a laparoscopic intracorporeal Boari flap, in three Latin American centers. In all cases the same surgical technique was employed. The database was recorded prospectively and analyzed retrospectively.

RESULTS

The mean age was 43.2 years (range 9 to 71 years). Most were women (22 of 30) with a slight predominance of left-side lesions (17 of 30). The most common cause of ureteral injury was hysterectomy in 14 patients (46.6%) and endoscopic ureterolithotomy in 9 patients (30%). The mean length of ureteral resection was 7 cm. (5 to 20 cm). The average operative time was 161.16 min (90 to 280 min). The average estimated blood loss was 123 mL. (0 to 500 mL), and hospital stay was 4.86 days (2 to 10 days). There were no intraoperative complications or conversion to open surgery. Postoperative complications occurred in 5 patients (16.6%), Clavien 1 in 2 patients (6.6%) and Clavien 3 in three patients (10%). The success rate was 96.6% (29 patients) with a mean follow up of 32 months (5 to 60 months).

CONCLUSIONS

Laparoscopic Boari flap in our hands had good short and long term results.

Laparoscopic lumbar-aortic lymphadenectomy in residual post-chemotherapy tumours in testicular cancer

INTRODUCTION

Open lumbar-aortic lymphadenectomy (OLAL) is the gold standard for treating post-chemotherapy retroperitoneal masses. Laparoscopic OLAL (L-OLAL) has emerged in recent years as an alternative for the handling of patients with these masses, with the additional potential benefits of minimal invasion.

OBJECTIVE

To present our experience with the laparoscopic handling (L-OLAL) of residual post-chemotherapy masses in patients with advanced testicular cancer.

MATERIAL AND METHODS

Between 1993 and 2009, 43 patients underwent post-chemotherapy L-OLAL. A transperitoneal technique was employed in all patients. We assessed demographic, perioperational and pathological variables, as well as complications and follow-up.

RESULTS

A unilateral dissection was performed in 17 patients, while 26 patients underwent a bilateral retroperitoneal dissection. In the first group, 4 patients relapsed. In the second group, there were no relapses. After an average follow-up of 21 months, the overall survival rate reached 95%. We recorded a rate of perioperative complications of only 9.3%.

CONCLUSIONS

In experienced hands, L-OLAL is a technically feasible surgical alternative for the treatment of patients who are carriers of advanced testicular cancer with residual post-chemotherapy masses. The dissection performed should be bilateral to avoid tumour relapses and increase the survival rate of these patients.

Robotic partial nephrectomy with selective parenchymal compression (Simon clamp)

OBJECTIVE

To present our initial experience using selective renal parenchymal ischemia, without hilar clamping, in robotic-assisted partial nephrectomy.

MATERIAL AND METHODS

In four patients with T1a renal tumor we performed robotic-assisted partial nephrectomy, using the Simon's clamp (Aesculap). It provides selective parenchymal compression without the need of vascular clamping. All patients had exofitic renal tumors in polar location. Renal parenchymal reconstruction was done as the standard technique.

RESULTS

The median age was 49.6 years (42-59), 3 male and 1 female patient. Median operative time was 71,6 minutes (40-120). Mean stimated bleeding was 250 ml (50-400). Average tumor size was 3,25 cm (1,5-5,3). There were no complications and the average hospital stay was 3,5 days (1-7). The pathology was informed as renal cell carcinoma in three patients and one hemorrhagic cyst. The surgical margins were negative.

CONCLUSION

Our preliminary results shows that selective renal parenchymal compression, with the Simon's clamp, provides an alternative to vascular control in selected patients with polar renal tumors.

[Robotic partial nephrectomy: an initial experience in 25 consecutive cases]

OBJECTIVE

To report our initial experience with robotic partial nephrectomy (RPN) in a series of 25 consecutively-operated patients.

MATERIAL AND METHODS

A series of 25 consecutive patients who underwent RPN from April 2010 to February 2011 were studied. We used the da Vinci S HD robotic system with transperitoneal approach. Total renal hilum control was used 22 cases and 3 patients underwent selective renal parenchymal compression with an ad-hoc device.

RESULTS

Mean age was 55.8 years (26-77) with a male/female ratio of 2:1. Mean operative time was 117.6 minutes (54-205) and the warm ischemia time was 20.2 minutes (9-34). Mean estimated blood loss was 440 ml (20-2000) and the mean tumor size was 3.25 cm (1-5.3). Five patients (20%) had complications, the most frequent being intraoperative bleeding (Clavien II). There was no conversion to open or laparoscopic surgery. Mean hospital stay was 3.5 days (1-7). The pathological study revealed renal cell carcinoma in 19 cases and benign lesions in 6 patients. There were no positive surgical margins and no mortality.

CONCLUSIONS

Our preliminary results show that RPN is a feasible surgical approach in small-sized renal tumors.

[Urethroplasty with dorsal oral mucosa graft in female urethral stenosis]

INTRODUCTION

Female urethral stenosis is not a very common pathology and its treatment is controversial. Therapeutic options vary from urethral dilatation and internal urethrotomy to other more complex reconstructive surgical techniques. The use of oral mucosa grafts to treat urethral stenosis has provided excellent long-term results in men, however there are few studies on their use in female urethral stenosis. We present our experience in the management of urethral stenosis using dorsal oral mucosa grafting.

MATERIALS AND METHODS

We present 2 cases of female patients with a history of repeated urinary tract infections associated with low obstructive uropathy. In both cases, we encountered distal urethral stenosis, where both were treated with urethral plasty by means of dorsal oral mucosa grafting.

RESULTS

The surgery took place without complications. Hospitalization time was 24 hours in both cases. The catheter was removed on the tenth postoperative day. The urethrocystography showed good urethral calibre with no signs of urinary fistula. After a mean follow-up of 18 months, neither patient presented symptoms of low obstructive uropathy or urinary incontinence.

CONCLUSIONS

Urethroplasty with dorsal oral mucosa grafting is a reproducible and effective therapeutic option for the treatment of urethral stenosis in women.

[Management of hemorrhagic radiation cystitis with hyperbaric oxygen therapy]

INTRODUCTION AND OBJECTIVES

hemorrhagic cystitis (HC) after pelvic radiotherapy occurs in 2-8% of patients. A variety of treatments have been described, most of them with uncertain results. We assessed the efficacy of hyperbaric oxygen therapy (HBOT) in HC cases.

PATIENTS AND METHODS

retrospective analysis of patients with HC after pelvic radiotherapy receiving HBOT at our center between January 2002 and January 2010. Our protocol included 40 sessions of HBOT in a multiplace hyperbaric chamber with 90minutes of 100% oxygen breathing at 2.2 atm. Success was evaluated in terms of total or partial stop of bladder bleeding. Telephone follow-up was updated at the time of submission in all cases.

RESULTS

twenty-five patients were treated (21 male, 4 female); the mean age was 66.7 years. Twenty men were irradiated for prostate cancer and one for bladder cancer. Three women had cervix cancer and one endometrial cancer. In all cases previous conservative treatment had failed and HBOT was considered only after other measures failed. All the patients responded to HBOT and none recurred after end of treatment at a mean follow-up of 21.2 months. There were no serious complications.

CONCLUSION

HBOT is a highly effective and safe, non-invasive therapy for HC secondary to pelvic radiation; it should be considered as first line alternative in these difficult cases.

[Rational and selective management of patients with anterior urethral stricture disease]

INTRODUCTION

the management of anterior urethral stricture is controversial. A review article was written, which updates the current situation of the surgical treatment of anterior urethral stricture.

MATERIALS AND METHODS

the experience of the Hospital del Trabajador in Santiago de Chile regarding its different surgical approaches, as well as scientific literature on the topic, were reviewed.

RESULTS

traditionally, anterior urethral stricture has been treated using minimally invasive techniques (dilatation and internal urethrotomy), which are unable to cure more than 30-35% of patients. On the other hand, urethral reconstruction surgery (urethroplasty) is more complex and requires training, however it can cure a wide majority of patients in a single surgical procedure. Due to a lack of experience and training in reconstructive surgery, non-invasive methods are overused and abused, to the detriment of the patients' quality of life. There is substantial evidence that internal urethrotomy is an excellent method for treating stricture of up to 1cm in length, however its efficacy decreases drastically above 1.5cm. Notwithstanding, urethroplasty is directly indicated for larger strictures, especially if prior urethrotomy failed.

CONCLUSION

this procedure must be managed selectively, applying the appropriate treatment aimed at curing and not only palliating the disease. Urologists must be better trained in urethroplasty and/or centres of excellence must be established to be able to offer the best treatment in each case.

[Partial laparoscopic adrenalectomy in primary hyperaldosteronism]

INTRODUCTION

primary hyperaldosteronism is one of the few potentially curable causes of secondary arterial hypertension. One of the most important variants is the adenoma of the adrenal cortex that produces aldosterona (Conn's Syndrome). The treatment of choice in this subgroup of patients was the removal of the lesion. An initial series of patients with aldosteronoma subjected to partial laparoscopic adrenalectomy is presented.

MATERIALS AND METHOD

We examined the case selection and methods applied to hypertensive patients subjected to partial laparoscopic adrenalectomy between November 2001 and March 2004 due to primary hyperaldosteronism. They all presented an imaging study (CT scan) compatible with a tumour of the adrenal cortex and, in two patients the lesion was bilateral. One patient had a history of incidental adrenalectomy during and open colecistectomy performed some years previously.

RESULTS

we operated on 16 patients, 13 of them women and 3 men, with a mean age of 55.4 years. We performed 18 laparoscopic adrenalectomies: 17 conservative operations and one total adrenalectomy of a 4.3 cm tumour in a patient with bilateral lesion. The mean duration of the operations was 70.9 minutes, with a mean bleeding rate of 30 ml. There were no complications or the need to resort to open surgery. Postoperative hospital stay was 2.8 days. In all the cases, the hypertension improved totally or partially.

CONCLUSION

although small, the series confirmed that partial laparoscopic suprarenalectomy can be performed with good results and with the advantages of minimally invasive surgery.

Isolated soy protein improves endothelial function in postmenopausal hypercholesterolemic women

BACKGROUND

Postmenopausia and hypercholesterolemia are related to endothelial dysfunction, a pathogenic event in atherosclerosis. Soy protein reduces plasma cholesterol, but there is scanty information about its effect on endothelial function.

OBJECTIVE

To evaluate the effect of isolated soy protein compared to caseinate on plasma lipoproteins and endothelial function in postmenopausal hypercholesterolemic women.

DESIGN

Randomized, double-blind, cross-over trial.

SETTING

Outpatient clinic of the Catholic University of Chile.

SUBJECTS

Eighteen healthy, postmenopausal women with hypercholesterolemia were recruited, included and completed the protocol.

INTERVENTIONS

During the trial, all patients followed a low fat/low cholesterol diet and were randomly assigned to receive isolated soy protein or matching caseinate for 4 weeks, and then the alternative treatment until week 8. At pre-study and at the end of the first and second period, plasma lipoprotein levels and endothelial function (flow-mediated dilatation (FMD) of the brachial artery) were evaluated.

RESULTS

Plasma total and low density lipoprotein (LDL)-cholesterol concentration were significantly lower with the low fat/low cholesterol diet compared to pre-study, either with caseinate or soy protein. No significant differences in plasma lipid concentration between caseinate or soy protein interventions were observed. FMD did not change with the caseinate. In contrast, when soy protein was administered, FMD was significantly higher compared to pre-study (9.4+/-1.8% vs 5.3+/-1.2%; P<0.05) and compared to caseinate intervention (9.4+/-1.8% vs 4.9+/-1.5%; P<0.033).

CONCLUSIONS

These results suggest that in postmenopausal hypercholesterolemic women, soy protein improves endothelial function, regardless of changes in plasma lipoproteins.

The parkinsonian neurotoxin, MPP+ induces phosphorylated c-Jun in dopaminergric neurons of mesencephalic cultures

The stress-activated protein kinase (SAPK) cascade serves a critical role in the apoptotic death of neuronal cells in response to a variety of cellular stresses. Recent in vitro and in vivo evidence has directly implicated this kinase in the death of dopaminergic nigral neurons in the MPTP model of Parkinson's disease (PD). To assess the involvement of c-Jun, a key transcription factor substrate of SAPK (also known as c-Jun N-terminal kinase, or JNK) in the MPTP-induced death of dopaminergic nigral neurons, we determined the ability of MPP+, the active toxin metabolite of MPTP, to induce the phosphorylated form of c-Jun in dopaminergic neurons in nigral (ventral mesencephalon) cultures. At a dose of MPP+ that specifically induces apoptotic changes in nuclear morphology in tyrosine hydroxylase-positive (dopaminergic) cells in these cultures, MPP+ induces nuclear phospho-c-Jun immunoreactivity (IR). The peak induction of phospho-c-Jun IR was observed 16h after beginning MPP+ exposure, and preceded the maximal induction of apoptotic nuclear changes by approximately 8h. These data support an important role for the SAPK/JNK pathway including its c-Jun transcriptional target in the apoptotic death of dopaminergic nigral neurons in the MPTP model of PD.

A unique fasciocutaneous flap for posterior urethral repair

The anatomic restrictions produced by male to female gender reassignment surgery necessitated a new surgical solution to treat a traumatic posterior urethral stricture. Aesthetic considerations were of paramount importance to the patient. A unique use of the pudendal thigh fasciocutaneous flap is presented which satisfied the reconstructive needs of well-vascularized tissue for reconstruction of the posterior urethral segment, and addressed the patient's aesthetic concerns. Correction of the posterior urethral stricture was successful, and the flap donor site inconspicuous. This procedure has not been described previously for urethral reconstruction and is an additional regional source of vascularized tissue for urethral repair.

Multilocular cysts of kidney. A study of 29 patients and review of literature

Multilocular renal cyst is a distinct renal tumor whose gross external appearance and absence of normal renal tissue within the septa of loculi distinguish it clearly from other renal cystic lesions. Interlocular septa may contain either (1) fibrous tissue alone or (2) embryonic tissue separating adjacent loculi. Of 29 patients with multilocular renal cysts, 24 underwent a renal-sparing procedure, and only 5 had radical nephrectomy. None of the histologic specimens showed evidence of immature renal tissue or neoplasia. Patients were followed from three months to eight years (mean, 39 months), and no evidence of local recurrence or metastatic disease was found. Because it is difficult to distinguish multilocular renal cyst from cystic Wilms tumor and multicystic clear cell carcinoma on the basis of imaging studies alone, surgical intervention is the only effective method to differentiate multilocular renal cyst from a malignant lesion of the kidney.

Augmentation cystoplasty and the artificial genitourinary sphincter

In 18 patients with urinary incontinence secondary to decreased bladder compliance and sphincteric incompetence, augmentation cystoplasty and the artificial genitourinary sphincter were combined successfully to produce complete urinary control. Insertion of the sphincter was simultaneous with augmentation cystoplasty in 11 patients. In 6 patients the artificial sphincter was placed before augmentation cystoplasty. One patient underwent placement of a sphincter subsequent to enterocystoplasty and failed Young-Dees reconstruction of the vesical neck. It is noteworthy that in all 6 patients who underwent sphincteric placement before bladder augmentation decreased bladder compliance and urinary incontinence developed with time, and upper tract deterioration developed in 2 patients. Fifteen patients empty the bladder by intermittent self-catheterization, and 3 teenagers void by relaxation of the pelvic musculature and abdominal straining. In selected patients with complex urinary incontinence augmentation cystoplasty and placement of an artificial genitourinary sphincter cuff can be combined successfully without increase in morbidity over that with either procedure performed separately.