Volume 74, january-march de 2014, Issue 1 … 74, january-march de 2014, Issue 1 Volume 74, Issue 1....

Volume 74, january-march de 2014, Issue 1V

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* ARTEMISA * SSALUD * LILACS * IMLA * PERIODICA-UNAM * IMBIOMED * LATINDEX

Impreso ISSN: 0185-4542, electrónico ISSN: 2007-4085

www.elsevier.es

Urinal and other things

Nomogram application in Mexico for bladder cancer in patients at the Hospital General “Dr. Manuel Gea González”

Urodynamic evaluation of stress urinary incontinence severity: a comparative study for detecting intrinsic external urethral sphincter de�ciency

Single-port laparoscopic nephrectomy: a preliminary experience

Ureteroneocystostomy with laparoscopic psoas hitch as treatment for ureterovaginal �stula: a preliminary experience

Technique and anatomic references in laparoscopic diagnostic pelvic lymphadenectomy

Intravesical prostatic median lobe size as a trial without transurethral catheter result predictor in patients with acute urinary retention

Current aspects of the medical and surgical manage-ment of Peyronie’s disease

Laparoscopic treatment of a complex vesicovaginal �stula

Kidney cancer metastatic to the testis

Laparoscopic partial nephrectomy guided by high de�nition laparoscopic ultrasound

Editor Dr. José Guzmán Esquivel Co-editor Dr. Miguel Maldonado Ávila

ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA

Intraoperative laparoscopic ultrasound for defining the edges and depth of the resection. pp. 55-59

Image showing tumor resection after laparo-scopic ultrasound. pp. 55-59

Image after resection and renorrhaphy for documenting the absence of residual tumor. pp. 55-59

•CONTENT•CONTENIDO

Editorial

Urinal and other things 1 E. E. Quintero-García

oriGiNal artiClES

Nomogram application in Mexico 3 for bladder cancer in patients at the Hospital General “Dr. Manuel Gea González”G. E. Mayorga, et al.

Urodynamic evaluation of stress urinary 9 incontinence severity: a comparative study for detecting intrinsic external urethral sphincter deficiencyR. Pérez-Ortega, et al.

Single-port laparoscopic nephrectomy: 15a preliminary experience J. A. Zapata-González, et al.

Ureteroneocystostomy with laparoscopic 19 psoas hitch as treatment for ureterovaginal fistula: a preliminary experienceJ. A. Zapata-González, et al.

Technique and anatomic references in 25 laparoscopic diagnostic pelvic lymphadenectomyJ. G. Campos-Salcedo, et al.

Intravesical prostatic median lobe size as a trial 30without transurethral catheter result predictor in patients with acute urinary retention M. Maldonado-Ávila, et al.

Editorial

De mingitorios y esas cosas 1 E. E. Quintero-García

artíCuloS oriGiNalES

Aplicación de nomogramas en México 3 para cáncer de vejiga en pacientes del Hospital General “Dr. Manuel Gea González”G. E. Mayorga, et al.

Evaluación de la severidad de la incontinencia 9 urinaria de esfuerzo con estudios urodinámicos: un estudio comparativo para detectar deficiencia intrínseca del esfínter uretral externoR. Pérez-Ortega, et al.

Nefrectomía laparoscópica por puerto único: 15experiencia inicial J. A. Zapata-González, et al.

Ureteroneocistostomía con psoas Hitch 19 laparoscópico como tratamiento de fístula ureterovaginal: experiencia inicialJ. A. Zapata-González, et al.

Técnica y referencias anatómicas en 25 linfadenectomía pélvica diagnóstica laparoscópicaJ. G. Campos-Salcedo, et al.

Tamaño del lóbulo medio prostático intravesical 30como predictor del resultado del intento de retiro de sonda transuretral en pacientes con retención aguda de orina M. Maldonado-Ávila, et al.

MASSON DOYMA MÉXICO, SA. Av. Insurgentes Sur 1388,Piso 8, Col. Actipan Del. Benito Juárez,CP 03230, México, D.F. Tels.: 5524-1069, 5524-4920, Fax: 5524-0468.

Pedro Turbay GarridoDirector General:

Editada por:

rEViEW artiClE

Current aspects of the medical and surgical 35 management of Peyronie’s diseaseE. A. Ramírez-Pérez, et al.

CliNiCal CaSES

Laparoscopic treatment of a complex 44vesicovaginal fistulaJ. A. Zapata-González, et al.

Kidney cancer metastatic to the testis 48 J. D. Farias-Cortés

Laparoscopic partial nephrectomy guided 55by high definition laparoscopic ultrasoundJ. G. Campos-Salcedo, et al.

artíCulo dE rEViSiÓN

Aspectos actuales en el manejo médico-quirúrgico 35 de la enfermedad de PeyronieE. A. Ramírez-Pérez, et al.

CaSoS ClíNiCoS

Tratamiento laparoscópico de una fístula 44vesicovaginal complejaJ. A. Zapata-González, et al.

Metástasis de cáncer renal a testículo 48 J. D. Farias-Cortés

Nefrectomía parcial laparoscópica guiada 55por ultrasonido laparoscópico de alta definiciónJ. G. Campos-Salcedo, et al.

0185-4542 © 2014. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.


www.elsevier.es/uromx

Rev Mex Urol 2014;74(1):1-2

Ne mingas contra ventum.Latin phrase.

Urinal: from the Latin urīna, urine. The dictionary definition is: a sanitary fitting, especially one fixed to a wall, used by men for urination; a room containing urinals; and any vessel for holding urine prior to its disposal.

Very few, if any, inventions have been as closely related to the primeval function of the urinary system, especially in men, as the Urinal (thus the capitalization), due to the extraordinary importance of adequately disposing of the pale yellow, slightly acid fluid that is urine.

Most certainly in prehistoric and closely related epochs, bladders were emptied anywhere - out in the open or in some corner of the caves in which these ancestors of ours lived. And we cannot ignore the fact that this attitude still exists today, because we frequently see people carrying out this important function in the street or “shielded” by some post, wall, car door, or between two parked cars, despite the risk of being caught in the act by an officer of the law and suffering the predictable consequences. Once I attended a wedding at the invitation of a patient; the accommodations were quite rustic, and when I very properly asked the host the whereabouts of the restrooms, he answered, “-when you step outside of this wedding room (which was a warehouse), any place is the restroom”.

Given such situations, it can be assumed that the subject of this theme has had a long and continuing evolution, dependent on each culture, age, and geography and the corresponding customs and traditions (figs. 1, 2, and 3).

During the Roman Empire under Claudius, a device called a mingere prestorium was implemented. In the hands of the Emperor’s servants, it was of continuous assistance, because in his final days he supposedly suffered from intense urinary incontinence.

EDITORIAl

Of urinals and such

De mingitorios y esas cosas

Figure 1 Xanthippe Dousing Socrates. (c. 1655), oil on canvas, Reyer Jacobsz van Blommendael, The Museum of Fine Arts of Strasbourg

2 E. E. Quintero-García

A known custom that existed during the reigns of the many louis, kings of France, was for the servants to carry an elegant chamber pot through the halls and gardens as a service to the guests, so they could alleviate the conditions of a full bladder without having to interrupt their conversations or activities.

Special attention should be paid to louis Bourdaloue (1632-1704), a French Catholic priest. He facilitated the production of adequately shaped portable chamber pots for the women of that era, to be placed under the copious slips and skirts these elegant ladies wore, so that if they needed to urinate while he was delivering his very long sermons, they would not have to leave their seats in church; thus, this artifact is called the Bourdaloue chamber pot or simply the Bourdaloue.

likewise, in the saloons of Mexico in the nineteenth and early twentieth centuries, there was a canal running along the ground between the bar and its corresponding bench, where the customers could urinate without having to disturb their important undertaking. Hand-washing, before or after, had no significance.

As illustrated above, the characteristics of the different models of this valuable contrivance have evolved over a long period of time in regard to form, construction material, and systems.

There are historical references to the extensive variety of shapes and the sophistication or simplicity of urinals in photographs, paintings, and oral histories; they have been made of wood, from the most unpretentious to the most refined and precious elaborations; of clay, ceramic materials and porcelain; of pewter, tin, bronze, silver, and even gold. In recent times, they have been constructed from different plastics, materials that are more resistant, durable, and less expensive.

Many chamber pots made for the rich and powerful resulted in true works of art of extraordinary architectonic value. The creativity of the artisans of different countries has revealed their ingeniousness, humor, and special perspective in varied examples of these artifacts, whether stationary or mobile.

And we must not forget the wise saying that “necessity is the mother of invention”. This wisdom is corroborated by the conversion of a can of popular chiles jalapeños into a magnificently economic chamber pot, or when a plastic carboy for holding purified water, adequately cut and attached to a wall, becomes a very effective and convenient urinal.

Dr. E.E. Quintero-García*Urologist

Coordinator of the History and Philosophy Chapter

*Corresponding author at: Madero Sur No. 749, Centro, Hospital Santa Maria Zamora, Mich., México.

Telephone: (35) 1512 2839. Email: [email protected]

(E.E. Quintero-García)

Figure 2 Woman at her Toilet (c.1660), oil on canvas, Jan Havicksz Steen, Rijksmuseum. To the lower right is a glazed chamber pot.

Figure 3 Glazed chamber pot, 20th century, work of Antonio Tortosa, potter of Chinchilla, Ceramics Museum of Chinchilla de Montearagón (Albacete), Spain.



Rev Mex Urol 2014;74(1):3-8

Corresponding author at: Sagredo 33 Dpto. 403c, Colonia San José Insurgentes, Benito Juárez, Distrito Federal, 03900,Telephone: 5591850321. Email: [email protected] (G. E. Mayorga).

OrIGInal arTIClE

Nomogram application in Mexico for bladder cancer in patients at the Hospital General “Dr. Manuel Gea González”

G. E. Mayorga*, O. I. Ibarra, B. J. Sedano, O. L. Trujillo, D. V. Cornejo, R. A. Palmeros, T. I. Uberetagoyena, S. G. Garza, S. V. Osornio, C. A. Camacho, S. F. García, I. E. Muñoz, O. M. Cantellano, A. C. Martínez, M. G. Morales and G. C. Pacheco

Department of Urology, Hospital General “Dr. Manuel Gea González” SSA. Mexico City, Mexico

KEYWORDS nomograms; Bladder cancer; Mexico.

AbstractBackground: Bladder cancer is the most common neoplasia of the urinary tract. Seventy-five percent of the tumors are noninvasive and 25% are invasive. There is a 50%-70% recurrence and progression rate, and at 5 years it is 10%-15%. Sixty percent of the patients die after 5 years despite treatment. Aims: To determine whether the published predictive nomograms for bladder cancer are accurate for the Mexican population. Methods: The case records of patients diagnosed with bladder cancer within the time frame of 2007-2013 were analyzed and 6 different bladder cancer nomograms were applied. The predictive nomogram results were compared with patient progression. Results: Sixty patients were included in the study; 36% presented with invasive tumors and 64% with superficial tumors. Twelve of the patients had recurrence during the follow-up at a mean of 3.3 years. The nomogram predicted a recurrence rate at 5 years of 52%. The disease progression prediction at 5 years was 17% and in our patients it was 22%. The nomogram predicted an overall survival of 70% at 5 years and in our case series, there was a 4.5% mortality rate at 3.1 years. Conclusions: The nomograms studied do not appear to function with precision within the population studied, which may be due to ethnic differences, dissimilarity in the initial clinical stages and in the access to healthcare, or due to the retrospective study design.

Aplicación de nomogramas en México para cáncer de vejiga en pacientes del Hospital General “Dr. Manuel Gea González”

resumenIntroducción: El cáncer de vejiga es la neoplasia maligna más común del tracto urinario. El 75% son tumores no invasores y 25% son invasores. la recurrencia y progresión es de 50%-70% y 10%-15% a 5 años, respectivamente; el 60% mueren a 5 años a pesar del tratamiento.

PALABRAS CLAVE nomogramas; Cáncer de vejiga; México.

4 G. E. Mayorga et al

Introduction

Bladder cancer is the most common malignant urinary tract neoplasia. It is also the seventh most common cancer in men and the seventeenth in women. Worldwide incidence is 9 per 100,000 men and 2 per 100,000 women. 1 In latin america, bladder cancer has an incidence of 5.6 per 100,000 inhabitants; in Mexico it corresponds to 14.4% of the genitourinary cancers and is the fourth most frequent. 2 Mortality in men is 3 per 100,000 and in women it is 1 per 100,000 with a very high geographic variation due to unequal healthcare service access. 1 The incidence of bladder cancer and its mortality rate have decreased in the last few years due to reduced exposure to causal agents such as smoking and to health system improvements. 3-5

Smoking is the most important risk factor for bladder cancer and is present in 50% of the cases. 6,7 Tobacco conta ins aromat ic amines, aromat ic po lycyc l ic hydrocarbons, and chlorinated hydrocarbons that are excreted by the kidneys. Occupational exposure to aromatic amines, aromatic polycyclic hydrocarbons, and chlorinated hydrocarbons corresponds to 10% of the cases of bladder cancer and they are present in the paint, metal, and oil industries. 8 Other risk factors for developing bladder cancer include exposure to ionizing radiation, the use of cyclophosphamide and pioglitazone, as well as presenting with schistosomiasis. 3

approximately 75% of the patients present with bladder cancer confined to the mucosa (Ta, CIS) or submucosa (T1). These presentations are grouped into a category known as non-muscle-invading bladder cancer. 3

The non-muscle-invading tumors can be managed through transurethral endoscopic resection and intravesical BCG therapy. There is a 50%-70% recurrence of these tumors and the risk for progression is 10%-15% at 5 years.8-10 Up to 50% of the patients with muscle-invading tumors have distant metastasis within the first 2 years and 60% die at the fifth year despite treatment. 11,12 Disease progression to a measurable metastatic state occurs at a mean 1.2 years

after radical cystectomy and is fatal in the majority of the patients, despite a high initial response to chemotherapy rate. 11,12

It is necessary to have a way of accurately estimating the possibility of treatment success, complication rates, and long-term morbidity in order to adequately counsel the patient and make decisions supported by the best possible information. 13

Decisions are traditionally made based on the experience of the attending physician, but this manner of decision-making is not impartial and is liable to subjective and objective factors that can compromise the decision at each of the treatment phases. 14-17

In an attempt to resolve these limitations and obtain more precise and reliable predictions, prognostic and predictive tools have been developed based on statistical models. In general, these predictive models have been shown to be equal to or better than clinical judgment for predicting disease results. 18 nevertheless, the physician’s opinion is still very important for measuring the variables that are used within the predictive models, as well as for applying the models and interpreting the results. 19

Strictly defined, a nomogram is a graphic calculation method that can be based on any type of function, such as a logistic regression or Cox regression model. 20,21 The nomogram usually incorporates continuous or categorical variables. The effect of the variables in the result of interest is represented in the form of axes, and agreement points are attributed to the prognostic or predictive importance of the variable of interest (fig. 1).

The total point axis is used to estimate the combined effect of all the variables in the result probability. The format of the nomogram is unique because it allows the combination of multiple variables, whether continuous or categorical, in a single model. The concordance index quantifies the ability of the nomogram to identify which of 2 randomly selected patients will present with recurrence first. A 0.5 index means distinction is impossible and a 1.0 value represents perfect distinction. 19

Objetivo: Determinar si los nomogramas predictivos publicados para cáncer de vejiga, pueden ser aplicados de manera certera en nuestra población.Material y método: Se analizaron los expedientes con diagnóstico de cáncer de vejiga del 2007-2013 y se aplicaron 6 diferentes nomogramas de cáncer de vejiga. Se compararon los resultados predichos por el nomograma y la evolución del paciente.Resultados: Se incluyeron sesenta pacientes con cáncer de vejiga. El 36% con tumores invasores y 64% superficiales. Doce pacientes tuvieron recurrencias en seguimiento con promedio a 3.3 años, y el nomograma predijo una recurrencia a 5 años de 52%. Se predijo una progresión de 17% a 5 años, y en nuestros pacientes se presentó en 22%. la sobrevida global según el nomograma era de 70% a 5 años, y en nuestra serie hubo mortalidad de 4.5% a 3.1 años. Discusión: los nomogramas estudiados parecen no funcionar de manera exacta dentro de esta población, lo cual puede ser por diferencias étnicas, en las etapas clínicas iniciales y en el ac-ceso a la salud o por tratarse de un estudio retrospectivo.

0185-4542 © 2014. revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.

nomogram application in Mexico for bladder cancer in patients at the Hospital General “Dr. Manuel Gea González” 5

The predictive precision is the most important value to study in a nomogram and it should be evaluated and validated outside of the population the nomogram was created with. no predictive model is perfect and the accepted accuracy generally varies from 70% to 80%.19

a predictive model should be able to be generalized, given that the characteristics of the model and the patient can vary, making the model less precise. External validation should be carried out on patients with characteristics different from those of the patients used to produce the model. Before employing a nomogram, the physician should decide whether it applies to his or her patient, depending on the characteristics used. 22-26 nomogram generalization limitations can be related to differences in population characteristics, or due to migrations of status or grade, as well as to differences in inclusion and exclusion criteria. The majority of nomograms are created using populations from a single hospital, and thus cannot be generalized. 19

The first nomogram for bladder cancer was published in 2005 27 in a multinational study. The authors developed a nomogram that estimated the risk for recurrence and progression of non-muscle-invading tumors, with a precision of 0.848 for evaluating generalized recurrence, and set the stage for the development of the nomograms to follow.

The tools for adequately predicting the progression of bladder cancer patients are extremely important because they can affect the decision to use multimodal therapy. Due to the large number of predictive models, it is important to understand the mechanisms by which they work and the advantages and disadvantages of each one. Unfortunately there are no randomized prospective studies that clearly show that nomogram use improves patient treatment. However, until such studies are conducted, nomograms are the best option in the doctor/patient decision-making process. 28-31

The aim of this article was to determine whether the published international predictive nomograms for bladder cancer are an accurate instrument in the Mexican population.

Methods

The case records were reviewed of patients diagnosed with urothelial bladder cancer within the time frame of 2003 to 2013, including patients with muscle-invading and non-muscle-invading tumors. The data of these patients was put in a total of 6 different nomograms, 32-35 and the nomogram predictions were compared with the actual evolution of the patient. recurrence and progression of non-muscle-invading tumors at 1 and 5 years were evaluated, along with the risk for locally advanced disease in radical cystectomy, the risk for lymph node metastasis in radical cystectomy, the risk for recurrence at 5 years, specific cancer mortality at 5 years, and the total mortality in patients with muscle-invading tumors. Means, medians, and percentages were used in making the comparisons.

Results

a total of 60 patients diagnosed with bladder cancer were found. Mean age at the time of diagnosis was 62 years; 78% of the patients were men and 22% were women. Thirty-six percent of the patients presented with muscle-invading tumors and 64% with superficial tumors (table 1). a total of 12 patients (20%) had recurrence during the follow-up and the mean presentation time was 3.3 years; four of those patients had received BCG therapy. The nomogram (EOrTC) had predicted a mean recurrence at 5 years of 52%. The non-muscle-invading tumor progression prediction was 17% at 5 years, and it was 22% in our patients. The nomogram prediction of risk for locally advanced disease in radical cystectomy was accurate when the risk was above 90%, but there was no correlation in values under 50%. The ability of the nomograms to predict the risk for lymph node metastasis was not accurate because positive metastasis presented in only one patient, despite the fact that the mean risk for n+ disease was 16.3%. Cancer-specific survival at 5 years in patients that had been operated on was calculated by the nomograms as 78% at 5 years and overall survival at 5 years as 70%; in our series the overall cancer-specific mortality rate was 4.5% at a mean 3.1 years in patients that had been operated on (table 2).

Discussion

In 2005, Shariat et al. proposed a probability nomogram in over 2,000 patients, studying recurrence-free survival and

Table 1 Clinical characteristics

Men 46 (78%)

Women 14 (22%)

age 62.5 years (86%-32%)

non-invasive tumors 38 (64%)

Invasive tumors 22 (36%)

Figure 1 Example of a classic nomogram.


progression-free survival with 87% accuracy, but only with internal validation. 27

In 2006, Karakiewickz et al. published a probability nomogram in patients managed with radical cystectomy, predicting stages T and n in the pathologic result and recurrence-free survival with 78% accuracy and internal validation. 29

In 2006, Bochner et al. published a probability nomogram for patients managed with radical cystectomy in over 9,000

patients with 76% accuracy and internal validation, and an attempt was made to predict recurrence-free survival at 5 years. 30

In 2007, Bassi et al. published an artificial neural network nomogram, the last large nomogram, in 369 patients managed with radical cystectomy, evaluating the recurrence-free survival at 5 years with 76% accuracy and internal validation 31 (table 3).

We can see that in the majority of the published nomograms, only internal validation was carried out and often with populations from a single hospital center or region of the country.32-35 nuhn et al.36 externally validated a nomogram produced in the United States and applied it to a multinational and multi-institutional population. The models were applicable to the 2,501 patients studied, but the predictions underestimated the real results, the same as in our study.

The heterogeneity of the patient populations (for example, ethnic, racial, genetic, environmental differences, and different risk factors) or differences in hospital strategies, attending physicians, or follow-up protocols can cause poor calibration of the nomogram in question. In order to use nomograms created in the United States and Europe, they must first be validated and calibrated in different types of populations, preferably prospectively and with patients of all racial and ethnic groups.

It should also be noted that the majority of nomograms studied herein and those applied in the majority of the urology departments in Mexico, do not take into account the new, recognized risk factors that can have an impact on patient outcome, such as the time lapse between diagnosis

Table 2 Comparative results between nomograms and our database

Parameter

nomogram

Hospital General “Dr. Manuel Gea

González”

recurrence at 5 years

52% (31%-78%) 20%

Progression at 5 years

17% (1%-45%) 22%

risk for n+ 16% (6.5%-45%) 0.6%

Cancer-specific survival at 5 years

78% (39%-92%) 95.5%

Overall survival at 5 years

70% (46%-87%) 95.5%

Table 3 Bladder cancer nomograms

reference

Form of prediction

Population

result

n° of patients

Variables

accuracy

Validation

ShariatProbability nomogram

nMI

recurrence-free survival and

progression-free survival

2,681age, sex,

cytologies, nMP22

84% for recurren-ce, 87% for

recurrence in T1 and high grade,

86% in >T2

Internal

Quershi neural network

TaT1TaT1T2-T4

recurrence at 6 months

recurrence-free survival

Cancer-specific survival

5610540

EGFr, erbB2, p53, stage, grade, size,

number, sex, CIS, location

75%80%82%

Internal

Karakiewi-cz

Probability nomogram

radical cystectomy

T and nrecurrence-free survival at 2, 5,

and 8 years

731

age, T, Grade, TUrP, n, lVI, CIS, neoadjuvant and adjuvant therapy

76% for T63% for n

78% for survivalInternal

BochnerProbability nomogram

radical cystectomy

recurrence-free survival at 5 years

9,064age, sex, T, n,

grade, histology, delay in surgery

75% Internal

Bassineural

networkradical

cystectomySurvival at 5 years 369

age, sex, T, n, lVI, grade

76% Internal

nMI: non-muscle-invading; EGFr: epidermal growth factor receptor; lVI= lymphovascular invasion; TUrP: transurethral resection of the prostate; CIS: carcinoma in situ.

nomogram application in Mexico for bladder cancer in patients at the Hospital General “Dr. Manuel Gea González” 7

and surgery, tumor size, hydronephrosis, surgical margin status, number of lymph nodes removed, and lymph node density.37,38 nomograms are not valid for non-urothelial tumors and so cannot be applied to this type of tumor; new nomograms need to be created that include them. The application of new technologies and molecular discoveries should be introduced into nomograms that then must be validated.

a limitation of our study is its retrospective design and the long amount of time the patients were studied, during which there have been modifications in staging and in the surgical techniques used, which can also change the results. Nevertheless, the aim of this study was to reflect a real-world setting and the daily practice of urology in Mexico in which nomograms play an important role in decision-making.

Conclusions

In our series, the nomograms studied did not appear to function adequately in this population, which could be due to the ethnic differences between our population and that in which the models were developed, or to differences in the initial clinical stages, in the access to healthcare services, or also because the study was a retrospective one. However, it lays the foundation for a necessary joint prospective validation study or for the development of prediction models appropriate for and adjusted to the Mexican population.

Conflict of interest

The authors declare that there is no conflict of interest.

Financial disclosure

No financial support was received in relation to this article.

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26. Steyerberg EW, roobol MJ, Kattan MW, et al. Prediction of indolent prostate cancer: validation and updating of a prognostic nomogram. J Urol 2007;177:107–112, discussion 112.

27. Shariat SF, Zippe C, ludecke G, et al. nomograms including nuclear matrix protein 22 for prediction of disease recurrence and progression in patients with Ta, T1 or CIS transitional cell carcinoma of the bladder. J Urol 2005;173:1518–1525.

28. Parmar MK, Freedman lS, Hargreave TB, et al. Prognostic factors for recurrence and followup policies in the treatment of superficial bladder cancer: report from the British Medical research Council Subgroup on Superficial Bladder Cancer (Urological Cancer Working Party). J Urol 1989;142:284–288.

29. Karakiewicz PI, Shariat SF, Palapattu GS, et al. Precystectomy nomogram for prediction of advanced bladder cancer stage. Eur Urol 2006;50:1254–1262 (discussion 1261–2).


30. Bochner BH, Kattan MW, Vora KC. Postoperative nomogram predicting risk of recurrence after radical cystectomy for bladder cancer. J Clin Oncol 2006;24:3967–3972.

31. Bassi P, Sacco E, De Marco V, et al. Prognostic accuracy of an artificial neural network in patients undergoing radical cystectomy for bladder cancer: a comparison with logistic regression analysis. BJU Int 2007;99:1007–1012.

32. Sylvester rJ, van der Meijden aPM, Oosterlinck W, et al. Predicting recurrence and Progression in Individual Patients with Stage Ta T1 Bladder Cancer Using EOrTC risk Tables: a Combined analysis of 2596 Patients from Seven EOrTC Trials. European Urology 2006;49:466- 477.

33. Shariat SF. nomograms Provide Improved accuracy for Predicting Survival after radical Cystectomy. Clin Cancer res 2006;12(22): 6663-6676.

34. Karakiewicz PI. Precystectomy nomogram for Prediction of advanced Bladder Cancer Stage. European Urology 2006;50:1254–1262.

35. Karakiewicz PI. nomogram for Predicting Disease recurrence after radical Cystectomy for Transitional Cell Carcinoma of the Bladder. Journal of Urology 2006;176:1354-1362.

36. nuhn P, May n, Sun M, et al. External validation of postoperative nomograms for prediction of all-cause mortality, cancer-specific mortality, and recurrence in patients with urothelial carcinoma of the bladder. Eur Urol 2012;61(1):58-64.

37. Herr HW, Faulkner Jr, Grossman HB, et al. Surgical factors influence bladder cancer outcomes: a cooperative group report. J Clin Oncol 2004;22:2781–2789.

38. May M, Herrmann E, Bolenz C, et al. association between the number of dissected lymph nodes during pelvic lymphadenectomy and cancer-specific survival in patients with lymph node-negative urothelial carcinoma of the bladder undergoing radical cystectomy. ann Surg Oncol 2011;18:2018–2025.



Rev Mex Urol 2014;74(1):9-14

* Corresponding author at: Durango N° 33, Colonia Roma, Delegación Cuauhtémoc, C.P. 06700, México D.F., México. Telephone: (55) 5208-3162. Email: [email protected] (R. Pérez-Ortega).

ORigiNal aRTiCle

Urodynamic evaluation of stress urinary incontinence severity: a comparative study for detecting intrinsic external urethral sphincter deficiency

R. Pérez-Ortegaa,*, A. Gutiérrez-Gonzálezb, D. García-Sánchezc, M. Reyes-Gutiérrezd, R. Gutfrajnd-Feldmanne and L. Gastelum-Félixf

a Medical Administration, Centro de Continencia, Hospital Ángeles, Clínica Londres, Mexico City, Mexicob Coordination of the Postspecialization Course in Neuro-Urology and Urodynamics, Universidad Autónoma de Nuevo León, N. L., Mexicoc Hospital STAR Médica Centro, Mexico City, Mexicod Hospital General de México, Mexico City, Mexicoe Hospital Ángeles Lomas, Mexico City, Mexico f Hospital de Especialidades del Centro Médico Nacional Del Noroeste, IMSS, Ciudad Obregón, Sonora, Mexico

KEYWORDS Stress urinary incontinence; Urodynamics; Mexico.

AbstractAims: To determine the sensitivity and specificity of the abdominal leak point pressure (ALPP) in order to comparatively evaluate the presence of intrinsic sphincter deficiency (iSD) with maximum urethral closure pressure (MUCP) and establish the corresponding clinical and urodynamic correlation. Results: Thirty-four patients with stress urinary incontinence (SUi) were evaluated. Seventeen of those patients (50%) were urodynamically diagnosed with iSD through alPP and 9 of them had severe SUi. Only 2 patients were diagnosed with iSD through MUCP; one of them had severe SUi and the other presented with moderate SUI. Eighteen patients were clinically classified with severe SUi, 17 of whom had moderate to severe iSD diagnosed through alPP (94%). Conclusions: Urodynamic evaluation of SUi made it possible to clearly establish the pathophysiology of concomitant lower urinary tract dysfunction and to objectify the presence of SUi through alPP in at least 85% of the cases. alPP had a much higher sensitivity and specificity for diagnosing ISD than MUCP.

10 R. Pérez-Ortega et al

0185-4542 © 2014. Revista Mexicana de Urología. Publicado por elsevier México. Todos los derechos reservados.

Introduction

Stress urinary incontinence (SUi) noticeably alters the quality of life of the women that present with it. Meta-analyses reveal a prevalence of 30% in women between the ages of 30-60 years. 1

As a symptom, SUI is defined as the involuntary escape of urine during physical effort, such as coughing, sneezing, abrupt movements, and laughing. 2 it becomes a sign when we objectively demonstrate its presence through physical examination, whether by having the patient cough or with Valsalva maneuvers. 3

it is a urodynamic condition when the involuntary escape of urine is shown by an increase in abdominal pressure due to coughing or the Valsalva maneuver, in the absence of detrusor muscle contraction during filling cystometry. 4

Urge urinary incontinence is the involuntary escape of urine accompanied by or immediately before the urge to urinate. The presence of involuntary or uninhibited detrusor contractions is objectified in the filling cystometry. 5,6

in mixed urinary incontinence, involuntary escape of urine is present both during the increase in abdominal pressure and when there are involuntary detrusor contractions, and can be demonstrated in the same urodynamic study. 7-10

The 2007 management guideline discussion panel of the american Urological association (aUa) proposes the following as standard evaluation: clinical history and directed physical examination objectively demonstrating the escape of urine during effort, residual volume measurement, and urine culture.

as other recommended measures, they propose characterizing the type of incontinence, defining whether it

is genuine, urge, or mixed SUi, utilizing a micturition diary and quality of life questionnaires.

as additional recommendations they propose the diaper test, urodynamic studies, cystoscopy, and imaging studies.

McGuire (1993) described the test known as the abdominal leak point pressure (ALPP), which is carried out during filling cystometry at a capacity of 200 cc. The patient coughs at regular intervals and the bladder pressure at which urine escapes without detrusor contraction is registered. a pressure under 60 cm/H2O correlates with intrinsic sphincter deficiency and a pressure above 60 signifies urethral hypermobility. 11-13

The urethral pressure profile (UPP) was popularized by Brown and Wickman in 1969. It utilizes a small catheter with lateral openings with a constant infusion at a velocity of 1-2 ml/min, and catheter traction at a velocity of 1-2 mm/sec along the entire urethra. The profile evaluates, among other parameters, the maximum urethral closure pressure (MUCP), which is the maximum difference between the urethral pressure and the bladder pressure. The normal figures are from 40 to 60 cm/H2O. Many authors have used a figure of less than 20 cm/H2O to define intrinsic sphincter deficiency and a figure above 20 cm/H20 correlates with urethral hypermotility. 14

The aim of the present article was to determine the sensitivity and specificity of the ALPP for evaluating intrinsic external urethral sphincter (eUS) deficiency in SUi in women, its severity, and its comparison with the MUCP, establishing the corresponding clinical and urodynamic correlation.

Methods

a comparative, prospective, and cross-sectional study was conducted that evaluated the sensitivity and specificity of the urodynamic diagnostic tests (alPP and MUCP), determining their positive and negative predictive values

Evaluación de la severidad de la incontinencia urinaria de esfuerzo con estudios urodinámicos: un estudio comparativo para detectar deficiencia intrínseca del esfínter uretral externo

ResumenObjetivo: Determinar la sensibilidad y especificidad del punto de presión de fuga abdominal (ALPP), para evaluar la presencia de deficiencia intrínseca del esfínter (DIE) comparativamente con la presión máxima de cierre uretral (MUCP, por sus siglas en inglés), estableciendo la corre-lación clínico-urodinámica correspondiente.Resultados: Fueron evaluadas 34 pacientes con incontinencia urinaria de esfuerzo (iUe); 17 pa-ciente (50%) fueron diagnosticadas urodinámicamente con Die por punto de alPP; 9 tuvieron iUe severa mientras que sólo 2 (5.8%) lo fueron por MUCP, de las cuales una tuvo iUe severa y otra, iUe moderada. Dieciocho pacientes fueron catalogadas clínicamente como iUe severa, de las cuales 17 tuvieron Die por alPP entre severa y moderada (94%).Conclusiones: la evaluación urodinámica de la iUe permite establecer de manera clara la fisiopatología de una disfunción del tracto urinario inferior concomitante, con la posibilidad de objetivar la presencia de iUe con el alPP en al menos 85% de los casos, con una sensibilidad y especificidad para diagnosticar DIE muy superior a la MUCP.

PALAbRAS cLAvE incontinencia urinaria de esfuerzo; Urodinamia; México.

Urodynamic evaluation of stress urinary incontinence severity: a comparative study for detecting intrinsic external urethral sphincter deficiency 11

in order to analyze urinary incontinence severity and detect the intrinsic deficiency of the external urethral sphincter.

The study was carried out within the time frame of November 2012 and august 2013 and was conducted on female patients diagnosed with SUi that had been referred to our center for complete urodynamic study that included alPP and MUCP. When alPP was not easy to assess, it was determined without the transurethral catheter.

Those patients with a surgical history of SUi treatment and with neuropathy were excluded from the study.

Because the patients had been referred by their attending physicians, the clinical evaluation of both incontinence severity and quality of life was carried out with the iCiQ- Ui-SF questionnaire validated in the United Kingdom. 3

According to the score, incontinence was classified as mild, moderate, or severe. The clinical and urodynamic correlation was determined by taking the ALPP values into consideration. according to established standards, when the value is above 60 cm/H2O it corresponds to urethral hypermotility and when it is below that figure, it correlates with intrinsic external sphincter deficiency; for the MUCP, the values are above 20 cm/H2O and below 20 cm/H2O, respectively.

Results

Thirty-four women were included that had been diagnosed with SUi and referred to our center for complete urodynamic study. The age range was 37 to 80 years with a mean age of 58 years. Clinically, 23 patients (67.65%) presented with mixed urinary incontinence and 11 (32.35%) with pure SUi. Of the mixed urinary incontinence cases, 9 (39.13%) presented with uninhibited contractions (fig.1).

Of the patients with uninhibited contractions, 5 (55%) presented with urge urinary incontinence (fig. 2).

Of the 34 patients, 29 (85%) presented with positive alPP, and it was negative in 5 patients, although without transurethral catheter (14.7%); this is regarded as type 0 occult SUi, in other words, not demonstrated urodynamically (fig.3).

Of the 34 patients, 17 presented with positive alPP under 60 cm/H2O, which was classified as intrinsic sphincter deficiency (iSD) and 12 above 60 cm/H2O, which was regarded as urethral hypermotility, and 5 with negative ALPP (fig.4).

Clinically, SUi was classified as severe in 18 cases, moderate in 14, and mild in 2.

Of the 17 cases of alPP under 60 cm/H2O (iSD), 9 had severe SUI, 7 moderate, and one mild (fig.5).

Only 2 cases of the 34 were diagnosed as iSD through MUCP (5.8%) vs. 50% through ALPP (fig.6).

The sensitivity and specificity of ALPP and MUCP, as well as the respective positive and negative predictive values for each test are shown in tables 1 and 2, respectively.

Discussion

Various studies have shown that in women with pure SUi and no obstructive pathology, urodynamic studies do not provide greater additional information for making the diagnosis.

The european guidelines (2006) recommend urodynamic studies in the following cases: 1) if hyperactive detrusor is suspected, 2) if there is a surgical history of treating stress incontinence or pelvic prolapse, and 3) if there are data suggestive of infravesical obstruction. 15

The question has been posed whether urodynamic studies improve clinical progression or not, in cases of SUi. There is much controversy regarding this, however, there is no doubt that in complex cases and when faced with irreversible treatment, urodynamic studies are mandatory,

MUI

Type of incontinence

URODYNAMIC SUI

Fre

que

ncy

25

20

15

10

5

0

2367.65%

1132.35%

Mixed urinary incontinence

Uninhibited contractions

YesNo

Co

unt

12.5

10.0

7.5

5.0

2.5

0.0

9.039.13%

14.060.87%

Figure 1 Clinical evaluation detected cases of mixed urinary incontinence, establishing the corresponding clinical/urodyna-mic correlation.

Figure 2 Not all the patients with mixed urinary incontinence presented with uninhibited contractions.

MUi: mixed urinary incontinence SUi: stress urinary incontinence.


especially based on the fact that through them we can establish the pathophysiologic findings of the underlying alteration, allowing the adequate treatment to be chosen. 1

another controversial point is related to the evaluation of SUi severity with urodynamic studies such as alPP and MUCP. in this regard, the 4th Committee for Dynamic Studies (2009) recommended using these studies with caution and not as the only factor for progression and for pred ict ing therapeut ic resu l t s . L ikewise, they recommended the continuation of controlled and randomized research studies in order to correctly standardize the application of these diagnostic methods.

in 1993 Mcguire et al. evaluated 125 women with SUi and correlated a severe grade of incontinence with alPP under 60 cm/H2O in up to 81% of the cases, which was considered to be “fixed urethra” in 75% of the cases, classifying it as intrinsic deficiency of the external urethral sphincter. In our study there were 17 cases with alPP under 60 cm/H2O, of which only 9 (52.9%) corresponded to clinically severe SUi.

it has been reported that alPP is negative in up to 15% of the cases, despite the fact that the patient complains of SUi; this can be related to the obstruction caused by the urethral catheter. in our study, 5 patients had negative alPP, corresponding to pelvic prolapse in all the cases. Once the prolapse was manually reduced, the Marshall test was

Occult stress urinary incontinence

NoYes

Fre

que

ncy

30

20

10

0

514.71%

2985.29%

Mild Moderate

Clinical/urodynamic correlation of SUI severity

Severe

Fre

que

ncy

10

8

6

4

2

0

15.88%

741.18%

952.94%

<60 cm H2O (ISD) >60 cm H2O (UHM)

Intrinsic sphincter de�ciency vs urethral hypermobility through ALPP

Negative LPPA

Fre

que

ncy

20

15

10

5

0

1750.00%

1235.29%

514.71%

MUCP <20 cm H2O MUCP >20 cm H2O

ISD vs UHM through MUCP

25.88%

Fre

que

ncy

40

30

20

10

0

3294.12%

Figure 3 Five patients had negative abdominal leak point pressure despite transurethral catheter removal and all had pelvic prolapse.

Figure 5 Of the 18 patients with clinically severe inconti-nence only 9 had an abdominal leak point pressure under 60cm/H2O.

Figure 4 Five patients presented with occult urinary inconti-nence. Upon reducing the prolapse, the escape of urine during stress was obvious in all the patients.

Figure 6 Only 2 patients had an abdominal leak point pressure under 20 cm/H2O.

ISD: intrinsic sphincter deficiency; UHM: urethral hypermotility; ALPP: ab-dominal leak point pressure.

SUi: stress urinary incontinence. ISD: intrinsic sphincter deficiency; UHM: urethral hypermobility; MUCP: max-imum urethral closure pressure.

Urodynamic evaluation of stress urinary incontinence severity: a comparative study for detecting intrinsic external urethral sphincter deficiency 13

positive, which is urodynamically classified as occult urinary incontinence.

in the majority of continent women, the length of the functional urethra is approximately 3 cm and the MUCP is 40-60 cm/H2O, although normal values may vary widely.

Many authors have used the definition of a MUCP under 20 to identify ISD. Nevertheless, this definition can have the same problems as establishing iSD through alPP. another warning in relation to urethral profilometry is that this test does not diagnose SUI (unlike ALPP) and a continent woman may have the same MUCP as an incontinent one. 16-18

in our study, only 2 cases (clinically, one with severe and one with moderate SUi) were diagnosed as iSD through MUCP, with a sensitivity of 5.56% vs. 56.25% through alPP,

concurring with the international literature. The conclusion we found after a review of the literature was that MUCP cannot be used for evaluating SUi severity and that alPP can be a useful tool for analyzing SUi-related urethral dysfunction, with the limitation of a current lack of technique standardization.

conclusions

The urodynamic evaluation of SUi, carried out under the indications determined by the international Committee, clearly established the pathophysiology of a concomitant lower urinary tract dysfunction, as well as making it possible to objectify the presence of SUi through alPP in at least 85%

Table 1 Sensitivity of 56.25%, specificity of 38.46%

ALPP sensitivity and specificity for ISD

95% Ci

lower limit Upper limit

Disease prevalence 55.17% 35.98% 73.05%

Correctly diagnosed patients 48.28% 29.89% 67.10%

Sensitivity 56.25% 30.55% 79.25%

Specificity 38.46% 15.13% 67.72%

Positive predictive value 52.94% 28.53% 76.14%

Negative predictive value 41.67% 16.50% 71.40%

Positive probability quotient 0.91 0.50 1.68

Negative probability quotient 1.14 0.47 2.75

ALPP: abdominal leak point pressure; ISD: intrinsic sphincter deficiency.

Table 2 Sensitivity of 5.56%, specificity of 93.75%. Specificity was very high due to the sample size

MUCP SeNSiTiViTY aND SPeCiFiCiTY FOR iSD

95% Ci

lower limit Upper limit

Disease prevalence 52.94% 35.40% 69.84%

Correctly diagnosed patients 47.06% 30.16% 64.60%

Sensitivity 5.56% 0.29% 29.38%

Specificity 93.75% 67.71% 99.67%

Positive predictive value 50% 2.67% 97.33%

Negative predictive value 46.88% 29.51% 64.97%

Positive probability quotient 0.89 0.06 13.08

Negative probability quotient 1.01 0.85 1.19

MUCP: maximum urethral closure pressure; ISD: intrinsic sphincter deficiency.


of the cases, with a much higher sensitivity for diagnosing iSD than MUCP. However, neither of the 2 tests were adequate for clearly determining SUi severity and therefore should not be the only factors used for predicting surgical treatment results, as has been established by the international Consensus Committee on invasive Urodynamic Studies. This international body also suggests that further multicenter, prospective, and randomized studies be conducted in order to establish the true value of these diagnostic tests.


The authors declare that there is no conflict of interest



References

1. incontinence. 3rd international Consultation on incontinence. abrams P, Cardozo l, Wein a. Vol. i, pp. 627-631. Co-sponsored by international Continence Society and Societé internationale d’Urologie. Paris 2005

2. Wein a. Campbell-Walsh Urology. USa: elsevier; 2012. 3. abrams P. Urodynamics. USa: Springer; 2006.4. Dmochowski RR, Blaivas JM. Update of AUA Guideline on the

Surgical Management of Female Stress Urinary Incontinence. J Urol 2012;183:1906-1914.

5. de Lancey JOL. Stress Urinary Incontinence: Relative importance of Urethral Support and Urethral Closure Pressure. J Urol 2008;179:2286-2290.

6. Nager CW. Urodynamic Measures do not Predict Stress Continence Outcomes after Surgery For Stress Urinary Incontinence in Selected Women. J Urol 2008;179:1470-1474.

7. Lowenstein L. The Volume at which Women Leak First on Urodynamic Testing is Not associated with Quality of life, Measures of Urethral Integrity on Surgical Failure. J Urol 2007;178:193-196.

8. Sinha D, Nallaswamy V. Value of Leak Point Pressure Study in Women with Incontinence. J Urol 2006;176:186-188.

9. Gray M. Traces: Making Sense of Urodynamics Testing-Part.7. evaluation of Bladder Filling/Storage: evaluation of Urethral Sphincter incompetence and Stress Urinary incontinence. Urol Nurs 2011;35(5):267-277.

10. Nygaard ie. Stress Urinary incontinence. am Coll Obstet and gynecol 2004;104(3):607-620.

11. Weber aM, Walters MD. Cost-effectiveness of Urodynamic Testing Before Surgery For Women With Pelvic Organ Prolapse and Stress Urinary Incontinence. Am J Obstr Gynecol 2000;183(6):1346-1347.

12. Weidner aC, Myers eR, Visco ag, et al. Which Women With Stress Incontinence Require Urodynamic Evaluation? Am J Obstet gynecol 2000;184(2):20-27.

13. Chaliha C. Changes in Urethral Function With Bladder Filling in Presence of Urodynamic Stress incontinence and Detrusor Overactivity. USa: elsevier; 2005.

14. Nager CW. Testing in Women with lower Urinary Tract Dysfunction. Clin Obstet and gynecol 2004;47(1).

15. Diokno AC. Office Based Criteria For Predicting Type II Stress Incontinence Without Further Evaluation Studies. J Urol 1999;161:1263-1267.

16. Obder K. The coexistence of Intrinsic Sphincter Deficiency with Type II Stress Incontinence. J Urol 1999;162:1365-1366.

17. Schick E. Predictive Value of Maximum Urethral Closure Pressure, Urethral Hypermobility and Urethral incompetence in The Diagnosis of Clinically Significant Female genuine Stress Incontinence. J Urol 2004;171:1871-1875.

18. Latini JM. Association Between Valsalva and Cough Leak Point Pressure and Pelvic Organ Prolapse Quantification in Women With Stress Incontinence. J Urol Vol 2005;173:1219-1222.



Rev Mex Urol 2014;74(1):15-18

* Corresponding author at: Arístides N° 640, Colonia Cumbres Tercer Sector, Monterrey, N. L., México. Telephone: (81) 8300 3922. Email: [email protected] (J. A. Zapata-González).

OriGiNAL ArTiCLe

Single-port laparoscopic nephrectomy: a preliminary experience

J. A. Zapata-González*, J. B. Camacho-Castro, A. I. Reyna-Bulnes, S. M. García-Sánchez, F. Reyes-Verástegui, L. E. Niño-Ortiz, F. Vázquez-Venegas and A. Ramos-Valdes

Hospital General de Zona N° 1, IMSS, Saltillo, Coah., México

PALABRAS CLAVE Single-port nephrectomy; Mexico.

Abstract Background: Single-port laparoscopic surgery has been proposed as a development of standard laparoscopy and since its introduction, urologists worldwide have increasingly adopted it. Aims: To demonstrate our preliminary experience with single-port laparoscopic access for nephrectomy. Methods: We present herein our initial experience in single-port surgery in simple and radical nephrectomy. A total of 10 procedures were performed with this technique within the time frame of November 2010 to August 2012. Results: All the procedures were carried out successfully using the GelPOiNT Advanced Access Platform™. Mean age was 48.2 (range: 29-61) years and 6 of the patients were women and 4 were men. Mean surgery duration was 125.5 (range: 110-145) min, mean blood loss was 117 (range: 100-160) mL, hospital stay was 2.7 (range: 2-3) days, and incision size was 4.6 (range: 4-5) cm. Ketorolac was the only analgesic administered (90 mg daily). Discussion: The conceptual hypothesis is that fewer ports reduce pain, trocar-related complications, and recovery time, as well as providing better cosmetic results. Conclusions: Urologic laparoscopy has made it possible to perform major surgery with small incisions. in an effort to discontinue incisions, conventional laparoscopic surgery “through the umbilicus” is being attempted with promising results so far.

Nefrectomía laparoscópica por puerto único: experiencia inicial

Resumen Introducción: La cirugía laparoscópica por un solo puerto ha sido propuesta como una evolución de la laparoscopía estándar. A nivel mundial su adopción se ha incrementado entre los urólo- gos desde su introducción.Objetivos: Mostrar nuestra experiencia preliminar en el acceso laparoscópico por puerto único para nefrectomía.

KEYWORDSSingle-port nephrectomy; Mexico.

16 J. A. Zapata-González et al

Introduction

Single-port surgery has been proposed as an evolutionary aspect of standard laparoscopy and its worldwide adoption among urologists has increased since its introduction. The conceptual hypothesis is that reducing the number of ports in turn reduces pain, trocar-related complications, and recovery time and provides better cosmetic results. Over the last few years, many urologic diseases have been successfully treated with single-port surgery. However, the position of single-port surgery in the field of minimally invasive surgery still remains to be determined. 1-3 Some comparative studies have shown that single-port surgery is at least comparable to the results obtained through conventional laparoscopy. 4,5 The majority of reported cases are procedures carried out in the upper urinary tract. The transumbilical single-port technique is chosen in the majority of the cases, utilizing ports with articulated instrumentation. 6-9

We present herein our initial experience with single-port laparoscopic surgery in the performance of simple and radical nephrectomy. A total of 10 procedures with this technique were carried out within the time frame of November 2010 and August 2012.

Methods

A total of 10 procedures were performed: 2 radical nephrectomies (T2N0MO), 2 simple nephrectomies due to polycystic disease, one simple nephrectomy with the diagnosis of renal exclusion secondary to a failed pyeloplasty, and 5 nephrectomies due to renal exclusion secondary to lithiasis. All the cases were evaluated using plain and contrast-enhanced computed tomography (CT) urography and kidney scintigram was used in only 5 cases. Preoperative diagnosis, surgery duration, blood loss, pathology result, surgical wound size, and complications were recorded. All the patients were given the same analgesic regimen.

The following technique was employed:

— Position: after general anesthesia and peridural block, the patient is placed in the lateral (flank) decubitus position. The table is flexed and the support points protected. The patient is secured to the table and transurethral Foley catheter is placed. The umbilicus is positioned over the point of maximum flex of the operating table. The GelPOiNT Advanced Access Platform System™ from Applied Medical is used in all the cases, placing only 3 trocars. Standard laparoscopic surgery instrumentation is used along with a 3 mm instrument as an accessory port, 10 mm clips and the Hem-o-Lok® ligation system, and a standard or conventional 10 mm laparoscope with a 30° lens.

— Access: After p lac ing the pat ient in the abovementioned position, the table is turned 45° laterally to expose the umbilicus and perform a 4-5 cm supra- and infra-umbilical mini-laparotomy. The internal ring is placed at this site, and on the outs ide, an external r ing (A lex i s Wound retractor™). After tensing both rings over the abdominal wall, the trocars to be used are placed in the device (GelSeal Cap) that is attached to the outer ring (fig. 1). Pneumoperitoneum intra-abdominal pressure reaches 12 mmHg and the flow rate is 6 L per minute.

— exposure of the kidney: After the exploratory laparotomy, Toldt’s fascia is incised from the iliac vessels to the splenic or hepatic angle, depending on the case. Medial traction and mobilization of the colon expose Gerota’s fascia and help identify the psoas muscle. Liver retraction is sometimes necessary and we use 3 mm instrumentation for that purpose.

— Ureter mobilization: we generally localize the medial portion of the ureter in the retroperitoneal fat adjacent to the psoas muscle. We then identify the gonadal vein and from there, the renal vein. We move the ureter and the terminal portion of Gerota’s fascia to adequately expose the renal

Material y métodos: Presentamos nuestra experiencia inicial en cirugía de puerto único, reali-zando nefrectomía simple y radical. en total, de noviembre de 2010 a agosto de 2012 fueron realizados 10 procedimientos con esta técnica. Resultados: Todos los procedimientos han sido realizados exitosamente utilizando Gelpoint Ad-vanced Access PlatformTM. La edad promedio fue de 48.2 (rango 29-61) años. Seis mujeres y 4 hombres fueron incluidos. Tiempo quirúrgico promedio 125.5 (rango 110-145) minutos. Sangrado promedio 117 (rango 100-160) mL. estancia hospitalaria 2.7 (rango 2-3) días. Tamaño de la inci-sión 4.6 (rango 4-5) cm. el único analgésico administrado en todos los pacientes fue ketorolaco (90 mg diarios). Discusión: Conceptualmente está la hipótesis de que la reducción en el número de puertos dis-minuye el dolor, complicaciones de los trocares, tiempo de recuperación y mejores resultados cosméticos.Conclusiones: La laparoscopía urológica ha permitido realizar intervenciones mayores con peque-ñas incisiones. en esfuerzo por abandonar las incisiones se está tratando de realizar cirugías lapa-roscópicas convencionales “a través del ombligo”, siendo hasta ahora los resultados promisorios.

0185-4542 © 2014. revista Mexicana de Urología. Publicado por elsevier México. Todos los derechos reservados.

Single-port laparoscopic nephrectomy: a preliminary experience 17

pedicle. When performing radical surgery, after identifying the gonadal vein we clip it and then cut it, achieving better exposure of or access to the lumbar vein and the renal artery. We identify the entire renal vein and tributaries, stapling the latter. The renal artery is identified and secured with the Hem-o-Lok® system and the same is done with the renal vein. in radical surgery we also clip the adrenal vein (fig. 2). The specimen is usually extracted in a glycine retrieval bag with a cable that is introduced when removing the access platform. A Penrose drain is generally placed to verify hemostasis.

Results

All the procedures were successfully performed with no conversion to standard laparoscopy or open surgery. Our only experience is with the GelPOiNT Advanced Access Platform™ and conventional instruments (fig. 1). With respect to articulated instrumentation, it is expensive and would increase the overall cost of this surgical procedure. in 2 cases, we placed a 3 mm accessory trocar and in one case a 5 mm accessory trocar for the purpose of performing countertraction. We have carried out a total of 6 left nephrectomies and 4 right nephrectomies. Six of the patients were men and 4 of the patients were women. Two of the left radical nephrectomies resulted in stage T1b tumor. Both tumors were located centrally and the final histopathologic report was renal cell carcinoma with Fuhrman grade 2 and grade 3 and negative surgical margins.

in regard to the simple nephrectomies, 5 patients had a history of lithiasis, 2 had polycystic disease, and one patient had a failed redo pyeloplasty. Mean age was 42.8 (range:

29-61) years. Surgery duration was 125.5 (range: 110-145) minutes; blood loss was 117 (range: 100-160) mL. Mean hospital stay was 2.7 (range: 2-3) days, and mean incision size was 4.6 (range: 4-5) cm (table 1).

Discussion

Urologic laparoscopy has enabled the performance of major operations with small incisions. in an effort to discontinue incisions, conventional laparoscopic surgeries “through the umbilicus” are being attempted. This has currently undergone extensive review. Single-port surgery for nephrectomy, pyeloplasty, and donor nephrectomy are now standard procedures in the field of single-port surgery. 9 The introduction of articulated instrumentation eliminates the need for triangulation; however, we have seen that this is irrelevant, given that by working with conventional instruments in a crossed manner (they cross at the entrance point of the abdominal cavity), the problem of triangulation disappears; in addition, the rigidity and strength of conventional instruments are taken advantage of (for dissection), without increasing costs. in particular we prefer a 30 cm laparoscope with a 10 mm diameter and a 30° lens. The use of an extra port has been reported in up to 23% of cases. Two-thirds of the cases have used 5 and 12 mm ports. We have used accessory ports in 3 cases, coinciding with that reported in the literature. Up to a fifth of the cases have been reported as conversions to conventional laparoscopy, and even to open surgery. At the international level, 2 case series were published by experienced centers in 2009 and their results were not lower than those of conventional laparoscopy with respect to less postoperative pain and better cosmetic results. 6,7 After performing standard laparoscopy it is necessary to master working with crossed instruments, the loss of triangulation, and in-line view. On certain occasions an accessory port must be used

Figure 1 Gel Point Advanced Access PlatformTM placed through a 4 cm umbilical incision. Note the 3 trocars in this device.

Figure 2 Laparoscopic vision of a right simple nephrectomy. The already sectioned renal vein can be seen, after the place-ment of 2 proximal Hem-o-Lok® clips and the renal artery is about to be sectioned. The laparoscopic instruments are crossed. The laparoscopic scissors is being manipulated with the surgeon’s right hand; his left hand is using a grasper for cephalad displacement of the liver.

renalartery

renalvein

inferior vena cava


in order to carry out countertraction, to expose structures, or to suture. The Da Vinci technology is not exempt from the single-port approach. Kaouk reported the first case series with single-port access utilizing the Da Vinci system in 2008. 8 The articulated instruments overcome the problem of triangulation, but the force of traction and separation is something that often limits dissection.

All the patients undergoing single-port nephrectomy had a body mass index (BMi) under 32. We have performed single-port surgery in patients with a BMi of 33 with no technical problems up to the present. Our results with respect to surgery duration are important, at a mean 125 (range: 110-145) minutes. Compared with conventional laparoscopy, we believe this is acceptable. Nevertheless, it is our preliminary learning curve experience. in all the cases, postoperative pain was managed with 90 mg of ketorolac daily; no other analgesic was required.

Conclusions

Single-port renal surgery is safe and reproducible. Perhaps the most important step in this procedure for successful outcome is the patient selection criteria.


The authors declare that there is no conflict of interest



References

1. raman JD, Cadeddu JA, rao P, et al. Single-incision laparoscopic surgery: initial urological experience and comparison with natural orifice transluminal endoscopic surgery. BJU int 2008;101(12):1493-1496.

2. Gettman MT, Box G, Averch T, et al. Consensus statement on natural orifice transluminal endoscopic surgery and single-incision laparoscopic surgery: heralding a new era in urology? eur Urol 2008;53(6):1117-1120.

3. Gill iS, Canes D, Aron M, et al. Single port transumbilical (e-NOTeS) donor nephrectomy. J Urol 2009;181(1):418-419.

4. Tracy Cr, raman JD, Cadeddu JA, et al. Laparoendoscopic single site surgery in urology: where have we been and where are we heading? Nat Clin Pract Urol 2008;5(10):561-568.

5. Desai MM, rao PP, Aron M, et al. Scarless single port transumbilical nephrectomy and pyeloplasty: first clinical report. BJU int 2008;101(1):83-88.

6. White WM, Haber GP, Goel rK, et al. Single port urological surgery: single-center experience with the first 100 cases. Urology 2009;74(4):801-804.

7. Desai MM, Berger AK, Brandina r, et al. Laparoendoscopic single site surgery: initial hundred patients. Urology 2009;74(4):805-812.

8. Kaouk JH, Goel rK, Haber GP, et al. robotic single-port transumbilical surgery in humans: initial report. BJU int 2009;103(3):366-369.

9. Kurien A, rajapurkar S, Sinha L, et al. Standard laparoscopic donor nephrectomy versus laparoendoscopic single-site donor nephrectomy: a randomizedcomparative study. J endourol 2011;25(3):365-370.

Table 1 Surgical procedure results per patient are shown

Patient No. Age* Sx duration** Blood loss*** Hospital stay**** incision*****

1 55 140 100 3 5

2 61 145 110 3 5

3 45 130 120 3 5

4 39 130 130 3 5

5 29 120 140 3 5

6 32 120 160 2 5

7 36 110 110 2 4

8 41 110 100 3 4

9 40 120 100 3 4

10 50 130 100 2 4

Mean 42.8 125.5 117 2.7 4.6

Max 61 145 160 3 5

Min 29 110 100 2 4

range 32 35 60 1 1

* Years. ** Minutes. *** mL. **** Days. ***** Centimeters.



Rev Mex Urol 2014;74(1):19-24


OriGiNAL ArTiCLe

Ureteroneocystostomy with laparoscopic psoas hitch as treatment for ureterovaginal fistula: a preliminary experience


Hospital General de Zona N° 1, IMSS, Saltillo, Coah., Mexico

KEYWORDS Ureterovaginal fistula; Psoas hitch; Laparos-copic ureteral reim-plantation; Mexico

AbstractBackground: Numerous approaches have been described for the surgical repair of ureterovaginal fistulas, including the psoas hitch and Boari flap. With the continual refinement of laparoscopic techniques, reconstructive approaches have gone from being practically experimental, to becoming common practice. Aims: We present herein our preliminary experience in ureteroneocystostomy with laparoscopic psoas hitch in referred patients presenting with ureterovaginal fistula. Methods: Five cases of ureterovaginal fistula were retrospectively identified that were treated with Lich-Gregoir ureteral reimplantation and psoas hitch within the time frame of September 2010 to July 2012 at our institution. Indication for surgery was: ureterovaginal fistula with or without stricture in the distal third of the ureter. Results: The 5 patients presented with fistula secondary to hysterectomy for benign disease. Mean age was 37.2 (range: 34-43) years. Percutaneous nephrostomy was placed in 2 patients prior to surgery and double-J catheter placement was achieved in 3 patients. The fistula involved the right ureter in 2 patients and the left ureter in 3. Mean stricture length was 1.9 (range: 1.4-2.2) cm, mean surgery duration was 174 (range: 160-180) min, and estimated blood loss was 130 (range: 50-200) mL.Discussion: The first laparoscopic ureteral reimplantation was performed in 1994 by Erlich et al. in a pediatric patient. Also in 1994, reddy and evans published a report on the first ureteroneocystostomy in the adult population. Conclusions: Laparoscopic ureteroneocystostomy is a safe procedure with the advantages of minimally invasive surgery: rapid recovery and short convalescence, with similar results to those of open surgery.


Introduction

Laparoscopic urology covers a wide spectrum of urinary pathology management that extends from experimental techniques to procedures of proved effectiveness. 1

Ureteral procedures such as pyeloplasty, ureterolithotomy, and ureterolysis are now commonly performed and their effectiveness as minimally invasive techniques has been recognized. 2 Various management options for ureteral strictures are well known; however, length, etiology, and location are the factors that determine the choice of a given technique. 3 These same factors are also the ones taken into account when deciding on the adequate management technique for ureterovaginal fistulas.3 Ureteral damage is recognized as a complication of pelvic surgery, with a 0.3% to 2% incidence after gynecologic surgery. 4

Approximately 70% of the patients with ureteral damage are identified in the immediate postoperative period, due to total incontinence. A small group representing 5% to 10% of patients are recognized in the late postoperative period due to pain secondary to hydronephrosis.

Open surgery has been the traditional option for managing this pathology. Ureteral reimplantation is regarded as the preferred treatment. initial endoscopic management (double-J catheterization) should be attempted in all the patients, but even though double-J catheter placement is sometimes successful, it rarely resolves the problem. 5 When this procedure fails and there is hydronephrosis,

nephrostomy should be placed in order to salvage the renal unit.

We present herein our preliminary experience in performing ureteroneocystostomy with laparoscopic psoas hitch in referred patients presenting with ureterovaginal fistula.

Methods

Five cases of ureterovaginal fistula were retrospectively identified that were treated laparoscopically with Lich-Gregoir ureteral reimplantation and psoas hitch at our institution. Indication for surgery was ureterovaginal fistula with or without stricture in the distal third of the ureter.

All the procedures were performed by the same surgeon with experience in laparoscopic pelvic surgery.

A retrospective study was conducted that included a total of 5 patients diagnosed with ureterovaginal fistula that were seen within the time frame of September 2010 to July 2012. Four of the patients were referred between one and 7 weeks after hysterectomy. One patient had been diagnosed for 2 years. All of the patients had a history of open hysterectomy secondary to benign disease and had undergone previous unsuccessful endourologic procedures. A percutaneous nephrostomy was placed in 2 of the patients (after failed attempt at placing a double-J catheter) and double-J catheter placement was achieved in 3 of the patients presenting with severe hydronephrosis.

Ureteroneocistostomía con psoas Hitch laparoscópico como tratamiento de fístula ureterovaginal: experiencia inicial

ResumenIntroducción: Múltiples abordajes han sido descritos para la reparación quirúrgica de las fístulas ureterovaginales, incluyendo psoas Hitch y Boari flap. Con el continuo refinamiento de las téc-nicas laparoscópicas, los abordajes reconstructivos han pasado de un terreno prácticamente experimental, incluso anecdótico a la práctica habitual.Objetivo: Presentamos nuestra experiencia inicial con ureteroneocistostomía con psoas Hitch laparoscópico, en pacientes que han sido referidos con fístula ureterovaginal.Material y métodos: Retrospectivamente, identificamos 5 casos de fístula ureterovaginal trata-da mediante reimplante ureteral tipo Lich Gregoir y psoas Hitch en nuestra institución, de sep-tiembre de 2010 a julio de 2012. La indicación de la cirugía fue: presencia de fístula ureterova-ginal con o sin estenosis de uréter de tercio distal. Resultados: Las 5 pacientes tuvieron fístula secundaria a histerectomía por enfermedad benig-na. La edad promedio fue de 37.2 (rango 34-43) años. A 2 pacientes se les colocó nefrostomía percutánea, previo a la cirugía. A 3 pacientes se les logró colocar catéter doble J. involucro de la fístula: uréter derecho 2 y uréter izquierdo 3. La media de la longitud de las estenosis fue de: 1.9 (rango 1.4-2.2) cm. Tiempo quirúrgico promedio fue de 174 (rango 160-180) minutos. San-grado transoperatorio promedio 130 (rango 50-200) mL.Discusión: el primer reimplante ureteral laparoscópico fue realizado en 1994 por erlich et al., en un paciente pediátrico. reddy y evans publicaron la primera ureteroneocistostomía en 1994, en la población adulta. Conclusiones: La ureteroneocistostomía laparoscópica es un procedimiento seguro, reproduci-ble, que muestra las ventajas de la cirugía de mínima invasión: rápida recuperación, poca con-valecencia, corta estancia hospitalaria, con resultados equiparables a la cirugía abierta.


PALABRAS CLAVE Fístula ureterovaginal; Psoas Hitch; Reimplante ureteral laparoscópico; México.

Ureteroneocystostomy with laparoscopic psoas hitch as treatment for ureterovaginal fistula: a preliminary experience 21

Preoperative evaluation included the studies available at our hospital: urine culture, excretory urography (eU), plain and contrast-enhanced abdominopelvic computed axial tomography (CAT) scan, kidney scintigram, cystogram, cystoscopy, ureteroscopy, retrograde pyelography (rPG), and in 2 cases, antegrade pyelography (AP).

All the fistulas had a partial or complete obliteration of the ureter. The length of the stricture was measured through RPG and the mean length was 1.9 (range: 1.4-2.2) cm (fig. 1).

TechniquePosition of the patient and access: prior to the laparoscopic approach in the lithotomy position, diagnostic cystoscopy is carried out. Afterwards, the patient is placed in the supine decubitus forced Trendelenburg position and a Foley catheter is placed with the sterile technique before the procedure. The pneumoperitoneum is created through the Hasson method, and a 10 mm trocar for the 0° lens laparoscope is placed at the level of the umbilicus. Three more 5 mm ports are placed under direct vision, the lateral one at 2-3 cm from the anterior superior iliac crest and the third one at the middle of the imaginary line between the pubic symphysis and the umbilical trocar (fig. 2).

We work with only one assistant positioned at the left side of the patient. After freeing the adhesions in the abdominal cavity (present in all 5 cases), the dissection of the ureter is begun. it is freed from above the intersection of the iliac vessels to its entrance into the bladder. Ureteral dissection must be gentle so that no healthy tissue is devascularized. The ureter is dissected distally up to the point where it is surrounded by scar tissue. At that point it is sectioned and sent to the pathology department to rule out malignancy. The proximal end of the stricture is spatulated. The bladder

is totally freed and a completely open space of retzius is observed. This step provides sufficient bladder mobility; up to now, it has not been necessary to sacrifice any vascular pedicle in order to mobilize the bladder.

Ureteral reconstruction: the parameters evaluated for making the decision of which ureteral reconstruction technique to use are: 1) length of the ureteral stricture and 2) bladder capacity. We performed the psoas hitch and the Lich-Gregoir extravesical ureteroneocystostomy in the 5 cases. Once the bladder is freed, 2 lateral sutures are placed in the bladder dome (seromuscular layer) and the psoas muscle, lateral to the genitofemoral nerve. After resecting the segment of the ureter with the stricture and fibrosis, the distal end of the ureter is spatulated and anastomosed to the bladder with separate sutures using Monocryl® SH 3-0 (fig. 3).

The Lich-Gregoir extravesical reimplantation was the technique employed, first creating a tunnel in the seromuscular layer until the bladder mucosa is exposed. Bladder mucosa-ureteral mucosa sutures are placed and then detrusorrhaphy is carried out as an antireflux technique (fig. 4). A double-J catheter is placed in each of the patients and 150 cc of solution is instilled through a transurethral Foley catheter to check for leakage. The transurethral catheter was left in all the patients for 7-10 days after the operation. The double-J catheter was removed after 6 weeks. A kidney scintigram and/or excretory urogram were carried out 2 months after double-J catheter removal in order to demonstrate permeability. Follow-up was every 6 months for 2 years with kidney ultrasound, kidney scintigram or intravenous urogram, and micturition cystogram.

Results

The 5 patients presented with fistula secondary to hysterectomy carried out due to benign disease. All of them

Figure 1 Simultaneous anterograde and retrograde pyelogra-phy showing left ureterovaginal fistula and the approximately 1.4 cm stricture segment..

Figure 2 Trocar and port placement: a 10 mm transumbilical trocar, 5 mm trocars 2-3 cm from the anterior superior iliac crest, and a 5 mm trocar midway between the umbilicus and the pubic symphysis.

4

10 mm

3

5 mm

12


had adhesions in the abdominal cavity from the previous surgical procedures. each of the fistulas had partial or complete obliteration of the ureter. The length of the stricture segment was measured through RPG and the mean length was 1.9 (range: 1.4-2.2) cm.

The preoperative results are shown in table 1. Mean age was 37.2 (range: 34-43) years. Percutaneous nephrostomy was placed in 2 patients prior to surgery (after failed attempt at placing a double-J catheter) (fig. 5); double-J catheter placement was achieved in 3 patients. The fistula involved the right ureter in 2 patients and the left ureter in 3. There were no major complications. The double-J catheter had to be readjusted 24 hours after surgery in one of the patients with the nephrostomy because it had stayed in the percutaneous tract. The intraoperative and immediate postoperative results are shown in table 2. Mean surgery duration was 174 (range: 160-180) minutes, the estimated blood loss was 130 (range: 50-200) mL, and mean hospital stay was 3.2 (range: 3-4) days. Mean follow-up for

all the patients has been over 4 months. The drain was removed when output was under 40 cc and the mean time for beginning oral ingestion was 8 hours.

The double-J catheter was removed 6 weeks after surgery. Excretory urogram and/or kidney scintigram have not shown obstruction in the follow-up of all 5 patients carried out every 3 months. Micturition cystogram was initially done every 3 months. Only one patient showed grade II reflux.

Discussion

Fistulas and distal ureteral strictures are frequently caused during pelvic surgery, by complete transection and/or thermal damage and incidental ligature. The non-surgical causes of stricture include radiation, blunt trauma, infection, and retroperitoneal fibrosis. The repair of these lesions can vary, with a wide spectrum of situations in which knowing the length and location of the lesion is essential for treatment. Another factor to be taken into account is periureteral fibrosis.3,6,7 Ureteral reimplantation in the adult is often performed due to pathologies that involve the distal third of the ureter: trauma, stricture, fistula. 8-11

When the distal segment of the lost ureter is not very long, reimplantation with psoas hitch or Boari flap can be

Figure 3 Laparoscopic vision of the bladder and ureter at the moment of performing the ureteroneocystostomy. A) Bladder mucosa. B) Posterior mucosa-mucosa vertex suturing. C) Spatu-lated ureter.

Figure 4 Laparoscopic vision of the psoas hitch and detrusor-rhaphy of the ureteroneocystostomy.

Table 1 Preoperative patient characteristics

Patient No.

Age*

Time of progression**

Length***

BMI****

Cause of hysterectomy

Catheter

Preoperative/ postoperative creatinine

1 35 14 1.4 cm 27.1ruptured ectopic

pregnancyCatheter 1.1/1.1

2 37 12 2 cm 30.9ruptured ectopic

pregnancyNephrostomy 1.4/1.4

3 37 16 2.1 cm 28.6 Uterine myomatosis Catheter 0.8/0.9

4 34 15 1.8 cm 31.2 Uterine myomatosis Nephrostomy 1.3/0.9

5 43 2 años 2.2 cm 37 Myomatosis Catheter 1.2/1.2

BMI: body mass index. * Years. ** Months. *** Centimeters. ****Kg/m2

A¶

B¶

Psoas Hitch

Bladder

Detrusorrhaphy

Ureter

C¶

Ureteroneocystostomy with laparoscopic psoas hitch as treatment for ureterovaginal fistula: a preliminary experience 23

performed. 12-14 The first laparoscopic ureteral reimplantation was carried out in 1994 by Erlich et al. in a pediatric patient. 12 reddy and evans published a report on the first ureteroneocystostomy in the adult population, also in 1994. 13 It is difficult to evaluate the length of the damaged segment (fibrotic or stenotic) in the acute event. The damage is not self-limited before a few weeks in the majority of cases. This is why we never operate on a patient until at least 10 weeks after hysterectomy.

As is known, laparoscopic surgery has the advantages of less pain, a rapid recovery, and a shorter convalescence. in our circumstance, it is important to mention that the magnified surgical field makes the procedure safer and possibly with better results in relation to open surgery.

The success rate of laparoscopic ureteroneocystostomy is from 92% to 98%. 5,8-14 Laparoscopic reconstructive surgery has the disadvantage of being very demanding and requires a long learning curve. Very few case series conducted in centers have been published, reporting on their experience with this procedure. The principal aim of a reimplantation is to achieve an antireflux anastomosis, with no medium- or long-term obstruction. The success of this procedure has been reported up to 100%. 5 We prefer to always use the psoas hitch technique in all patients to create a tension-free anastomosis; we do not perform much ureteral mobilization, resulting in less risk for devascularization. We did not carry out any Boari flap procedure in the present cases because the ureteral

Figure 5 Coronal view of the plain CT urogram. The psoas hitch, double-J catheter, and nephrostomy can be seen.

segments in all of them were relatively short (2.1 cm). The curve that the ureter makes upon entering the bladder is not modified with the emptying of the bladder.

An important aspect (as in any other reimplantation) is to conserve the 1:4 ratio, diameter: length of the submucosal tunnel.

in regard to age, the majority of the patients in this report were in the third and fourth decades of life. There is little information available about the effect of these treatments (open or laparoscopic) on the sex life of the patients.

We routinely use the double-J catheter during reimplantation. Some published case series omit double-J catheter placement, employing the criteria used for kidney transplant reimplantation, instead.5 The spatulation of the ureter, the correct suturing of the bladder mucosa to the ureteral mucosa, and detrusorrhaphy are the cornerstones of the surgical technique. 15-17

Rassweiler et al. compared open and laparoscopic ureteroneocystostomy. 18 Their study compares the laparoscopic psoas hitch or Boari flap technique with the open technique. With the latter technique, 2 patients presented with urinoma. Stricture recurrence typically develops in the first postoperative year. Even though our follow-up period is short, we will carry out a re-evaluation after a longer period of time.

The use of robotic technology for complex urologic surgery has aided in overcoming many of the technical d i f f icu l t ies encountered dur ing laparoscopy. in particular, thanks to three-dimensional vision and the EndoWrist® versatility of movement, intracorporeal suturing is no longer an obstacle for this procedure. Uberoi et al. published an article on the first robotic ureteroneocystostomy with psoas hitch, 19 and Casale et al. have published the largest case series of robotic-assisted extravesical ureteral reimplantation. 20

Conclusions

Ureteral damage occurs in 2% to 10% of routine pelvic operations and goes up to 30% in pelvic surgery carried out due to malignant processes, especially in the open procedures.4 Laparoscopic ureteroneocystostomy is a safe procedure for the treatment of this pathology. it is reproducible and has the advantages of minimally invasive surgery: rapid recovery, short convalescence, and short hospital stay. Moreover, its results are comparable to those of open surgery.






References

1. Yohannes P, Gershbaum D, rotariu Pe, et al. Management of uretera l s t r icture d i sease dur ing laparoscopic ureteroneocystostomy. J Endourol 2001;15(8):839-843.

2. Gerspach JM, Schulam PG, Kavoussi r. Laparoscopy as applied to the upper urinary tract. AUA update series 2003;XVI.

3. Streem SB, Franke JJ, Smith JA. Surgery of the ureter 7th ed. in: Walsh PC, Retik AD, Vaughan Jr ED (editors). Campbell’s Urology. Vol. 3. Philadelphia: WB Saunders; 2003. p. 2327.

4. Ostrzenski A, Radolinski B, Ostrzenska KM. A review of laparoscopic ureteral injury in pelvic surgery. Obstet Gynecol Surv 2003;58(12):794-799.

5. Pranjal Modi, rahul G, rizv i S. Laparoscopic ureteroneocystostomy and Psoas Hitch post hysterectomy Ureterovaginal Fistula. J Urol 2008;180(2):615-617.

6. O’Boyle PJ, Galli EM, Gow JG. The surgical management of tuberculous lower ureteric stricture. Br J Urol 1976;48(2):101-105.

7. Rafique M, Arif MH. Management of iatrogenic ureteric injuries associated with gynecological surgery. Int Urol Nephrol 2002;34(1):31-35.

8. Atala A, Kavoussi L, Goldstein DS, et al. Laparoscopic correction of vesicoureteral reflux. J Urol 1993;150(2 Pt 2):748-751.

9. Lakshmanan Y, Fung LC. Laparoscopic extravesical ureteral reimplantation for vesicoureteral reflux: recent technical advances. J Endourol 2000;14:589–593.

10. Nezhat C, Nezhat F. Laparoscopic repair of ureter resected during operative laparoscopy. Obstet Gynecol 1992;80(3 Pt 2):543-544.

11. Fergany A, Gill iS, Abdel-Samee A, et al. Laparoscopic bladder flap ureteral reimplantation: survival porcine study. J Urol 2001;166(5):1920-1923.

12. ehrlich rM, Gershman A, Fuchs G. Laparoscopic vesicoureteroplasty in children: initial case reports. Urology 1994;43(2):255-261.

13. reddy PK, evans rM. Laparoscopic ureteroneocystostomy. J Urol 1994;152(6 Pt 1):2057-2059.

14. Castillo OA, Litvak JP, Kerkebe M, et al. Early experience with laparoscopic boari flap at a single institution. J Urol 2005;173(3):862-865.

15. Laguna MP, Schreuders LC, Rassweiler JJ, et al. Development of laparoscopic surgery and training facilities in europe: results of survey of the european Society of Uro-Technology (eSUT). eur Urol 2005;47(3):346-351.

16. Png JC, and Chapple Cr. Principles of ureteric reconstruction. Curr Opin Urol 2000;10(3):207-212.

17. Stief CG, Jonas U, Petry KU, et al. Ureteric reconstruction. BJU Int 2003;91(2):138-142.

18. Rassweiler JJ. Ureteral reimplantation for management of ureteral strictures: a retrospective comparison of laparoscopic and open techniques. eur Urol 2007;51(2):512-522.

19. Uberoi J, Harnisch B, Sethi AS, et al. Robot-assisted laparoscopic distal ureterectomy and ureteral reimplantation with psoas hitch. J Endourol 2007;21(4):368-373.

20. Casale P, Patel rP, Kolon TF. Nerve sparing robotic extravesical ureteral reimplantation. J Urol 2008;179(5):1987-1989.

Table 2 intra and perioperative characteristics

Patient No.

Procedure

Sx duration**

Blood loss**

Days of hospital stay

Oral ingestion***

Complications

results

UCG

Pain Opiates

1Psoas Hitch/extravesical

reimplantation160 50 cc 3 1 No Nl

VUr ii

No


reimplantation175 150 cc 3 1 No Nl Nl No

3Psoas Hitch/ extravesical

reimplantation175 100 cc 3 1 No Nl Nl no


reimplantation180 200 cc 3 1

Double-j catheter readjustment the day after surgery

Nl Nl No

5Psoas Hitch/ extravesical

reimplantation160 150 cc 4 2 No Nl Nl No

* Minutes. ** mL. *** Days.



Rev Mex Urol 2014;74(1):25-29

* Corresponding author at: Blvd. Manuel Ávila Camacho s/n, Lomas de Sotelo, Av. Industria Militar y General Cabral, Delegación Miguel Hidalgo, C.P. 11200, México D.F., México. Telephone: (01) 5557 3100, ext. 1535. Email: [email protected] (G. A. Hernández-Palacios).

OrIGInAL ArTICLe

Technique and anatomic references in laparoscopic diagnostic pelvic lymphadenectomy

J. G. Campos-Salcedoa, G. A. Hernández-Palaciosb,*, G. Hernández-Martínezb, J. A. Castelán-Martínezb, E. I. Bravo-Castrob, M. Castro-Marínc, C. E. Estrada-Carrascod, A. Sedano-Lozanod, J. J. Torres-Salazard, J. C. López-Silvestred and L. A. Mendoza-Álvarezd

a Urology Ward Management, Hospital Central Militar, Mexico City, Mexicob Urology Speciality Residency, Escuela Militar de Graduados de Sanidad, Mexico City, Mexico c Department of Urology Management, Hospital Central Militar, Mexico City, Mexicod Department of Urology, Hospital Central Militar, Mexico City, Mexico

KEYWORDSLymphadenectomy; Pelvic lymphadenectomy; Laparoscopic lymphadenectomy, Laparoscopy; Mexico

AbstractBackground: Urologic neoplasias can be correctly staged through pelvic lymphadenectomy and this procedure is useful for making therapeutic decisions. Aims: To describe and standardize the technique of laparoscopic pelvic lymphadenectomy. Methods: A 73-year-old man presented with a stage T1b nx M0 prostate tumor with a Gleason score of 6 (3+3) and a bladder tumor (urothelial neoplasia of potentially low malignancy). A contrast-enhanced computed tomography urography showed a 1 cm right internal iliac lymph node. Laparoscopic pelvic lymphadenectomy was performed to histopathologically determine the lymph node origin. Results: Surgery lasted 129 minutes, 4 left and 7 right lymph nodes were resected, the drain was removed on the fourth day, and the patient was released on the fifth day. The histopathologic report was negative. Discussion: The rate of positive lymph nodes reported for pelvic lymphadenectomy varies from 3.2 to 26.2%, depending on the population studied. The technique should be standardized in the uro-oncologic centers in order to have comparative and reliable results. It is a minimally invasive, safe, and effective treatment for tumor staging. Conclusions: The description and standardization of the surgical technique makes it reproducible in the hospital environment for physicians that do not have enough experience, offering a step-by-step guide with anatomic references explained in this article.

26 J. G. Campos-Salcedo et al

Introduction

Prostate cancer has surpassed other malignant tumors as the main cancer in men. Since the advent of the era of prostate-specific antigen (PSA) the finding of lymph node metastases in surgical candidates with prostate cancer has diminished significantly. The majority of the data are reported in relation to a dissection template in the obturator fossa. 1-4 The dissection of pelvic lymph nodes (lymphadenectomy) is the most precise staging procedure for lymph node invasion (LnI) in clinically localized prostate cancer. 5 ever since laparoscopic pelvic lymphadenectomy was established as a staging procedure in prostate cancer patients, its indications have been broadened to include staging of cancers of the bladder, penis, and urethra. 6 Unfortunately, imaging studies such as computed tomography (CT) and standard magnetic resonance (MrI) have a very limited capacity for predicting tumor activity in lymph nodes. 7 Laparoscopic pelvic lymphadenectomy has been thoroughly described for the respective anatomic templates in international journals. 8,9

We will describe the laparoscopic technique used at the Hospital Central Militar for the purpose of standardizing it so that this approach can be conventionally adopted. This article offers a detailed step-by-step surgical approach for this procedure.

Methods

A 73-year-old man presented with the associated comorbidity of high blood pressure that was adequately controlled. He was studied due to lower urinary tract

symptomatology and underwent transurethral resection of the prostate (TUrP). The histopathologic study reported prostate adenocarcinoma with a Gleason score of 6 (3+3) in more than 5% of the resected tissue and the CaP was staged as T1bnxM0. During the resection, a monofocal bladder tumor of 1 cm was observed and separately resected. The histopathologic study reported a stage T1nxMx urothelial neoplasia with a low malignancy potential. extension studies with CT-urography only revealed a contrast-enhanced 1 cm right internal iliac lymph node. A bone scintigram was negative for bone metastases and it was decided to carry out a diagnostic pelvic lymphadenectomy to determine the lymph node origin (secondary to prostate or bladder neoplasia) in order to provide definitive management of both known primary tumors.

Description of the technique The abdominal wall was insufflated. The open or Hasson technique was used to place the initial trocar. The Hasson system consists of a trumpet valve with a conic sleeve and a blunt-tipped obturator. A 2 cm incision was made in the skin at the umbilical level, the pre-peritoneal fat was retracted and the fascia was incised. The peritoneum was lifted with a pair of Kelly forceps and incised with a cold knife.

The peritoneal cavity was thus accessed and the trocar was inserted, attaching it to the fascia. Hemoperitoneum was established through the Hasson trocar and the complete abdominal cavity was visualized with the aid of a 30º laparoscopic lens.

Técnica y referencias anatómicas en linfadenectomía pélvica diagnóstica laparoscópica

ResumenIntroducción: La linfadenectomía pélvica sirve para una correcta estadificación de neoplasias urológicas, siendo útil para tomar de decisiones terapéuticas.Objetivo: Describir la técnica de la linfadenectomía pélvica laparoscópica y estandarizarla. Material y métodos: Se realizó linfadenectomía pélvica laparoscópica a paciente masculino 73 años de edad, con tumor prostático Gleason 6 (3+3) T1bnxM0 y tumor vesical (neoplasia urote-lial de bajo potencial maligno), con urotomografía que demostró ganglio linfático ilíaco interno derecho de 1 cm, con reforzamiento de medio de contraste para determinar histopatológica-mente origen de ganglio linfático.Resultados: Se realizó la cirugía en 129 minutos, resecando 4 ganglios izquierdos, 7 derechos, retirando drenaje al cuarto día y egresándose al quinto día. el reporte histopatológico fue nega-tivo.Discusión: La tasa de ganglios positivos reportados en linfadenectomía pélvica varían desde 3.2% hasta 26.2%, dependiendo la población estudiada. La técnica deberá estandarizarse en los cen-tros urooncológicos para tener resultados comparativos y confiables. Es un tratamiento de míni-ma invasión, seguro y eficaz para la estadificación tumoral.Conclusiones: La descripción y estandarización de la técnica quirúrgica la hace reproducible en el ámbito hospitalario para aquellos médicos que no cuenten con experiencia suficiente, esto los guiará paso a paso con las referencias anatómicas explicadas en el presente artículo.


KEYWORDSLymphadenectomy; Pelvic lymphadenectomy; Laparoscopic lymphadenectomy, Laparoscopy; Mexico.

Laparoscopic pelvic lymphadenectomy 27

Five trocars were placed under direct vision with the help of the laparoscopic video camera. A 10 mm trocar was placed at the umbilical level for laparoscopic camera access. A second trocar was placed on the left side and a third trocar on the right side at the umbilical level lateral to the inferior epigastric vessels, and aligned with the anterior superior iliac crest. Two additional trocars were placed laterally, midway between the umbilicus and the pubic symphysis. Dissection was begun on the side where there was greater suspicion of malignant lymph node disease.

The operating table was in the 25°-30º Trendelenburg position to allow the intestinal structures to descend in the direction of the diaphragm and distance them from the operating field.

The umbilical ligament, the iliac vessels, the internal inguinal ring, the vas deferens, and the spermatic cord structures were identified (fig. 1).

The incision line on the peritoneum was determined through these anatomic references. With the testis prepared inside the operating field, the surgeon could apply traction to the testis on the side of the dissection in order to identify the spermatic cord structures as they enter the internal inguinal ring.

Laparoscopic scissors were used to expose the external iliac artery and vein and a curved grasper was used to carry out traction and countertraction. The incision was made precisely medial to the umbilical ligament from the pubic bone toward the common iliac artery (fig. 2).

The vas deferens was exposed during the dissection of the peritoneum and was isolated, tied, and cut with laparoscopic clips. The external iliac vein and artery were carefully dissected; the dissection limits were the same as in open surgery. The artery was circumflexed inferiorly, the internal iliac artery superiorly, the internal iliac vein externally, and the obturator nerve medially. Lateral dissection was begun with the identification of the external iliac vein, recognized through the pulsation coming from the external iliac artery. The fatty tissue inferior to the

arterial pulsation was lifted and the vein was exposed through gentle blunt dissection in a cephalad and caudal direction.

The lax connective tissue and the lymphatic tissue were lifted above the vein and dissection extended from the level of the common iliac vein bifurcation toward the pubic bone and then medially until the internal obturator muscle was seen.

The lymphatic tissue was dissected from the lateral surface of the pelvic wall with a combination of blunt and cutting dissection (fig. 3). The assisting surgeon medially lifted the lymph node package to facilitate the dissection of the pelvic wall. The accessory blood vessels were clipped and cut.

Once the lateral portion of the dissection was complete, attention was directed to the lymph node package near the umbilical ligament and the bladder wall. The assistant medially retracted the lymph node tissue in order to expose, through blunt dissection, the plane between the umbilical ligament and the nodular package. After isolating and defining the lateral and medial limits, the apex of the lymph node package near the pubic bone was clipped and divided. The cephalad retraction of the distal portion of the nodal package provided a clear view of the obturator nerve.

The remainder of the lymphadenectomy involved the cephalad retraction of the nodal package and blunt dissection of the deep portion, moving away from the pelvic wall. The obturator nerve should always be kept in sight to avoid injuring it.

The contralateral lymphadenectomy was performed with the same technique.

The resected tissue was extracted through a 10-12 mm port, preventing its loss by removing it through an extraction bag. A Blake drain was placed close to the surgical site.

Results

The total surgery duration of the laparoscopic bilateral pelvic lymphadenectomy was 129 minutes, having

Figure 1 Preliminary dissection. Photograph showing the identification of the iliac vessels, the internal inguinal ring (blue ellipse), vas deferens (signaled by the Maryland dissecting forceps) and the spermatic cord.

Figure 2 Iliac vessel dissection. The peritoneum is incised, carefully dissecting the external iliac vein and artery.

TrUe PeLVISPUBIC SYMPHYSIS

ILIAC ArTerY


completely resected 4 left and 7 right pelvic lymph nodes. The patient presented with a serosanguineous discharge through the drain that progressively diminished until the drain was removed on the fourth postoperative day. The patient was released with no drain on the f i fth postoperative day. The histopathologic report was negative for malignancy and there was no evidence of tumor activity at the obturator fossa level. The patient was offered radical prostatectomy as cancer management, but he chose radiotherapy management instead. The bladder cancer is presently being managed with intravesical BCG and surveillance, with follow-up control cystoscopies.

Discussion

Pelvic lymphadenectomy continues to be a controversial theme for evaluating its indications, the extension of anatomic templates, and its possible therapeutic value.

Some studies have demonstrated metastatic lymph node activity in prostate cancer in lymph nodes of the obturator fossa.1-3 Comparative studies between limited vs. extended pelvic dissection should be conducted to document the under or overstaging of prostate cancer. 10-12

The positive lymph node rate reported for open pelvic lymphadenectomy varies from 3.2% to 26.2%, depending on the population studied. 13-15

In the present case, laparoscopic pelvic lymphadenectomy had a negative histopathologic report in relation to neoplastic activity of known primary site origin. A study with a larger number of patients should be carried out in order to obtain results that are comparable to those reported in the international literature.

Conclusions

S t a n d a r d i z a t i o n o f t h e l a p a r o s c o p i c p e l v i c lymphadenectomy technique will facilitate this surgical approach in future patients, as well as have a beneficial

effect on oncologic staging results for prostatic and/or vesical neoplasias, with better and more reliable histopathologic results.

The transperitoneal approach provides adequate exposure of the anatomic structures.

A standardized approach was described for performing laparoscopic pelvic lymphadenectomy for prostatic and/or vesical neoplasias.

The description and standardization of the surgical technique makes it reproducible in the hospital environment for physicians with insufficient experience, offering a step-by-step guide with anatomic references explained in this article.





References

1. Fowler Je, Whitmore Jr WF. The incidence and extent of pelvic lymph node metastasis in apparently localized prostate cancer. Cancer 1981;47(12):2941-2945.

2. McDowel II CG, Johnson JW, Tenney DM, et al. Pelvic lymphadenectomy for staging clinically localized prostate cancer: indications, complications, and results in 217 cases. Urology 1990;35(6):476-482.

3. Partin AW, Yoo J, Carter HB, et al. The use of prostate specific antigen, clinical stage and Gleason score to predict pathological stage in men with localized prostate cancer. J Urol 1993;150(1):110-114.

4. Danella JF, Dekernion JB, Smith rB, et al. The contemporary incidence of lymph node metastases in prostate cancer: implications for laparoscopic lymph node dissection. J Urol 1993;149(6):1488-1491.

5. Aus G, Abbou CC, Bolla M, et al. european Association of Urology. eAU guidelines on prostate cancer. eur Urol 2012;48:546-551.

6. Moore rG, Kavoussi Lr. Laparoscopic lymphadenectomy in genitourinary malignancies. Surg Oncol 1993;2 Suppl 1:51-66.

7. Paik ML, Scolieri MJ, Brown SL, et al. Limitations of computerized tomography in staging invasive bladder cancer before radical cystectomy. J Urol 2000;163(6):1693-1696.

8. Gershman A, Daykhovsky L, Chandra M, et al. Laparoscopic pelvic lymphadenectomy. J Laparoendosc Surg 1990;1(1):63-68.

9. Beer M, Staehler G, Dorsam J. Laparoscopic pelvic lymphadenectomy. Indications, technique, initial results. Chirurg 1991;62(4):340-344.

10. Bluestein DL, Bostwick DG, Bergstralh eJ, et al. eliminating the need for bilateral pelvic lymphadenectomy in select patients with prostate cancer. J Urol 1994;151(5):1315-1320.

11. Petros JA, Catalona WJ. Lower incidence of unsuspected lymph node metastases in 521 consecutive patients with clinically localized prostate cancer. J Urol 1992;147(6):1574-1575.

12. Danella JF, Dekernion JB, Smith rB, et al. The contemporary incidence of lymph node metastases in prostate cancer: implications for laparoscopic lymph node dissection. J Urol 1993;149(6):1488-1491.

Figure 3 Iliac vessel dissection. The lymph node tissue was dissected from the lateral surface of the pelvic wall with a combination of blunt and cutting dissection.

ILIAC VeIn

ILIAC ArTerY

VAS DeFerenS

Laparoscopic pelvic lymphadenectomy 29

13. Bader P, Buckhard FC, Markwalder r, et al. Is a limited lymph node dissection an adequate staging procedure for prostate cancer? J Urol 2002;168(2):514-518.

14. Allaf Me, Palapattu GS, Trock BJ, et al. Anatomical extent of lymph node dissection: impact on men with clinically localized prostate cancer. J Urol 2004;172(5 Pt 1):1840-1844.

15. Heidenreich A, Varga Z, VonKnobloch r. extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis. J Urol 2002;167(4):1681-1686.



Rev Mex Urol 2014;74(1):30-34

* Corresponding author at: Dr. Balmis N° 148, Colonia Doctores, Delegación Cuauhtémoc, C.P 06800, México D.F., México. Telephone: +52 (55) 2789 2000, ext. 1031. Cell phone: (+52) (55) 5104 7158. Email: [email protected] (M. Maldonado-Ávila).

OrigiNal arTiCle

Intravesical prostatic median lobe size as a trial without transurethral catheter result predictor in patients with acute urinary retention

M. Maldonado-Ávila*, J. A. Sierra-Ramírez, J. D. Carrillo-Ruiz, H. A. Manzanilla-García, J. Guzmán-Esquivel, J. C. González-Valle and I. R. Labra-Salgado

Department of Urología, Hospital General de México “Dr. Eduardo Liceaga” O.D. School of Medicine, Instituto Politécnico Nacional, Mexico City, Mexico

KEYWORDS intravesical protrusion; Prostatic hyperplasia; acute urinary retention; Median lobe; Tamsulosin; alfuzosin; Mexico

Abstract Background: acute urinary retention (aUr) is a urologic emergency commonly treated with bladder catheterization and the administration of alpha-adrenergic antagonists, followed by a trial without catheter. intravesical prostatic protrusion (iPP) is an enlargement of the prostate in which the median lobe protrudes into the bladder. it has been suggested that the size of this lobe can predict the result of a trial without catheter. Aims: To determine the relation between the size of the intravesical prostatic lobe and the success of spontaneous voiding recovery in patients treated with alpha blockers. Methods: Men above the age of 50 years that presented with urinary retention within the time frame of September 2010 to February 2013 were randomly included in one of the 3 study groups: group 1 tamsulosin; group 2, alfuzosin; and group 3, placebo. The catheter was removed on the fifth day and transrectal ultrasound was carried out, categorizing the size of the prostatic lobe as grade i: <5 mm, grade ii: 5-10 mm, and grade iii: >10 mm. Success was considered if the first micturition volume was > 100 mL and residual urine < 200 mL.Results: a total of 78 patients were included. The success percentages of grades i-iii were: 37.5%, 36.8%, and 41.7%, respectively. logistic regression analysis showed that the size of the intravesical lobe was not a predictive factor of success (Or=0.857; 95%Ci=0.184-3.983; p= 0.844).Conclusions: The intravesical lobe is not a predictive factor for successful micturition after catheter removal, regardless of the drug used.

intravesical prostatic median lobe size as a trial without transurethral catheter result predictor in patients with acute urinary retention 31

Introduction

acute urinary retention (aUr) is a urologic emergency that is defined as the inability to urinate. it usually presents suddenly and is accompanied by pain. 1 The annual aUr incidence in different countries varies from 2.2 to 6.8 per 1,000 men. 2-6 Unfortunately, there are no studies in Mexico describing the incidence or prevalence of this condition.

The majority of aUr cases are caused by benign prostatic hyperplasia. Some of the identified predictive factors are advanced age, a flowmetry with low values, increased post-micturition residual urine, significant prostate enlargement, and an elevated prostate-specific antigen (PSA) level.

Preliminary management involves the gradual emptying of the bladder with transurethral catheter placement. Until recently, the majority of patients were referred for surgery after an aUr event. However, surgery in these patients is associated with a high risk for transfusion, postoperative complications, and mortality in the first 30 days. 7-9

The risk associated with the permanence of transurethral catheter has increased the practice of its removal after 1-8 days of pharmacologic treatment, enabling the recovery of spontaneous micturition in 34%-60% of the patients. 10-12 The most frequently used drugs for this purpose are the alpha-adrenergic antagonists, alfuzosin and tamsulosin. Their similar effectiveness has been reported. 13-16 The direct benefit is improved quality of life and reduced morbidity associated with transurethral catheter. 17

On the other hand, a particular form of prostatic growth is the so-called intravesical median prostatic lobe, in which

the median lobe protrudes into the interior of the bladder. Previous studies have suggested that this growth may be a factor in predicting the result of a successful trial without catheter in patients treated with alpha blockers like alfuzosin and tamsulosin. 18-20 However, up to the present, there are no studies directly comparing alfuzosin and tamsulosin that determine if this particular type of growth constitutes a prediction factor in the result of a trial without transurethral catheter.

The aim of this study was to investigate the relation between the size of the intravesical prostatic protrusion (iPP) and the successful recovery of spontaneous micturition after transurethral catheter removal in patients treated with tamsulosin, alfuzosin, and placebo, as well as to determine whether the size of the prostatic median lobe could predict and identify patients with a greater probability of trial without transurethral catheter failure.

Methods

Patient selectionThe inclusion criteria were the following: men above the age of 50 years, with first symptoms of AUR secondary to benign prostatic hyperplasia, that sought medical attention at the outpatient service of the Hospital General de México.

The exclusion criteria were: more than one episode of symptoms of aUr, patients that had been treated for prostate enlargement (alpha blockers, phytotherapy, etc.) raised levels of creatinine and urea (serum creatinine > 120

Tamaño del lóbulo medio prostático intravesical como predictor del resultado del intento de retiro de sonda transuretral en pacientes con retención aguda de orina

resumen Introducción: la retención aguda de orina (raO) es una urgencia urológica habitualmente tratada con sondeo vesical y la administración de bloqueadores alfa-adrenérgicos, seguido de intento de retiro de sonda.la protrusión prostática intravesical (PPi) es un crecimiento del lóbulo medio de la próstata hacia el interior de la vejiga. Se ha sugerido que el tamaño del lóbulo prostático puede predecir el resultado del intento de retiro de sonda. Objetivo: Determinar la relación entre el tamaño del lóbulo prostático intravesical y el éxito en la recuperación de la micción espontánea, en pacientes tratados con bloqueadores alfa-adrenérgicos.Material y métodos: De septiembre de 2010 a febrero de 2013, fueron incluidos varones mayores de 50 años con retención urinaria en forma aleatorizada a algunos de los 3 grupos: grupo 1, tamsulosina; grupo 2, alfuzosina; grupo 3, placebo. al quinto día se retiró la sonda y se realizó ultrasonido transrectal, categorizándose el tamaño del lóbulo prostático en grado i: < 5 mm, grado ii: 5-10 mm y grado iii: > 10 mm. Se consideró éxito si el volumen de la primera micción era > 100 ml y orina residual < 200 ml.Resultados: Se incluyeron 78 pacientes. los porcentajes de éxito del grado i-iii fueron: 37.5%, 36.8% y 41.7%, respectivamente. la regresión logística mostró que el tamaño del lóbulo intravesical no es un factor predictivo del éxito (Or=0.857; iC 95%=0.184-3.983; p=0.844).Conclusiones: el lóbulo intravesical no es un factor predictor del éxito al retiro de sonda, independientemente del fármaco empleado.


PALAbRAS CLAVE Protrusión intravesical; Hiperplasia prostática; retención aguda de orina; lóbulo medio; Tamsulosina; alfuzosina; México.

32 M. Maldonado-Ávila et al

mmol/ml), hydronephrosis due to reflux, more than one presentation of urinary tract infection or hematuria, active urinary infection, suspicion of prostate cancer through the digital rectal examination, suspicion of bladder cancer, suspicion of urinary retention distinct from prostatic pathology, neurogenic bladder, urethral stricture, blood clots, bladder lithiasis, confirmed diagnosis or suspicion of prostate cancer, aUr secondary to an anesthetic procedure due to major surgery, patients with an inability to understand or authorize informed consent, patients with a history of postural hypotension (blood pressure reduction >20 mm Hg in the systolic or diastolic value) or syncope, patients with severe or unstable heart failure, patients taking cholinergic, anticholinergic, or MaO inhibiting medication, and patients with severe liver failure.

a comparative, longitudinal, randomized, simple-blind clinical trial was conducted. a total of 78 men were assigned to one of three groups by a randomization table: group i, tamsulosin 0.4 mg p. o. every 24 hours for 4 days; group ii, alfuzosin 10 mg p.o. every 24 hours for 4 days; and group iii, placebo.

Based on previous studies that reported successful trial without catheter with alfuzosin in 62% of the patients 12 and with tamsulosin in 48%, 10 and due to the reported superiority of either of the 2 alpha blockers with respect to a placebo, we decided to include a 2:1 ratio in relation to the placebo. Contingent on the formula for 2 proportions, assuming an 80% power, and a significance level of 0.05, and assuming a success of 64% when the iPP was less than 10 mm and a success of 33% when the iPP was greater than 10 mm,19 we required a sample size of 30 patients per alpha blocker group and 15 patients in the placebo group.

Once the diagnosis of aUr due to prostate enlargement was established and it was determined that the patient met the selection criteria to enter the study, the trial characteristics were explained. all the selected patients signed statements of informed consent for participating in the study in accordance with the Declaration of Helsinki principles. in addition, this study was approved by the ethics and research committees of the Hospital General de México, O.D., register DiC/10/1085/04/109.

The information was gathered in a file that contained the personal data of the patient, demographic data, clinical history and complete physical examination, as well as lower urinary tract symptoms based on the international Prostate

Symptoms Scale (iPSS), date and time of transurethral catheter placement, digital rectal examination findings, laboratory test results, and transrectal ultrasound images. The iPP was measured by tracing a transverse line marking the bladder and bladder neck that went from the anterior to the posterior commissure, identified in a sagittal view of the transrectal ultrasound. at the center of that line another vertical line was drawn that went toward the median lobe of the prostate. The transurethral catheter was removed on the fifth day and patients were asked to drink 1.5 l of water. When they had the desire to urinate, the volume of the first micturition was measured in a calibrated cup. afterwards, a 14 Fr Nelaton catheter for input/output monitoring was placed and the volume of the post-micturition residual urine was measured. The waiting period was a maximum of 4 hours for the first micturition. If spontaneous micturition did not present or the patient was unable to urinate, had suprapubic pain, or presented with a distended bladder, the trial without catheter was considered failed.

The IPP grade was classified into 3 groups: grade i: under 5 mmgrade ii: between 5 and 10 mmgrade iii: above 10 mm

Statistical analysisThe data were described through means ± standard deviation (SD) or percentages, depending on the variable. We carried out analysis of variance (aNOVa) to compare the means of the continuous quantitative variables.

logistic regression analysis was used to establish the correlation between variables. The SPSS® for Windows version 15 statistics program (SPSS, Chicago, il, USa) was employed.

Results

Within the time frame of September 2010 to February 2013, a total of 78 patients were consecutively included in the study: 32 in the tamsulosin group, 30 in the alfuzosin group, and 16 in the placebo group.

There were no statistically significant differences in relation to age, weight, height, body mass index, or prostate-specific antigen among the 3 groups. The ANOVA test for comparing the means of the prostatic protrusion

Table 1 Variables demográficas por grupo

Variable

Tamsulosin (32 patients)

alfuzosin (30 patients)

Placebo (16 patients)

p*

age (years) 65 ± 9.6 65.1 ± 9.1 69.6 ± 7.8 0.210

PSa (ng/ml) 7.5 ± 4.4 10.2 ± 9 4.58 ± 2.89 0.187

Weight (Kg) 69.4 ± 13.1 70.0 ± 12.1 64.8 ± 10.9 0.461

Height (cm) 160.9 ± 7.3 161.9 ± 7.6 163.4 ± 6.7 0.585

BMi (Kg/m2) 26.9 ± 5.4 26.6 ± 3.6 24.1 ± 2.9 0.160

iPP (mm) 14.43 ± 7.88 12.74±6.69 12.97±8.39 0.648

* Significance level p<0.05. PSA: prostate-specific antigen; BMI: body mass index; IPP: intravesical prostatic protrusion.

intravesical prostatic median lobe size as a trial without transurethral catheter result predictor in patients with acute urinary retention 33

measurements showed no statistically significant differences (p=0.648) among the 3 groups (placebo 12.97 ± 8.39, tamsulosin 14.43 ± 7.88, alfuzosin 12.74 ± 6.69).

Table 2 shows the patient distribution per drug and iPP grade. eight patients presented with iPP grade i, 19 with iPP grade ii, and 51 with iPP grade iii.

The percentage of successful trial without catheter based on the iPP grades was 37.5% for grade i, 36.8% for grade ii, and 41.7% for grade III (fig. 1).

logistic regression analysis showed that the iPP grade was not a significant independent variable that could be regarded as a predictive factor for trial without catheter success, with an odds ratio of 0.857 (95% Ci 0.184- 3.983) (p= 0.844) (table 3).

Discussion

The iPP is an ultrasonographic measurement of the median lobe of the prostate that projects into the bladder and it has been suggested that this particular enlargement of the prostate causes “valve effect” obstruction, altering the physiologic funneling mechanism that the bladder neck performs during the dynamics of micturition. This particular anatomic condition would cause major infravesical obstruction if there were growth of the lateral prostatic lobes, exclusively.

Different studies have demonstrated that there is a correlation between the severity of urinary obstruction and iPP grade. Mariappan et al. (2007) reported that those patients with an iPP above 10 mm would present a 6 times higher risk for failed trial without transurethral catheter. likewise, Tan and Foo (2003) suggested that patients with

grade I IPP would benefit from receiving drug treatment and then undergoing the trial without transurethral catheter and that the patients with grade iii iPP would not respond to conventional treatment and would require immediate surgical management.

in contrast, the results of the present study showed that IPP grade was not a significant independent variable that could be regarded as a predictive factor in trial without catheter success. This discrepancy is probably due to the fact that the previous studies only made a comparison with a placebo and not directly with an alpha blocker.

Despite the abovementioned, we do not rule out the possibility that the characteristics of our study population are different, given that numerous studies have identified diverse factors that may condition acute urinary retention symptoms. among the most frequently mentioned are excessive liquid intake, alcohol ingestion, sexual activity, associated urinary tract infection, and generalized weakness of the patient, suggesting that all these mechanisms can be precipitant and that the cause of aUr may not necessarily be the progression of benign prostatic hyperplasia or a type of growth in particular, such as intravesical prostatic median lobe growth.

Conclusions

in the present study, iPP was not a predictive factor of trial without transurethral catheter success, regardless of the drug that was used.

1 2 3

% S

ucce

ss

50

40

30

20

10

0

37.5 36.841.7

Figure 1 Success percentage of catheter removal per intra-vesical prostatic protrusion grade (iPP).

Table 2 Patient distribution per drug and intravesical prostatic protrusion grade (n=78)

Tamsulosin alfuzosin Placebo Total

grade i (< 5 mm)

1 3 4 8

grade ii(5-10 mm)

9 8 2 19

grade iii(> 10 mm)

22 19 10 51

Patient total

32 30 16 78

Table 3 logistic regression model analysis of intravesical prostatic protrusion as a predictive factor in the trial without catheter result

Variable Or 95% Ci p*

intravesical prostatic protrusion (iPP) 0.857 0.184-3.983 0.844

* Significance level p<0.05.

34 M. Maldonado-Ávila et al





Acknowledgements

The authors wish to thank the nurses ana María Hernández Peñaloza and Concepción lira Olmos for the efficient management of the patients and Dr. Juan Carlos lópez alvarenga for his contributions to the statistical analysis.

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4. Verhamme KM, Dieleman JP, van Wijk Ma, et al. low incidence of acute urinary retention in the general male population: the triumph project. eur Urol 2005;47(4):494-498.

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6. Hunter DJ, Berra-Unamuno a, Martin-gordo a. Prevalence of urinary symptoms and other urological conditions in Spanish men 50 years old or older. J Urol 1996;155(6):1965-1970.

7. Cravens DD, Zweig S. Urinary catheter management. am Fam Physician 2000;61(2):369-376.

8. McNeill Sa, Hargreave TB. alfuzosin once daily facilitates return to voiding in patients in acute urinary retention. J Urol 2004;171(6 Pt 1):2316-2320.

9. Mebust WK, Holtgrewe Hl, Cockett aT, et al. Transurethral prostatectomy: immediate and postoperative complications. a

cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 1989;141(2):243-247.

10. Zeif HJ, Subramonian K. alpha blockers prior to removal of a catheter for acute urinary retention in adult men. Cochrane Database Syst rev 2009(4):CD006744.

11. emberton M, Fitzpatrick JM. The reten-World survey of the management of acute urinary retention: preliminary results. BJU int 2008;101 Suppl 3:27-32.

12. Tiong HY, Tibung MJ, Macalalag M, et al. alfuzosin 10 mg once daily increases the chances of successful trial without catheter after acute urinary retention secondary to benign prostate hyperplasia. Urol int 2009;83(1):44-48.

13. Buzelin JM, Fonteyne e, Kontturi M, et al. Comparison of tamsulosin with alfuzosin in the treatment of patients with lower urinary tract symptoms suggestive of bladder outlet obstruction (symptomatic benign prostatic hyperplasia). The european Tamsulosin Study group. Br J Urol 1997;80(4):597-605.

14. lucas Mg, Stephenson TP, Nargund V. Tamsulosin in the management of patients in acute urinary retention from benign prostatic hyperplasia. BJU int 2005;95(3):354-357.

15. Wilde Mi, Fitton a, McTavish D. alfuzosin. a review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in benign prostatic hyperplasia. Drugs 1993;45(3):410-429.

16. McNeill Sa, Hargreave TB, roehrborn Cg. alfuzosin 10 mg once daily in the management of acute urinary retention: results of a double-blind placebo-controlled study. Urology 2005;65(1):83-9; discussion 9-90.

17. McNeill Sa, Daruwala PD, Mitchell iD, et al. Sustained-release alfuzosin and trial without catheter after acute urinary retention: a prospective, placebo-controlled. BJU int 1999;84(6):622-627.

18. Chia SJ, Heng CT, Chan SP, et al. Correlation of intravesical prostatic protrusion with bladder outlet obstruction. BJU int 2003;91(4):371-374.

19. Mariappan P, Brown DJ, McNeill aS. intravesical prostatic protrusion is better than prostate volume in predicting the outcome of trial without catheter in white men presenting with acute urinary retention: a prospective clinical study. J Urol 2007;178(2):573-7; discussion 7.

20. Tan YH, Foo KT. intravesical prostatic protrusion predicts the outcome of a trial without catheter following acute urine retention. J Urol 2003;170(6 Pt 1):2339-2341.



Rev Mex Urol 2014;74(1):35-43

* Corresponding author at: Gelati N° 29, Consultorio 401-B, Colonia San Miguel Chapultepec, Delegación Miguel Hidalgo, CP 11850, México D.F., México. Telephone: 5277 6165. Email: [email protected] (E. A. Ramírez-Pérez).

REviEw ARTiClE

Current aspects of the medical and surgical management of Peyronie’s disease

E. A. Ramírez-Péreza,*, U. Sánchez-Aquinob, R. López-Magueyb and J. C. López-Silvestrec

a Centro de Uretra México (CEU) Administration, Mexico City, Mexico b General Surgery Speciality Residency at the Hospital Ángeles Mocel, Mexico City, Mexico c Genitourinary Reconstructive Surgery Division Management at the Hospital Central Militar, and CEU, Mexico City, Mexico

KEYWORDSPeyronie’s disease; Erectile dysfunction; Medical treatment; Surgical management; Plication; Graft; Mexico.

Abstract Peyronie’s disease is characterized by an alteration in the scarring process of the tunica albuginea that conditions deformity, curvature, and narrowing and shortening of the penis, along with significant sexual dysfunction. Numerous non-surgical treatments have been studied and suggested, but none of them has shown a real and effective correction of penile deformity. Therefore surgery continues to be the criterion standard for the correction of curvature and deformity caused by Peyronie’s disease. This article describes important aspects to be considered in the diagnosis and medical and surgical management of Peyronie’s disease.

Aspectos actuales en el manejo médico-quirúrgico de la enfermedad de Peyronie

Resumen la enfermedad de Peyronie es una enfermedad que se caracteriza por una altera-ción en el proceso de cicatrización de la túnica albugínea que condiciona deformidad peneana, curvatura, estrechamiento y acortamiento del pene, y compromete la función sexual de manera importante. Aunque se han estudiado y sugerido múltiples tratamientos no quirúrgicos, ninguno de estos ha demostrado de manera real y efectiva la corrección de la deformidad peneana. Por dicha razón, la cirugía continúa siendo el estándar de oro para la corrección de la curvatura y deformidad generada por la enfermedad de Peyronie. En este artículo mencionamos aspectos importantes a considerar en el diagnóstico y manejo médico-quirúrgico de la enfermedad de Peyronie.


PALAbRAS CLAvE Peyronie’s disease; Erectile dysfunction; Medical treatment; Surgical management; Plication; Graft; Mexico

36 E. A. Ramírez-Pérez et al

Introduction

For many men the form, size, and function of the penis are the scale by which they measure their health and masculinity. The appearance of any disease that conditions dysfunction or deformity in the penis causes great concern. Penile deformities are more frequent than what is generally thought. They cause severe sexual function alteration sometimes resulting in serious problems for the couple, given that penetration can be impossible and also painful. This conditions great frustration and depression that leads to psychosexual dysfunction, which in turn causes erectile dysfunction. Peyronie’s disease is one of the acquired penile deformities. It was first described by Francois Gigot de la Peyronie in 1743 and is a condition that presents deformity of the penis characterized by a fibrous plaque in the penile tunica albuginea.

Erectile dysfunction and pain are a frequent manifestation of this disease. its etiology and the mechanism by which it is produced are not fully understood. Microtrauma and the alteration of scarring mechanisms are accepted as the main cause.

Medical treatment advances have been made, but there is still no effective medication. Surgical management continues to be the criterion standard once the formation of plaque has stabilized.

Epidemiology

The epidemiologic data of Peyronie’s disease has varied widely since it was first reported. In 1928 Polkey reported 550 cases worldwide and an italian report published in 1966 described 3,600 affected patients. in 1968 ludvik established a rate of 0.3%-0.7% in patients seen in urologic private practice.1 in 1991 lindsey postulated a prevalence of 388.6 cases of Peyronie’s disease per 100,000 patients in Rochester, Minnesota.2 At the Devine Center, close to 1% of the medical population between the ages of 30 and 65 years has Peyronie’s disease. 3 Peyronie’s disease diagnosis has been established much more frequently in autopsies. Smith observed a mild form of Peyronie’s disease in 23 of 100 postmortem examinations. 4 in 2002 in a study conducted by the Urology Department of the University Hospital of Cologne, Germany in which 4,432 patients were surveyed, Schwarzer et al. reported a prevalence of 3.2%.5 in the last few years the reported prevalence has been between 3% and 9% in the adult male population. 6,7

Peyronie’s disease prevalence may be greater, given that patients are reluctant to report this pathology.

Pathophysiology

Peyronie’s disease mainly affects the tunica albuginea of the penis. Elastic fibers are found there that maintain the structure of collagen bridges. However, this disease has functional effects on the tissue of the corpora cavernosa adjacent to the plaque, exhibiting ultrastructural changes in vitro in the smooth muscle and endothelial cells. 8

The plaque in Peyronie’s disease is due to the replacement normal structural elements of the tunica albuginea with disorganized and excessive collagen, fragmented elastic

fibers, and their eventual calcification. 9 Histologically, it is a process of inflammation characterized by chronic infiltration of the tunica albuginea by lymphocytes and plasma cells.

The origin of this inflammatory process is unknown, but microtrauma and an unregulated wound healing process with excessive proliferation of fibroblasts and extracellular matrix deposition is the most accepted cause. 10

Fibrin deposit seems to be an early event in the pathophysiology of plaque formation. 11

After an initial period, the plaque present in Peyronie’s disease progresses to fibrosis. This plaque is composed mainly of type i and type iii collagen, the latter being the most abundant. 12

An overexpression of the transforming growth factor beta 1 (TGF-ß1) has been demonstrated in patients with Peyronie’s disease and the relation between this factor and fibrosis has been described. The transcription of genes that control the synthesis and deposit of collagen and proteoglycans is increased and protease secretion is decreased, resulting in the synthesis of proteins that inhibit protease activity, reducing the synthesis of nitric oxide (NO) by transcriptional inhibition of inducible nitric oxide synthase (iNOS), while reactive oxygen species (ROS) are simultaneously created. 13 These changes have been replicated in animal models injected with cytomodulin, a TGF-ß1 analog. 14

Fibrin has been directly applied to the tunica albuginea in animal models, producing plaque similar to that in Peyronie’s disease, sooner than in those injected with TGF-ß1, but TGF- ß1 levels were found to be significantly higher in the lesions. 15

Establishing fibrin as the initiator of the pathophysiology of Peyronie’s disease has been limited because the samples are obtained during surgical correction, when there is no immature plaque.

Addit ional ly, the overexpress ion of monocyte chemoattractant protein-1 (MCP-1) has been associated with fibrosis in organs such as the liver, kidney, lung, and skin and it has been tested as a potential target of directed therapy in Peyronie’s disease. 16

Platelet-derived growth factors (PDGF-A, PDGF-B) can exacerbate fibroblast proliferation; their receptors have been found to be strongly expressed in cells similar to fibroblasts in the tunica of samples from men with Peyronie’s disease.17

Myofibroblasts (differentiated fibroblasts that have acquired an intermediate phenotype between the progenitor cell and the smooth muscle cells) are replicated and activated to produce collagen, cytokines, TGF-ß1, and other inflammatory mediators, NO and ROS; in addition they have receptors for TGF-ß1, PDGF, and fibroblast growth factor. 18

The potential role of chromosomal instability in the pathophysiology of Peyronie’s disease has been studied in cell cultures derived from plaque. They have been shown to have random chromosomal changes, suggesting karyotypic instability, whereas cell cultures derived from adjacent t issue have been normal. Aneusomies have been demonstrated in chromosomes 7,8,17, 18, and X; and recurrent Y chromosome deletions. 19

Current aspects of the medical and surgical management of Peyronie’s disease 37

The ROS are reduced by the antioxidant effect of NO, which is not fibrogenic, but can be pro-apoptotic in high concentrations. The balance between NO and ROS determines the balance between fibrosis and normal wound healing.

Gene therapy has been used for administering iNOS in the fibrotic plaque created with fibrin in animal models, resulting in significant plaque reduction, highlighting a new treatment option for Peyronie’s disease. 20

Diagnosis

An internationally accepted evaluation standard has not yet been established for Peyronie’s disease. A form of standardized evaluation has been suggested that includes the medical history, physical examination, diagnostic imaging, and not-yet-validated questionnaires. 21

The anamnesis should contain the time of onset, the initial symptoms and how they presented, including pain, deformity, and palpable plaque. The patient should be asked about any event of trauma preceding symptom onset in the previous months and whether there is a family history of Peyronie’s disease or other disorders such as Dupuytren’s disease. He should be asked about previous treatments he may have received, the grade of erection on a scale of 0-10 before and after disease onset, and also asked to estimate the grade and direction of penile curvature. 22

The physical examination should include measuring the length of the penis; the technique described by wessells can be used in which the patient is in the supine position, the penis is stretched at a 90º angle, and with a rigid ruler pressing the fat up the pubic bone, is measured dorsally up to the corona of the glans penis or the meatus 23 (fig. 1).

The hands and feet should be examined for evidence of Dupuytren’s contractures and ledderhose nodules. Penile deformities should be measured and photographed in erection. Duplex ultrasound can be used in the initial evaluation for determining fibrosis of the body and calcification of the plaque, as well as the vascular integrity

of the penis in erection and the erectile response to vasoactive agents. Recent articles suggest that a resistance index below 0.8 in the Doppler ultrasound is predictive of postoperative erectile dysfunction and should be regarded as a parameter for placing a prosthesis vs. graft corporoplasty. 24 Curvature should be measured with a goniometer, measuring the width at the base, subcoronal area, and stretching zones.

Treatment

The appropriate therapy is chosen based on the erectile status of the patient, presence of pain, time of onset, and psychological state. in the initial stages, conservative management is usually recommended. indications include men that are in an early disease phase (<12 months) manifested by progressive and unstable deformity, painful erections, and patients that do not wish to undergo surgical management. 22,26

Oral therapy includes various medications such as: vitamin E, colchicine, potassium aminobenzoate (Potaba), tamoxifen citrate, carnitine, pentoxifyll ine, and 5-phosphodiesterase inhibitors. These medicines have not proved to be completely effective and larger studies are needed in order to recommend them as treatment. 22,25,27

intralesional therapy has used corticosteroids, calcium channel blockers, and different types of interferon with widely varying results. However, their possible benefits are that they stabilize the disease, prevent its progression, and in a very low percentage of patients, prevent disease recurrence. 27-29

Currently, special attention has been paid to collagenase Clostridium histolyticum, a biological agent classified as a specific matrix metalloproteinase -1, -8, and -13, which is applied intralesionally in a maximum of 4 cycles at doses of 0.58 mg (2 injections per cycle separated by 48 to 72 hours) followed by penile stretching or penile remodeling 3 times for 30 seconds. Each cycle is applied at 6-week intervals. This collagenase specifically degrades the collagen type I and type iii found in the plaque of Peyronie’s disease.30 The results of 2 large phase 3 randomized double-blind studies have recently been published that evaluated the

Figure 1 wessells technique for evaluating the length of the penis.

Figure 2 Evaluation of penile angulation in erection and the point of maximum curvature (PMC).

PMC


effectiveness, safety, and tolerability of collagenase applied by intralesional injection in 417 patients in one study and 415 patients in the other. The studies were begun in September 2010 and ended March 2012 and showed a 34% reduction in curvature compared with 18.2% in the placebo group, supporting its clinical efficacy for treating Peyronie’s disease. 31

The benefit of mechanical treatments that include iontophoresis, shock wave therapy, penile traction apparatuses, and radiation has not been demonstrated.32-34

Surgical treatment is indicated in patients presenting with stable disease (more than one year since onset with no change in deformity for at least 6 months) that have no pain in the penis, are unable to maintain sexual activity due to the deformity or inadequate rigidity, in whom conservative treatment has failed, and who present with plaque calcification.20,24 The possibility of persistence of residual

curvature of 20 degrees or less, curvature recurrence in 6%-10% of the patients, reduced penile length and rigidity in at least 5%, and diminished sexual sensitivity in about 20% of the patients should be discussed prior to surgical management. 35

Tunica albuginea plication techniques are recommended for patients with simple curvature of less than 60 to 70 degrees, no hinge or hourglass effect, and in whom a loss of less than 20% of the length of the penis is anticipated. A way of predicting the length of the shortening is by measuring the longitudinal axis of the penis in erection ventrally and dorsally from the base to the tip of the glans penis. The difference between the 2 measurements is the estimated loss of penile length in centimeters after plication. Numerous plication techniques have been described. The

Figure 3 Separation of the dorsal neurovascular complex (NvC).

Figure 5 Superficial transverse incisions on the albuginea at the plication site.

Figure 4 Dorsal correction is stimulated with 2 Allis tweezers at the point of maximum curvature (PMC), prior to suture placement for plication.

Figure 6 vicryl® 4-0 suture for the plication. The correction is evaluated through artificial erection.


Nesbit procedure involves the excision of the tunica on the side contralateral to the curvature and permanent suture closure.36 its variants in the Yachia technique use the Heineke Mikulicz technique (vertical incision and transverse closure), 37 the 16-dot procedure in which no incision is made and the tunica albuginea is only folded with non-absorbable lembert sutures. 38 Another variant is the Duckett-Baskin modification of tunica albuginea plication, in which parallel transverse incisions are made on the side contralateral to the greatest point of curvature and closed with non-absorbable sutures 39 (figs. 2-8).

All plication procedures reduce the length of the penis. They are not useful for hinge or hourglass deformities and can exacerbate these conditions producing instability. in addition, there may be pain associated with the sutures. 35

No plication technique has been shown to be superior to another, and therefore the ideal technique is the one the surgeon is most familiar with.

incision or partial excision techniques and graft are recommended for patients with complex curvature above 60 degrees that present with the hinge or hourglass effect or short penis. The patient should have adequate preoperative erections given that there is a high risk for postoperative erectile dysfunction, the predictors of which are age (>55 years), evidence of veno-occlusive dysfunction in the Doppler ultrasound study, ventral curvature, and the severity of the curvature. 22,27,40

Graft techniques include plaque incision or partial plaque excision. There is a high risk for erectile dysfunction with total plaque excision and therefore today a relaxing H or double-Y incision in the area of maximum curvature is preferred. This allows the tunica to expand at this site, correcting the curvature, after which these areas are covered with grafts. 41 Partial plaque excision at the site of greatest deformity can be useful in patients with severe indentation or important calcification of plaque. The geometric principle has been used in an effort to obtain the exact graft size and correct the curvature more precisely, without compromising the length of the penis42 (figs. 9-16).

Multiple grafts have been used that include the tunica vaginalis, dura mater, temporalis fascia, fascia lata, saphenous vein, and buccal mucosa; however, they need a second incision and increase the surgery duration. Synthetic grafts such as Dacron® and polytetrafluoroethylene (PTFE) have fallen into disuse due to the risk for infection, inflammation, and fibrosis that they provoke. Allografts and xenografts that include bovine and human pericardium and porcine intestinal submucosa are the 2 most commonly used types. Examples of these are Tutoplast®, a thin, strong graft processed from thin human and bovine pericardium that does not contract and Surgisis® ES, a graft from intestinal submucosa that has properties similar to the pericardium but has 25% contraction and therefore is associated with cases of recurrence. 43

Figure 7 Freeing of the medial suspensory ligament for in-creasing the length of the penis after plication. Figure 8 Measuring of length after surgery.

Figure 9 Erection induction to evaluate curvature.


Penile prostheses have been suggested for patients with Peyronie’s disease that present with erectile dysfunction that does not respond to medication, but clear criteria for its indication have yet to be described. A prosthesis simultaneously corrects the deformity and treats the erectile dysfunction. Penile prosthesis placement can be done without additional correction maneuvers if the patient has minimum curvature or an unstable penis; manual remodeling is recommended in patients with considerable curvature. if residual curvature is above 30 degrees, the tunica albuginea is incised and covered with a graft in incisions that condition a defect greater than 2 cm so that herniation of the prosthesis and scar contracture are prevented. 35

New therapeutic options still under research using inhibitors of activin receptor-like kinase 5 (AlK5), a type 1

receptor of TGF-ß, have demonstrated promising results. Significant plaque regression has been shown in studies on rats. The molecule currently referred to is iN-1130, but there are other similar molecules being studied that have displayed antifibrotic and anticancer activity. 44,45

Conclusions

Peyronie’s disease is a pathology that has a tremendous psychosocial impact on the adult and therefore the urologist should be thoroughly familiar with the disease and its integral approach. There are numerous treatment modalities, but up to the present, surgical correction of Peyronie’s disease, with or without the placement of a prosthesis, is regarded as the criterion standard for

Figure 10 Denuding the penis.

Figura 12 Dissection and separation of the neurovascular complex (NvC) at its dorsal portion for performing the relaxing incision at the point of maximum curvature (PMC).

Figure 11 Two paraurethral incisions in Buck’s fascia to sepa-rate the neurovascular complex (NvC).


correcting the deformity. These patients should be evaluated as carefully and judiciously as possible in order to offer them the most adequate treatment.

Oral or intralesional medical treatment can be used in an early phase of the disease for the purpose of stabilizing or attempting to prevent its progression, with widely varying results. it is very important to wait until the disease has stabilized (>6 months) before performing any surgical procedure. Surgical correction should be exhaustively explained in relation to each patient’s particular situation. The technique to be carried out (plication, graft corporoplasty, prosthesis placement) will depend on the clinical situation, type of deformity, shaft length, erectile function, plaque characteristics and location, and the experience of the surgeon. informed consent for a surgical procedure is of the utmost importance, given that a patient can have false hopes and not be aware of the behavior of a disease. This consent should warn the patient of the possible complications of curvature persistence or recurrence after surgery, shaft shortening even in graft application procedures, diminished rigidity or erectile dysfunction, and a decrease in

penile sexual sensation. Nevertheless, the selection of the adequate treatment for each individual case will provide successful results and patient satisfaction. The main treatment aim in Peyronie’s disease is based on incorporating the patients into a normal sexual life.





Figure 13 The relaxing incision at the point of maximum cur-vature is calculated based on the geometric principle.

Figure 15 The graft is placed symmetrically and sutured with Monocryl® 5-0 running suture over the created defect.

Figure 16 Final aspect of the curvature correction without compromising the length of the penis.

Figure 14 Rectangular appearance of the defect (D) created by a single incision on the tunica at the previously marked point of maximum curvature (PMC), leaving the erectile tissue (ET) exposed and not involving the neurovascular complex (NvC).

PCM

D

CNvD

TE

injerto


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Rev Mex Urol 2014;74(1):44-47


CLiNiCAL CASe

Laparoscopic treatment of a complex vesicovaginal fistula


Hospital General de Zona N° 1, IMSS, Saltillo, Coah., Mexico

KEYWORDS Vesicovaginal fistula; Laparoscopic approach; Mexico

Abstract Ninety percent of the vesicovaginal fistulas (VVF) are produced after a hysterectomy, with a frequency of one in 1,800 cases. Nezhat et al. were one of the first to publish an article on laparoscopic treatment of a VVF. There are very few reports with respect to the laparoscopic approaches of complex VVF. The aim of this report was to demonstrate the successful result of the O’Conor technique in complex fistula treatment. A 35-year-old woman had a past history of hysterectomy secondary to postpartum uterine hemorrhage in 2010. A VVF was diagnosed in the mid postoperative period and she underwent fistula repair through the vagina in March 2010. The fistula recurred and she underwent fistula repair in November 2010 with the open transabdominal approach using the O’Conor technique. The surgery failed. In June 2011 our team operated on her, performing vesicovaginal fistula repair with the laparoscopic approach. Laparoscopic surgery duration: 150 min. intraoperative blood loss: 50 cc. Hospital stay: 3 days. Time with transurethral catheter and bilateral ureteral catheterization: 4 weeks. The patient has been under active surveillance for 13 months and there has been no fistula recurrence. In the case of this patient, we call “complex VVF” a fistula that meets one of the following criteria: VVF larger than 2 cm, fistula that involves one ureteral meatus, fistula secondary to radiation, associated rectovaginal fistula, or fistula with failed surgical repair. The laparoscopic treatment of complex vesicovaginal fistulas has similar results to those of open surgery.

Tratamiento laparoscópico de una fístula vesicovaginal compleja

Resumen Noventa por ciento de las fístulas vesicovaginales (FVV) son producidas después de una histerectomía, con una frecuencia de uno en 1,800 casos. Nezhat et al. fue uno de los

PALABRAS CLAVE Fístula vesicovaginal; Abordaje laparoscópico;

Laparoscopic treatment of a complex vesicovaginal fistula 45

Introduction

Ninety percent of the vesicovaginal fistulas (VVFs) are produced after a hysterectomy, with a frequency of one in 1,800 cases. in certain selected cases treatment can be conservative, with a very low success rate. 1 When this management fails, surgical treatment is the option and has success rates as high as 97%; however, recurrence rates of up to 10% have been reported. Nezhat et al. were the first to publish a report on the laparoscopic treatment of a VVF. There are very few reports on laparoscopic approaches in relation to complex VVFs.

Case presentation

A 35-year-old woman had a past surgical history of hysterectomy secondary to a postpartum uterine hemorrhage in 2010. A VVF was diagnosed in the mid postoperative period and she underwent fistula repair via the vagina in March 2010, but the fistula recurred. She underwent fistula repair again in November 2010 with the open transabdominal approach and the O’Conor technique; once again the treatment failed. in June 2011 our team performed the VVF repair with the laparoscopic approach.

TechniqueUnder general anesthesia, cystoscopy was carried out. Both ureteral meatuses were catheterized with 6 Fr catheters; the fistulous tract was also catheterized. Gauzes with isodine® were placed in the vaginal dome and the patient was put in the forced Trendelenburg position, the same position used in radical prostatectomy with the Boudeux technique. A 10 mm supraumbilical trocar was placed using the Hasson method and 2 more trocars were placed above the external superior iliac crests. A fourth 5 mm trocar was placed midway between the camera trocar and the pubic

symphysis. Insufflation reached 12 mm Hg and flow rate was 6 mL/min (fig. 1). The multiple adhesions encountered were freed and the bladder dome was identified. Using the technique employed by O’Conor 2,3 an incision was made in the bladder, as close as possible to the vaginal dome. The fistula, previously situated with a catheter, was identified through the bladder, cutting around it (fig. 2). The vagina was carefully moved away from the bladder and separate closure was carried out with Monocryl 2-0. After closure of the vagina (fig. 3), we proceeded to interposition the

primeros en publicar el tratamiento laparoscópico de una FVV. Con respecto a los abordajes la-paroscópicos de las FVV complejas, pocos son los reportes que existen en este tema.el objetivo es mostrar la técnica de O´Conor realizada vía laparoscópica, y el resultado exitoso en fístulas complejas.Se presenta paciente femenino de 35 años, con historia de histerectomía secundaria a hemorra-gia uterina posparto en el año 2010, en el posoperatorio mediato se le diagnosticó FVV, siendo sometida a plastia de fístula vía vaginal en marzo de 2010, con recurrencia de la misma. Nueva-mente es sometida a plastia de fístula, en noviembre de 2010 con abordaje transabdominal abierto con técnica O´Conor, siendo fallida. en junio de 2011 es sometida por nuestro equipo a una plastia de FVV con abordaje laparoscópico. Tiempo quirúrgico laparoscópico: 150 minutos. Sangrado transoperatorio: 50 cc. Tiempo de estancia hospitalaria: 3 días. Tiempo de uso de sonda transuretral y cateterización ureteral bilateral: 4 semanas. Vigilancia por 13 meses, sin recidiva de la fístula.En el caso de esta paciente llamamos “FVV compleja”, a una fístula que cumple con uno de los siguientes criterios: FVV mayor de 2 cm, fístula que involucra un meato ureteral, fístula secun-daria a radiación, fístula rectovaginal asociada, fístula con una reparación quirúrgica fallida.La laparoscopía aplicada al tratamiento de las FVV complejas, tiene resultados similares a la cirugía abierta.


México.

Figure 1 Trocar arrangement. (1) 2 cm from the external su-perior iliac crest on an imaginary line between the umbilicus and the ipsilateral iliac crest. (2) At a point halfway between the umbilicus and the pubic symphysis. (3) The same as 1. (4) Transumbilical or supraumbilical.

4

10 mm

3

5 mm

12


omental appendage of the rectosigmoid colon between the vagina and bladder, before closing the bladder (fig. 4). We completely freed the paravesical spaces in order to reduce the tension of the bladder closure that was done with Monocryl® 2-0.

The laparoscopic surgery duration was 150 minutes; blood loss was 50 cc, and hospital stay was 3 days. The transurethral catheter and bilateral ureteral catheters remained in place for 4 weeks. The patient has been under active surveillance for 13 months with no sign of fistula recurrence.

Discussion

Simple abdominal hysterectomy or hysterectomy due to benign disease continues to be the most frequent cause of VVF in the developed countries. Other procedures that can produce VVF are anterior colpoperineorrhaphy and suspension with Pereira needles. No risk factors for fistula

formation have been identified in the majority of the patients, but previous cesarean section has been associated as one. 4-6

VVF can be repaired either via the abdomen or the vagina. We define a complex fistula, like the one in our patient, as a fistula that fits one of the following criteria: VVF larger than 2 cm; a fistula that involves the ureteral meatus; a fistula secondary to radiation; a fistula with failed surgical repair; and a fistula accompanied by another fistula or involving the digestive tract.

The ideal principles in surgical repair include the removal of necrotic or fibrotic tissue so there can be healthy well-irrigated tissue, a preferably negative urine culture, complete excision of the fistulous tract, tension-free closure, and placement of vascularized healthy tissue between the vagina and the bladder. This technique is described by O’Conor and has success rates of 95% to 100%. 7-10

Many gynecologists favor an initial transvaginal approach, leaving the transabdominal approaches 11 only for complex fistulas. We always perform a transvesical approach first using the O’Conor technique, whether the vesicovaginal fistula is complex or not. 7-9 This approach provides good cosmetic results and very few, if any, of the complications that arise from the abdominal cavity approach. An important step for us is to keep the surgical site free from blood in order to have better vision and to prevent hematomas that could complicate the procedure. 10

Conclusions

The laparoscopic approach for this pathology is safe and reproducible and it is equally as successful as open surgery.





Figure 2 Resection of the fistulous tract. The fistula has been cut around over the ureteral catheter. Gauzes are packed in the vaginal fundus.

Figure 3 Closure of the vagina. Note the separation of the vagina from the bladder.

Figure 4 interposition of the omental appendage of the rec-tosigmoid colon between the vagina and the bladder.

Bladder neck

Resected fistula

Vagina

Vagina

Ureteral meatus

Ureteral meatus

Bladder

Bladder

epiploic appendix of the rectosigmoid junction

Laparoscopic treatment of a complex vesicovaginal fistula 47

References

1. Derry DE. Note on five pelves of women in the Eleventh Dynasty in Egypt. J Obstet Gynecol Br Emp 1935;42:490.

2. Trendelenburg F. Operations for vesicovaginal fistula in the elevated pelvic position for operations within the abdominal cavity. Samml Vortr 1890;355:3373.

3. O’Conor JR. Review of experience with vesicovaginal fistula repair. J Urol 1980;123:367.

4. Latzko W. Postoperative vesicovaginal fistulas. Am J Surg 1942;58:211-6. Tancer ML. Observations on prevention and management of vesicovaginal fistula after total hysterectomy. Surg Gynecol Obstet 1992;175:501.

5. Everett HS, Mattingly RF. Urinary tract injuries resulting from pelvic surgery. Am J Obstet Gynecol 1956;71:502.

6. Lee RA, Symmonds Re, Williams TJ. Current status of genitourinary fistula. Obstet Gynecol 1988;72:313.

7. Nanninga JB, O’Conor VJ Jr. Suprapubic transvesical closure of vesicovaginal fistula. in: Buchshaum HJ, Schmidt JD (eds). Gynecologic and Obstetric Urology. Philadelphia: WB Saunders; 1993. p. 365–369.

8. Margolis T, Mercer LJ. Vesicovaginal fistula. Obstet Gynecol 1994;49:840.

9. Leach Ge, Raz S. Vaginal flap technique: A method of transvaginal vesicovaginal fistula repair. In: Raz S (ed). Female Urology. Philadelphia: WB Saunders; 1983. p. 372–377.

10. Sotelo R. Laparoscopic repair of vesicovaginal fistula. J Urol 2005;173:1615-1618.

11. Genadry RR. Obstetric fistulae. Int J Gynaecol Obstet 2007;99 Suppl 1:S51-56.



Rev Mex Urol 2014;74(1):48-54

* Corresponding author at: Av. Soledad Orozco N° 203, Colonia el Capullo, CP 45150, Zapopan, Jal., México. Telephone: (3310) 806462. Email: [email protected] (J. D. Farias-Cortés).

CliNiCAl CASe

Kidney cancer metastatic to the testis

J. D. Farias-Cortésa,*, A. Scavuzzob, M. A. Jiménez-Ríosb, A. Castro-Alfarob and J. C. Navarro-Vargasb

a Hospital Regional del ISSSTE “Valentín Gómez Farias”, Zapopan, Jal., Mexicob Uro-oncology Service, Instituto Nacional de Cancerología, Mexico City, Mexico

KEYWORDS Kidney cancer; Clear cell renal carcinoma; Metastatic pattern; Progression, Mexico

Abstract Kidney cancer is one of the first 10 malignant entities in the adult. its overall diagnosis is estimated at 270,000 new cases per year with 116,000 deaths. The sarcomatoid variant can be found in 1% to 8% of the patients with renal tumor, typically affecting patients between the ages of 56 and 61 years. There are symptoms at the time of diagnosis in up to 90% of patients due to metastasis, and the most common are pain and hematuria; multiple metastases are present in 47% of patients from the beginning of evaluation. Median survival is 13 months from the time of diagnosis, and 6 to 9 months when there is metastasis. The aim of this work was to present a multicenter review article using the MeDliNe® database to identify epidemiology, incidence, metastatic potential, and mortality rate of the sarcomatoid variant of renal tumors, as well as to describe a case report from our hospital unit. A 65-year-old man had a 10-year history of intense smoking and was recently diagnosed with high blood pressure. His illness began with painless, clot-forming gross hematuria. An abdominal computed tomography (CT) scan showed a tumor on the lower pole of the left kidney with no apparent evidence of metastasis. He underwent radical nephrectomy in August 2012 that reported a T4 N0 M0, 12 x 10 cm sarcomatoid tumor. He was scheduled for follow-up but appeared at the emergency department 2 months after surgery with an increase in volume of the left testis, asthenia, adynamia, medium-effort dyspnea, submentonian adenopathy, and general malaise. A chest CT revealed intense metastatic activity and a testicular ultrasound showed a heterogeneous image with hypoechoic areas. The patient underwent radical orchiectomy that reported a metastatic sarcomatoid renal cell tumor and he was referred for adjuvant chemotherapy. One month and a half after his latest surgery, the patient was readmitted with a frankly deteriorated status and mild-effort dyspnea. He was referred to home care for maximum benefit.

Kidney cancer metastatic to the testis 49

Introduction

Kidney cancer was responsible for the deaths of 12,840 persons in the United States, alone, in 2006, and the most common type is renal cell carcinoma (90%). its peak of greatest incidence is in the seventh decade of life and there is a slightly higher incidence in African American men.1 Kidney cancer is one of the 10 most common cancers, and renal cell carcinoma represents 3% of all adult neoplasias.2 it is estimated that 270,000 new cases of kidney cancer will be diagnosed annually worldwide and 116,000 will result in death.3

in 1997 the Heidelberg classification was described. it provides 4 subclassification types of renal cell cancer from the observed differences in histology, cytogenetics, aggressiveness, and outcome among them, and they are: conventional (clear cell), the most common; papillary; chromophobe; collecting duct; and the sarcomatoid variant. The latter was thought to be a state of high-grade tumor progression, but it is now viewed as a different pathologic entity with its own clearly recognized biologic activity. A nuclear Fuhrman grade 4 has been found in up to 94.7% and with distinct metastasis at the time of diagnosis in 55.3% vs. 10%-30% of the cases with clear cell renal cell carcinoma.4

The sarcomatoid variant can be found in 1% to 8% of the patients with renal tumor and it typically affects patients

between the ages of 56 and 61 years, with tumors between 9-11 cm in diameter at the time of diagnosis.5 Ninety percent of the patients have symptoms at the time of diagnosis due to metastasis, the most common of which are pain and hematuria. Forty-seven percent have multiple metastases at the beginning of their evaluation.6 The ability to diagnose this variant is poor, and it is also difficult through fine needle aspiration biopsy.7

Case presentation

A 65-year-old man born in Zurich, Switzerland, and residing in Mexico City was a retired public works supervisor. His family medical history was unremarkable in regard to his case. He had recently been diagnosed with high blood pressure that was being treated with ACe inhibitors. He had been an intense smoker for 10 years, but had quit smoking 20 years ago. His disease onset began in May 2012 when he sought medical attention due to general malaise and one episode of self-limited gross hematuria. He had no abdominal pain or weight loss at that time and his eCOG score was 0. Therefore, upon his arrival at our service an abdominal computed tomography (CT) scan was ordered. it revealed a 12 x 17 x 14 cm left renal tumor dependent on the left kidney at the mid portion and lower pole. Contrast enhancement was > 20 HU and the tumor was staged as Tc2b

Metástasis de cáncer renal a testículo

Resumen el cáncer renal es una de las 10 primeras entidades malignas en el adulto, globalmente se diagnosticará un estimado de 270,000 nuevos casos y morirán 116,000 anualmente. la variedad sarcomatoidea puede ser encontrada de un 1% a 8% de los pacientes con tumor renal, afectando típicamente a los pacientes entre 56 a 61 años mayormente hablando. Presenta síntomas al momento de su diagnóstico hasta en un 90% de los casos debido a la metástasis, siendo el dolor y la hematuria los principales; con metástasis múltiples hasta en un 47% desde el inicio del estudio, con una mediana de 13 meses de sobrevida desde el diagnóstico, y de 6 a 9 meses cuando se acompaña de metástasis.el propósito del presente trabajo es presentar un artículo de revisión multicéntrica utilizando la base informática Medline para identificar la epidemiologia, incidencia, potencial metastásico y mortalidad de la variante sarcomatoide de los tumores renales, así como hacer el reporte de un caso en nuestra unidad hospitalaria. Se presenta paciente masculino 65 años de edad, con antecedentes de tabaquismo intenso por 10 años, además de ser hipertenso de reciente diagnóstico, inicia su padecimiento con hematuria macroscópica indolora formadora de coágulos, se realiza tomografía (TC) de abdomen donde se evidencia tumor renal polo inferior sin evidencia de actividad metastásica en ese momento; es llevado a nefrectomía radical en agosto de 2012, reportando tumor 12 x 10 cm, T4N0M0 variante sarcomatoide, se cita para seguimiento pero llega 2 meses después de la cirugía al Servicio de Urgencias por presentar aumento de volumen testicular izquierdo, astenia, adinamia, disnea de medianos esfuerzos, adenopatía submentoniana y mal estado general; se realiza TC torácica la cual demuestra intensa actividad metastásica además de ultrasonograma testicular donde destaca imagen heterogénea con áreas hipoecoicas, es llevado a orquiectomía radical reportando tumor de células renales sarcomatoide metastásico, es enviado a quimioterapia adyuvante pero reingresa mes y medio después de su última cirugía con franco deterioro, disnea a leves esfuerzos, por lo que se envía a cuidados domiciliarios por máximo beneficio.


PAlAbRAS ClAVEStress urinary Kidney cancer; Clear cell renal carcinoma; Metastatic pattern; Progression, Mexico.

50 J. D. Farias-Cortés et al

(due to size), with no vascular involvement. Preoperative laboratory tests were carried out and showed normochromic, normocytic anemia (Hb 9.7 g). A chest-x-ray revealed no evidence of metastatic activity. The patient underwent radical nephrectomy on August 14, 2012, with no problems during surgery. After a short hospital stay he was sent home. During his control visits, the histopathologic study was obtained that reported: clear cell renal cell carcinoma with a sarcomatoid pattern in the entire tumor volume, a 20% area of necrosis central to the tumor, Fuhrman 4, 12 x 10 cm tumor size, lower pole location, and infiltrating the renal sinus, capsule, perirenal fibroconnective tissue, and Gerota’s fascia; the vascular structures of the renal hilum and the adrenal gland had no evidence of neoplastic invasion and the resection surgical margin was free from neoplasia. in conclusion the tumor was T4pN0M0. Follow-up was begun and the patient was scheduled for thoracic-abdominal CT and general laboratory tests. However, he was readmitted to the emergency department 2 months later presenting with asthenia, adynamia, medium-effort dyspnea, submentonian nodule, and increased volume of the left testis. A chest x-ray in 2 projections clearly showed multiple radio-opaque images (fig. 1).

in addition, an ultrasound of the gonads was carried out revealing a heterogeneous image of the entire structure with marked suspicion of neoplasia. The vasculature of the left testis was enlarged and there was important tortuosity of the pampiniform plexus (figs. 2, 3, and 4); the contralateral testis was normal. Thoracic-abdominal CT showed multiple hyperdense, parenchymal lesions larger than 3 cm in the pulmonary parenchyma and there was no evidence of pleural space effusion (figs. 5 and 6).

Preoperative evaluation resulted in ASA ii, Goldman ii, and Kanofsky 80% and preoperative laboratory tests showed anemia (Hb 9.1 g, Ht 28.8%) once again, with creatinine of 1.5 mg. electrolytes, coagulation times, liver function test and lactate dehydrogenase were in normal parameters and

the eCOG score was 2. The patient was transfused preoperatively with one red blood cell package. Radical orchiectomy was performed, producing a firm specimen that was not adhered to the scrotum, with a free spermatic cord. The patient was released from the hospital, and seen as an outpatient with the pathologic report: testis with metastatic sarcomatoid renal carcinoma, tumor size of 4.8 x 3.4 cm, and spermatic cord free of neoplastic cells. For evaluation and treatment he was referred to the Medical Oncology Department to begin chemotherapy and to the Head and Neck Department for biopsy of suspected adenopathy from submentonian metastatic disease. The patient returned to the emergency Department in December of the same year with general malaise, a clearly deteriorated state, and weight loss of more than 20 Kg from his initial weight, asthenia, hypodynamia, generalized paleness, and an eCOG score of 3. His relatives decided to continue only with palliative therapy at home, for maximum benefit. The patient died 20 days later.

Discussion

in the first half of the last century “renal sarcoma” was known as that poorly differentiated tumor in patients in very advanced stages. However, in later studies the same variant was observed in different types of tumors, and therefore was called “the final stage of kidney cancer” as the last undifferentiated tumor stage.7,8 that are 2%-10% depending on the case series, It is very common to find a pure sarcomatoid pattern in the 2% to 10% of patients, depending on the case series, that present with unclassifiable tumors. Besides identifying a sarcomatoid pattern in any renal tumor variant, there were no changes in outcome or treatment. Despite the different regimens employed, they all resulted in a poor outcome. Therefore it became necessary to identify this variant as a different pathologic entity. Although the majority of cases have very

Figure 1 Chest x-ray with multiple radio-opaque paramediastinal images and tracheal air column deviation.


poorly differentiated cellular nuclei, about 30% of sarcomatoid tumors have nuclei with Furhman 1 and 2 grades, suggesting the emergence of an independent cellular separation, rather than an undifferentiated entity.9

it should be mentioned that numerous studies indicate that the sarcomatoid pattern is more prevalent in men (approximately 75%). 2,4,5

HistologyMacroscopic sarcomatoid renal tumors are generally described as: firm, voluminous, and of white to greyish tones when cut.10 This variant is mainly associated with clear cell tumor, up to 8.7%, although these components can be observed in the chromophobe, papillary, and collecting duct types; there is necrosis in up to 90% of the patients.11 However, it is determined as an independent variant due to its metabolic and potentially metastatic activity mentioned before. 4

Microscopically, sarcomatoid components are described as images similar to fibrosarcomas, with intersections of malignant fusiform cell fascicles. in addition there is the possibility of finding undifferentiated pleomorphism similar to malignant fibrous histiocytoma (fig. 7). it does not generally require the support of special studies such as electron microscopy, immunohistochemistry, or molecular

genetics for its diagnosis. Genetically, a complex chromosomal gain and loss can be observed, with the absence in 13q (75%) and 4q (40%).10

Metastatic patternin patients with metastatic disease, it is most common to observe a purely sarcomatoid pattern in the sample in 97% of the patients, regardless of the primary differentiation at the place of origin.12 in the opposite case, if metastasectomy is performed first and no sarcomatoid pattern is found, it will be very difficult to find it in the primary tumor.9 Among the most common sites of metastasis are: regional lymph node chain 60%, lung 11%, liver 7.7%, and bone 3.8%. The percentage of sarcomatoid variant in the specimen is also important, because metastasis and time of death from the disease are more common in those patients with a percentage above 30%.12 One study states that alterations in the p53 gene are 5 times higher in regions with sarcomatoid differentiation,13

in addition to expression of more markers such as Ki67, VeGF, vimentin, and actin.14

Renal tumors can metastasize in virtually any part of the body.15 There are really very few studies that investigate the

Figure 3 Doppler enhancement with increased vascularity in left testicular heterogeneous image.

Figure 5 Tomographic image showing multiple voluminous metastatic activity in the pulmonary parenchyma.

Figure 4 Doppler image showing the tortuosity and apparent increase in the vascularity of the left testis.

Figure 2 Testicular ultrasound with heterogeneous image that is clearly suspicious for malignancy.


most common sites of the lesions according to their histologic subtype. The majority of the time the conclusion is: clear cell tumors are the principal metastasizing tumors, mainly involving the regional lymph nodes, but they also metastasize to the lung. Papillary tumors metastasize mainly to the regional lymph nodes, as well as to less common sites. Chromophobe tumors tend to metastasize to multiple sites, with a greater affinity for the liver, adjusting the incidence percentage (table 1).16

in various studies that followed, the conclusion was that outcome is less favorable when there are multiple metastasis sites compared with a single site. The result was statistically significant (p<0.001), with a median 13-month survival despite surgical treatment followed by adjuvant therapy vs. survival of up to 31 months in those patients with only pulmonary metastasis.17 Distant metastasis to rare sites such as the stomach,18 gallbladder,19 oropharynx,20 left ventricle,21 skin,22 tonsils,23 spleen, 24 pancreas,25 pituitary gland,26 thyroid,27 breast,28 gemellus muscle,29 duodenum,30 and testis31 have been reported as isolated clinical cases.

The incidence of metastasis from other organs to the testis is from 0.3% to 3.6%, the prostate being the most common.32 Reports state that the majority of cases are due to clear cell tumors, though chromophobe tumors have also been reported.31 They are generally ipsilateral and the left side is predominant, suggesting infiltration from the renal vein and migration of the tumor coagulate to the testicular vein as a possible cause.33

local and systemic treatment Due to the biologic nature of this tumor, radical therapy is the most accepted treatment when dealing with localized disease. The role of partial nephrectomy in these patients has not been analyzed due to the lack of prospective studies. Because it is a highly invasive and aggressive tumor, complete resection of the kidney unit is recommended.9 Due to the tangible absence of benefits in performing lymphadenectomy in patients undergoing radical nephrectomy with evidence grade 1A, it is not usually done,

although some authors recommend it if the adenopathies are obvious, because they have been shown to be positive in up to 33%. 34 Based on an evidence level of 1, cytoreduction is beneficial when speaking of systemic treatment of metastatic renal carcinoma with targeted therapy.35

in regard to systemic management, various regimens have been used with isolated reports of either partial or complete response.9 interleukin 2 has been used in immunotherapy and some cases have shown a mean survival of 10 months vs. 9 months in those patients that were not treated with anything; up to the present there are no long-term survival reports. 36 in the patients treated with chemotherapy, those that have benefitted the most are the patients that received a combination of doxorubicin and gemcitabine; one patient was reported to have had a complete response and an over 8-year survival, albeit this was an isolated report. 37 Patients undergoing antiangiogenic therapy with sunitinib have shown very limited benefit with a 4-month survival rate. 38

The results in patients treated with tyrosine-kinase inhibitors have not been very promising, with partial results of 19%, progression-free survival of 5.3 months, and overall survival of 11.8 months. A better result was seen in the patients previously treated with chemotherapy and in those with a percentage of sarcomatoid tumor under 20%. 39 in relation to mTOR therapy, the sarcomatoid variant has not been analyzed separately in the studies conducted.40 Cetuximab, geldanamycin, and bortezomib are drugs that have been used experimentally, and the final results in the follow-up reports are pending.41

Conclusions

Patients presenting with any percentage of tumor with sarcomatoid differentiation have a poor prognosis from the outset, compared with those that have tumors with other variants. Additionally, the presence of different pathologic characteristics such as renal capsule invasion, percentage of necrosis within the primary tumor, number of metastases, nuclear differentiation grade, and vascular invasion make up a primordial disease-specific survival pattern. Therefore it is necessary to carry out a thorough study of the surgical specimen in order to precisely determine the severity of the oncologic manifestation. We must also keep the functional

Figure 6 Note the great parahilar activity displacing the tra-chea at the midline.

Figure 7 Histopathologic image showing the apparent sarco-matoid pattern.


status of the patient in mind, because there is a lower survival rate when the disease presents with a previously comorbid patient. in regard to treatment, it is necessary to point out the poor gain in overall survival in relation to cytoreduction in advanced stage patients; therefore, management should be well planned out before proposing risky and radical treatment, and both patient and relatives must be informed as to the patient’s real status.





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20. Gammon Bl, Gleason BC, Thomas AB, et al. Sarcomatoid renal cell carcinoma presenting in the oropharynx. J Cutan Pathol 2010;37:1255–1258.

21. Aburto J, Bruckner BA, Blackmon SH, et al. Renal cell carcinoma, metastatic to the left ventricle. Tex Heart inst J 2009;36:48–49.

22. Srinivasan N, Pakala A, Al Kali A, et al. Papillary renal cell carcinoma with cutaneous metastases. Am J Med Sci 2010;339:458–461.

23. Massaccesi M, Morganti AG, Serafini G, et al. late tonsil metastases from renal cell cancer: a case report. Tumori 2009;95:521–524.

24. lelpo B, Mazzetti C, Venditti D, et al. A case of metachronous splenic metastasis from renal cell carcinoma after 14 years. int J Surg 2010;8:353–355.

25. Machado NO, Chopra P. Pancreatic metastasis from renal carcinoma managed by Whipple resection. A case report and literature review of metastatic pattern, surgical management and outcome. JOP 2009;10:413–418.

Table 1 The most common sites of metastasis according to histologic subtype.

Clear cell Papillary Chromophobe

Non-regional lymph nodes 3.8 % 10.3% 5.6%

Pulmonary 53.6% 33.3% 33.3%

Bone 25.3% 20.5% 16.7%

liver 9.7% 18% 33.3%

Other sites 22.4% 35.9% 33.3%

Multiple sites 15.6% 18% 22.2%


26. Kramer CK, Ferreira N, Silveiro SP, et al. Pituitary gland metastasis from renal cell carcinoma presented as a non-functioning macroadenoma. Arq Bras endocrinol Metabol 2010;54:498–501.

27. Manohar K, Mittal BR, Kashyap R, et al. Renal cell carcinoma presenting as isolated thyroid metastasis 13 years after radical nephrectomy, detected on F-18 FDG PeT/CT. Clin Nucl Med 2010;35:818–819.

28. Bortnik S, Cohen DJ, leider-Trejo l, et al. Breast metastasis from a renal cell carcinoma. isr Med Assoc J 2008;10:736–737.

29. Gozen AS, Canda Ae, Naser M, et al. Painful leg: a very unusual presentation of renal cell carcinoma. Case report and review of the literature. Urol int 2009;82:472–476.

30. Rustagi T, Rangasamy P, Versland M. Duodenal bleeding from metastatic renal cell carcinoma. Case Rep Gastroenterol 2011;5:249–257.

31. Wu HY, Xu lW, Zhang YY, et al. Metachronous contralateral testicular and bilateral adrenal metastasis of chromophobe renal cell carcinoma: a case report and review of the literature. J Zhejiang Univ Sci B 2010;11:386–389.

32. Schmorl P, Ostertag H, Conrad S. intratesticular metastasis of renal cancer. Urologe A 2008;47(8):1001-1003.

33. Sountoulides P, Metaxal, Cindolo l. Atypical presentations and rare metastatic sites of renal cell carcinoma: a review of case reports. Journal of Medical Case Reports 2011;5:429.

34. Blute M, leivobich B, Cheville J, et al. A protocol for performing extended lymph node dissection using pathological features for

patients treated with radical nephrectomy for clear cell renal cell carcinoma. J Urol 2004;172:465-469.

35. Pantuck AJ, Belldegrun AS, Figlin RA. Cytoreductive nephrectomy for metastatic renal cell carcinoma: is it still imperative in the era of targeted therapy? Clin Cancer Res 2007;13:693s–696s.

36. Kwak C, Park YH, Jeong CW, et al. Sarcomatoid differentiation as a prognostic factor for immunotherapy in metastatic renal cell carcinoma. J Surg Oncol 2007;95:317–323.

37. Dutcher JP, Nanus D. long-term survival of patients with sarcomatoid renal cell cancer treated with chemotherapy. Med Oncol 2011;28(4):1530-1533.

38. Choueiri TK, Wanling Xie, Kollmannsberger C, et al. The impact of Cytoreductive Nephrectomy on Survival of Patients With Metastatic Renal Cell Carcinoma Receiving Vascular endothelial Growth Factor Targeted Therapy. J Urol 2011;185:60-66.

39. Golshayan AR, George S, Heng DY, et al. Metastatic sarcomatoid renal cell carcinoma treated with vascular endothelial growth factor-targeted therapy. J Clin Oncol 2009;27:235–241.

40. Albiges l, Molinie V, escudier B. Non-Clear Cell Renal Cell Carcinoma: Does the Mammalian Target of Rapamycin Represent a Rational Therapeutic Target? Oncologist 2012;17:1051–1062.

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Rev Mex Urol 2014;74(1):55-59

* Corresponding author at: Hospital Central Militar. Blvd. Manuel Ávila Camacho s/n, Lomas de Sotelo, Av. Industria Militar y General Ca-bral, Delegación Miguel Hidalgo, CP 11200, México D.F., México. Telephone: (01) 5557 3100, ext. 1246. Email: [email protected] (J. G. Campos-Salcedo).

CLInICAL CASe

Laparoscopic partial nephrectomy guided by high definition laparoscopic ultrasound

J. G. Campos-Salcedoa,*, E. I. Bravo-Castrob, M. Castro-Marínc, A. Sedano-Lozanod, J. C. López-Silvestred, M. A. Zapata-Villalbad, L. A. Mendoza-Álvarezd, C. E. Estrada-Carrascod, H. Rosas-Hernándezd and J. L. Reyes-Equihuad

a Urology Ward Management, Hospital Central Militar, Mexico City, Mexicob Urology Speciality Residency, Escuela Militar de Graduados de Sanidad, Mexico City, Mexicoc Department of Urology Management, Hospital Central Militar, Mexico City, Mexicod Department of Urology, Hospital Central Militar, Mexico City, Mexico

KEYWORDS Laparoscopic partial nephrectomy; High-definition laparoscopic ultrasound; Partial nephrectomy; Mexico

Abstract Laparoscopic partial nephrectomy was described in 1993 and its indications extended due to the benefits of maintaining oncologic results and sparing the renal parenchyma. The aim of this report was to describe a patient with the diagnosis of a right renal tumor, stage T1a N0 M0, that underwent a laparoscopic partial nephrectomy guided by high definition laparoscopic ultrasound, with clamping of the renal artery.Surgery duration was 240 minutes, there was minimum blood loss, a minimum of postoperative pain, adequate urinary output, and short hospital stay. Imaging studies revealed satisfactory oncologic control.Laparoscopic partial nephrectomy is similar to radical nephrectomy in relation to survival in patients, such as ours, with localized tumors. Laparoscopic ultrasound is a tool for identifying and controlling tumor resection. In conclusion, the use of laparoscopic ultrasound in intraoperative tumor resection enables real-time resection control for carrying out complete renal tumor excision.

Nefrectomía parcial laparoscópica guiada por ultrasonido laparoscópico de alta definición

Resumen La nefrectomía parcial laparoscópica fue descrita en 1993, sus indicaciones se extendieron por sus beneficios al mantener los resultados oncológicos y preservación de parénquima renal. El objetivo del presente artículo es describir a una paciente con diagnóstico

PALABRAS CLAVENefrectomía parcial laparoscópica; Ultrasonido laparoscópico de alta definición;


Introduction

Laparoscopic partial nephrectomy was first described in 1993. It indications and use have been extending due to its benefits of offering adequate oncologic control, while conserving part of the patient’s renal function, as well as the added value of being a minimally invasive technique. 1-5

In the last few years, the new modalities in radiology studies and their relative access in the majority of Mexican hospitals, have not only brought about an increase in renal tumor diagnosis, but also at earlier stages. The survival rate at 5 years for a localized renal tumor is approximately 90%, justifying treatment for these patients.6

Curative treatment of localized renal tumors is surgical and the treatment of choice continues to be nephrectomy. Partial nephrectomy has shown similar oncologic control to radical surgery. The initial indications for partial nephrectomy were a single anatomic or functional kidney. These indications gradually broadened, as the safety of the technique was confirmed and adequate oncologic results were achieved.3,7 Moreover, with the increase in experience, larger and deeper tumors have been treated and renal parenchyma hemostasis, waterproof repair of the calyces through suturing after tumor excision, and

complete tumor resection are among the principal surgical goals.8-11

The aim of this report was to document how the use of a high definition laparoscopic ultrasound transducer was an important aid in achieving complete tumor excision.

Case presentation

A woman in the seventh decade of life had a past history of diabetes and chronic stage 2 nephropathy of the National Kidney Foundat ion (nKF), 4 cesarean sect ions, appendectomy, hysterectomy, tubal ligation, and ventral hernia repair through mesh placement. She was admitted to our hospital for a diarrheic syndrome. Computed tomographic urography was ordered as a complementary study and revealed a right 14 mm renal mass with 20 HU in the plain phase and 80 HU in the venous phase, suggestive of a tumor. It was staged T1aN0M0 (fig. 1) and laparoscopic partial nephrectomy was proposed.

Total surgery duration, blood loss, intra and postoperative complications, hospital stay, and oncologic control were evaluated. The procedure was performed with the following surgical technique: the patient was given general anesthesia and put in the left lumbotomy position to have access to the

de tumor renal derecho T1aN0M0, a la que se le realizó nefrectomía parcial laparoscópica guiada por ultrasonido laparoscópico de alta definición. Se somete paciente a dicho procedimiento, con pinzamiento de la arteria renal.Se realiza cirugía con un tiempo de 240 minutos, presenta sangrado mínimo, dolor postoperatorio mínimo y adecuado gasto urinario, tiempo corto de estancia hospitalaria; en estudios de imagen se encuentra con adecuado control oncológico.La nefrectomía parcial laparoscópica es similar a la nefrectomía radical en sobrevida en tumores localizados, como se demostró en la paciente, y el ultrasonido laparoscópico es una herramienta para la identificación del control de la resección tumoral.en conclusión, el uso de ultrasonido laparoscópico en la resección del control transoperatorio de tumores, es una herramienta que permite el control de la resección en tiempo real, además es un control para realizar la escisión tumoral renal completa.


Nefrectomía parcial; México.

Figure 1 Coronal and axial views of abdominal tomography scan showing a right renal tumor.

Laparoscopic nephrectomy guided by high-definition laparoscopic ultrasound 57

lumbar region. Three trocars were placed: a 12 mm blunt-tip transumbilical trocar, a 10 mm trocar at the subcostal level, and a 5 mm trocar at the mid-clavicular line. The transperitoneal approach was employed. The ureter and the gonadal vein were identified and laterally retracted. Dissection was performed along the psoas muscle and the renal hilum was dissected en bloc. Gerota’s fascia was dissected, separating it from the kidney. The renal tumor was identified at the lower pole and the adjacent perirenal fat was dissected (fig. 2). The 4-channel 10 mHz BK ProFocus 2202 high definition laparoscopic ultrasound transducer was then introduced through the 10 mm trocar (fig. 3) identifying the tumor edges and depth (fig. 4). Once this was done, the silk threads that were the reference points for the renal artery and vein were tightened. The tumor was resected with a laparoscopic cold scissors (fig. 5). Upon finishing the resection, the laparoscopic transducer was introduced again to make sure there were no areas of residual tumor, after which renorrhaphy with Vicryl® 1-0 was done, anchoring the sutures with Hem-o-Lok® (Weck Closure System, Research Triangle Park, NC). The traction of the renal vessels was then freed with a warm ischemia time of 30 minutes. A control ultrasound showed no evidence of residual mass (fig. 6) Hemostasis was achieved at the renorrhaphy site with the biologic sealant Floseal® (Baxter, Mountain View, CA) with no apparent signs of bleeding. The tumor was put in a waterproof bag and removed through the 10 mm port. A drain was placed, the ports were removed under direct vision and the wounds were closed with the usual technique.

The procedure took 180 minutes, with blood loss of 100 cc. There was no need for blood transfusion, the patient had a favorable postoperative period with minimal doses of analgesic. Pain was adequately controlled without rescue doses. The patient began to walk at 24 hours and the drain was removed after 48 hours. Control renal ultrasound at 48 hours showed no signs of perirenal hemorrhage and the patient was released 72 hours after surgery. She was checked 4 weeks later and had adequate progression. There was no evidence of recurrence at the control appointment at 3 months.

Discussion

Since the first published works by Robson, radical nephrectomy has been accepted as the reference treatment in localized renal carcinoma. 5 nevertheless, the new technologies that have been developed, along with the rise in minimally invasive surgery, have resulted in their being compared.

Partial nephrectomy has shown better conservation of renal function than radical nephrectomy, as well as having good oncologic results and being a safe option for treating tumors under 4 cm. In addition, recurrence and the risk of death from tumor disease are low; they have been related to pathologic stage and Fuhrman grade, but not to positive margins that can be found in 1.4% of the patients that undergo this treatment. Free-from-disease survival at 2 and 5 years has been reported at up to 99% and 97%, respectively.12

The approaches are retroperitoneal or transperitoneal, as with our patient. In the end, the choice of the approach will depend on the surgeon’s preferences, taking into account the size of the mass, location, body mass index or history of previous surgery, with no big differences in the complication rate between the approaches.3

One of the reported complications with the laparoscopic technique is parenchymal bleeding related to tumor size and depth, and added to the time limitation and the precision of laparoscopic suture placement, it does not compare with an open procedure. nevertheless, these effects can be reduced with adequate control of the hilum through appropriate instruments for that purpose,13 and secondarily through the use of hemostatic agents like Floseal®.

Another disadvantage associated with the procedure is the difficulty of achieving satisfactory surgical margins due to the limited angulation of the laparoscopic instruments, which tends to lessen the deeper the tumor, plus the poor visibility after beginning the parenchymal incision;13 this is where the use of intraoperative ultrasound provides better information as to the depth of the tumor and how far the

Figure 2 Tumor image before high-definition laparoscopic ul-trasound.

Figure 3 Introduction of the 4 channel 10 mHz BK Pro-Focus 2202 high definition laparoscopic ultrasound flexible transducer for identifying the tumor.


resection should be extended to confirm the existence of residual tumor.

In the present case, we observed the advantages of the laparoscopic approach that have been reported in other case series: short hospital stay and good pain control; for our patient it was 72 hours and she did not need to be given narcotics, only the common anti-inflammatory agents, and not at rescue doses.7,11-13

Conclusions

Renal cell carcinoma management continues to be surgical. However, unlike the first reports on the procedure, laparoscopic partial nephrectomy, when performed by an experienced urologist, has been shown to be a safe technique with lower morbidity and satisfactory oncologic results, compared with the open technique. However,

patients should be well selected and auxiliary techniques, such as laparoscopic ultrasound used in the case presented herein, should be employed in order to achieve resection margins guaranteeing long-term oncologic control.





References

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5. Robson C, Churchill B, Anderson W. The results of radical nephrectomy for renal cell carcinoma. J Urol 1969;101:297-301.

6. Consultado en enero de 2014. http://seer.cancer.gov/csr/1975_2006/

7. Lau W, Blute M, Weaver A, et al. Matched comparison of radical nephrectomy vs. nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc 2000;75:1236-1242.

8. Janetschek G, Jeschke K, Peschel R, et al. Laparoscopic surgery for stage T1 renal cell carcinoma-radical nephrectomy and wedge resection. eur Urol 2000;38(2):131-138.

9. Kim FJ, Rha KH, Hernandez F, et al. Laparoscopic radical versus partial nephrectomy - assessment of complications. J Urol 2003;170(2 Pt 1):408-411.

Figure 4 Intraoperative laparoscopic ultrasound for defining the edges and depth of the resection.

Figure 6 Image after resection and renorrhaphy for docu-menting the absence of residual tumor.

Figure 5 Image showing tumor resection after laparoscopic ultrasound.

Laparoscopic nephrectomy guided by high-definition laparoscopic ultrasound 59

10. Simon SD, Ferrigni RG, Novicki DE, et al. Mayo Clinic Scottsdale experience with laparoscopic nephron sparing surgery for renal tumors. J Urol 2003;169(6):2059-2062.

11. Maclennan S, Imamura M, Lapitan MC, et al. Systematic Review of Perioperative and Quality-of-life Outcomes Following Surgical Management of Localised Renal Cancer. Eur Urol 2012;62(6):1097-1117.

12. Favaretto RL, Sanchez-Salas R, Benoist N, et al. Oncologic Outcomes After Laparoscopic Partial Nephrectomy: Mid-Term Results. J endourol 2013;27(1):52-57.

13. Gill IS, Matin SF, Desai MM, et al. Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients. J Urol 2003;170(1):64-68.

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