Laparoscopic surgery in urology: refining indications and techniques.
Explore the source record for details and available documents.
Humans↗
Biomedical subjects
R O Parra
Publications and source records attributed to R O Parra.
Laser prostatectomy: initial experience and urodynamic follow-up.
OBJECTIVES: An evolving technology for the treatment of bladder outlet obstruction due to benign prostatic hyperplasia (BPH) is the use of the side-firing neodymium: yttrium-aluminum-garnet (Nd:YAG) laser to achieve prostatic tissue ablation. The purpose of this study was to determine the short-term efficacy of this procedure in both an objective and subjective manner. METHODS: We examined this technique by carefully evaluating our first 25 men undergoing the procedure. Each patient was subjected to careful symptom score analysis using the American Urological Association symptom index and multichannel urodynamics, including pressure-flow studies both preoperatively and at 3 months postoperatively. RESULTS: At the 3-month follow-up, symptom scores improved from a preoperative mean of 11.4 to 7.2 and the mean maximum flow rate improved from 6.1 to 14.5 cc/s. These are both significant at P < 0.001. Statistically similar improvement was seen in detrusor pressure at opening and at maximum flow. Eighty percent of the men studied had at least a 50% reduction in symptom score and a 50% improvement in flow rate. CONCLUSIONS: We conclude that laser prostatectomy is a promising minimally invasive treatment for bladder outlet obstruction secondary to BPH and deserves further evaluation at longer terms of follow-up.
Follow-Up Studies↗
Evaluation of fluid absorption during laser prostatectomy by breath ethanol techniques.
PURPOSE: Laser prostatectomy has evolved as a less invasive method of relieving bladder outlet obstruction due to prostatic enlargement. The elimination of adenomatous tissue by laser induced coagulation necrosis theoretically avoids the sequelae of fluid absorption noted during traditional transurethral resection of the prostate. However, to our knowledge no accurate determination of fluid absorption during laser prostatectomy has been performed to date. MATERIALS AND METHODS: A technique previously described to determine the amount of irrigant absorbed during transurethral resection of the prostate measures breath ethanol levels using a standard alcohol breath analyzer during the procedure after a predetermined amount of ethanol is added to the irrigant fluid. This method was used in 4 men undergoing laser prostatectomy. RESULTS: All 4 subjects had ethanol levels of 0 throughout the operation, indicating that little or no irrigant fluid was absorbed. CONCLUSIONS: We demonstrated in a quantitative manner that fluid absorption during laser prostatectomy is almost nil and patients are, indeed, at no risk for the transurethral resection syndrome.
Absorption↗
[Is there a place for radical prostatectomy without lymphadenectomy?].
OBJECTIVES: Herein we present the procedure we have followed to determine N+ low-risk factors which allow us to identify those patients with prostate cancer in whom radical perineal prostatectomy (RPP) can be performed without a previous staging lymphadenectomy, thereby maintaining the oncological principles but with less morbidity. METHODS: In a series of 88 patients who underwent RPP, we identified an N+ low-risk factor group; i.e., patients with clinically localized tumor of the prostate gland, a Gleason score of < or = 7 and PSA < or = 10 ng/ml. The foregoing criteria were based on the findings reported by Stamey and the status of the lymph nodes of our own series of radical prostatectomies. RESULTS: In 71 of the 88 patients with a follow up of more than one year, RPP was performed after laparoscopic pelvic lymphadenectomy. Of these 71 patients, 17 (19.3%) presented the above-mentioned low-risk characteristics and were all pN-. Since then, the subsequent patients who met this low-risk criteria (n = 17; 19.3% of the total) were submitted to RPP alone without previous staging lymphadenectomy. The rate of positive margins in this group was 17.6%, all cases maintaining PSA within feminization levels after a mean follow-up of 21.7 months. Considering the overall series, 38.6% of the patients could have avoided lymphadenectomy according to our criteria. CONCLUSIONS: We have found RPP without previous staging lymphadenectomy to be a valid therapeutic option for patients with clinically localized prostate cancer, preoperative PSA < or = 10 ng/ml and a Gleason score of < or = 7. According to our data, this group accounts for approximately 40% of the patients in whom radical prostatectomy had been recommended.
Follow-Up Studies↗
Laparoscopic simple cystectomy in a man.
Laparoscopic surgery is rapidly being assimilated into the urologic armamentarium. Already many operations commonly done by an open approach are being performed laparoscopically. We report on the laparoscopic performance of a simple cystectomy in a spinal cord-injured male patient suffering from recurrent pyocystis. The procedure proved to be technically feasible, with the patient experiencing a short convalescence period.
Adult↗
Comparison between standard flank versus laparoscopic nephrectomy for benign renal disease.
To evaluate the role of laparoscopic nephrectomy in the management of benign renal diseases, 12 patients undergoing laparoscopic nephrectomy were compared to 13 undergoing a classical flank nephrectomy. Both groups were similar in regard to patient age and indications for surgery. The underlying pathological conditions included vesicoureteral reflux, tuberculosis, hydronephrosis, hypertension and failed pyeloplasty. Overall, operative time ranged from 105 to 360 minutes (mean 145) for the laparoscopic group and 60 to 240 minutes (mean 156.6) for the open surgery group. Hospital stay and interval to return to regular preoperative activities were 2 to 6 days (mean 3.5) and 10 to 21 days (mean 16) for patients undergoing laparoscopic nephrectomy, which was significantly shorter than for those undergoing a flank procedure, 3 to 16 days (mean 8) and 35 to 84 days (mean 32.3), respectively. Pain medication requirements were also markedly decreased after laparoscopic nephrectomy. Of the patients in the laparoscopic group 2 experienced complications with only 1 requiring conversion to open nephrectomy. The laparoscopic technique is an effective as the flank approach for benign renal conditions, while providing a more rapid recuperation and superior cosmetic result.
Adult↗
Chronic hematospermia: assessment by transrectal ultrasound.
OBJECTIVE: To evaluate transrectal ultrasound in the assessment of chronic hematospermia. METHODS: Twenty-six patients aged between twenty-five and seventy-seven years (mean, 55.6 years) presenting with persistent hematospermia of an average duration of 10.2 months (range, 3 to 20 months) underwent transrectal ultrasound. Twenty-five asymptomatic men aged thirty-nine to eighty-two years (mean, 63 years) self-referred to our institution seeking transrectal ultrasound as a screening method for prostate cancer and with no previous history of hematospermia were used as controls. RESULTS: Significant sonographic findings not present in the control group were detected in 24 patients with hematospermia. These consisted of dilated seminal vesicles in 8, ejaculatory duct cysts in 4, ejaculatory or seminal vesicle calculi in 4, the presence of ejaculatory duct and seminal vesicle dilatation in 4, seminal vesicle cysts with ipsilateral renal agenesis and absence of the vas in 2, and an intraprostatic müllerian duct remnant in 2. Of the patients having biopsies, none was found to have malignancy. CONCLUSIONS: Transrectal ultrasound is the imaging modality of choice in the assessment of chronic hematospermia.
Adult↗
Nontraumatic elevation of prostate specific antigen following cardiac surgery and extracorporeal cardiopulmonary bypass.
We recently treated a number of patients with markedly elevated prostate specific antigen (PSA) levels associated with acute urinary retention in a post-cardiac surgery setting. A controlled study was conducted to determine if this elevation is secondary to trauma from urethral catheterization or more directly associated with the cardiac surgery and extracorporeal bypass. In 68 patients undergoing cardiac surgery serum PSA levels were determined preoperatively and 12 to 18 hours postoperatively (after urethral catheterization). The control patients were 23 men undergoing evaluation for chest pain in the cardiac care unit. The serum PSA level was markedly elevated in 38 patients (56%) after cardiac surgery. In contrast, only 1 control patient (4.3%) had an elevated level after urethral catheterization (p = 0.0001). The mean post-cardiac surgery PSA concentration was 9.14 +/- 16.08 ng./ml. (range 0.1 to 94.8) with a mean elevation of 528% (range -50 to 5,155%). This finding was statistically different from the mean post-catheterization level of 1.86 +/- 2.26 ng./ml. (range 0.2 to 9.1, p = 0.034) and mean elevation of 6% (range -50 to 100%, p = 0.0001) in the control patients. We conclude that cardiac surgery and extracorporeal cardiopulmonary bypass can cause a marked elevation in serum PSA that appears to be unrelated to urethral catheterization. Presently, the etiology of this elevation is unknown, although PSA measurements may eventually find use as a marker for prostatic damage associated with acute urinary retention in the postoperative setting.
Aged↗
Complications of laparoscopic urological surgery: experience at St. Louis University.
A total of 221 patients underwent laparoscopic surgery at our institution. An outcome analysis with regard to type of procedure, success and complications was done. Overall, 216 of 221 procedures (97.7%) were performed as originally planned. One operation was converted to an open procedure. Complications producing morbidity occurred in 33 of 217 patients (15.2%). There was no associated mortality. Most complications occurred early in the participating surgeons experience. Of the complications 11 (5.0%) were considered major and included formation of symptomatic lymphoceles (4 patients), vascular injury (1), ureteral transection (1), bladder perforation (1), bowel obstruction (1), cecal perforation (1) and cerebrovascular accident (1). One patient had an idiopathic reaction to the inhalation anesthetic. Of the 11 major complications 9 occurred among 98 patients undergoing pelvic lymphadenectomy and 7 of these occurred among a subset of 15 patients undergoing an extended dissection. Adjuvant surgical intervention was necessary in 13 patients: celiotomy in 5, laparoscopic techniques in 4 and minor surgical procedures or percutaneous techniques in 4. Our experience suggests that urological laparoscopic surgery is safe and offers a shorter convalescence. However, the technique must be regarded as major surgery, associated with a steep learning curve.
Adolescent↗
Laparoscopic repair of intraperitoneal bladder perforation.
Most intraperitoneal bladder injuries require a formal laparotomy for repair. With the rapid assimilation of laparoscopic techniques into urological surgery, procedures that otherwise would have included a standard open operation are now being performed on an endo-cavitary basis. A case is described of an intraperitoneal bladder rupture incurred during endoscopic surgery, which was successfully managed laparoscopically with significant benefits to the patient.
Aged↗
The value of laparoscopic lymphadenectomy in conjunction with radical perineal or retropubic prostatectomy.
A total of 76 men with clinically localized prostate cancer underwent surgical treatment at our institution during an 11-month period. Of the patients 26 underwent staging laparoscopic pelvic lymph node dissection followed by radical perineal prostatectomy (group 1), 24 underwent laparoscopic pelvic lymph node dissection and radical retropubic prostatectomy (group 2), and 26 underwent standard open lymphadenectomy and radical retropubic prostatectomy (group 3). Group 1 patients experienced statistically significantly less average blood loss (576 +/- 360 cc) than either group 2 (1,275 +/- 686.8) or 3 (1,100 +/- 459, p < 0.001). Hospital stay was also significantly less in group 1, with a mean of 4.6 +/- 1.9 days compared to 9.6 +/- 4.6 and 7.25 +/- 2.06 days for groups 2 and 3, respectively (p < 0.001). Our study supports the combination of laparoscopic pelvic lymph node dissection and radical perineal prostatectomy as a potentially less morbid approach to the surgical treatment of prostate cancer. However, no benefit was found for laparoscopic staging in patients before radical retropubic prostatectomy.
Aged↗
Simple detubularization technique for construction of continent colonic urinary reservoirs.
OBJECTIVES: Despite the advantages offered by continent urinary diversion techniques, wide acceptance of the procedure has been hampered by the length of time required to detubularize and suture the reconfigured bowel. With the purpose of simplifying the procedure, a linear stapler loaded with absorbable staples was used to accomplish simultaneous detubularization and closure of the reservoirs. METHODS: Six patients, 4 men and 2 women received a stapled detubularized reservoir following radical cystectomy. The male patients all had construction of a neobladder, whereas in the females a catheterizable continent stoma was designed. RESULTS: Operative time was shortened by an average of 30 to 45 minutes without technical difficulties. No postoperative complications related to the staple line occurred and with a follow-up of 6 months good functional results have been achieved, with no patient experiencing diurnal incontinence. CONCLUSIONS: This simple mechanical detubularization technique offers results similar to the hand suture method while at the same time shortening and simplifying the procedure.
Aged↗
Seminal vesicle volume as a sonographic predictor of prostate cancer stage.
OBJECTIVES: Accurate clinical staging of prostate cancer continues to challenge the urologist, with understaging a common problem. Preoperative identification of men with capsular penetration or seminal vesicle invasion would allow deferment of radical surgery unlikely to cure the patient. We investigated the ability of seminal vesicle volume as determined by transrectal ultrasound (TRUS) to predict the stage of prostate carcinoma. METHODS: Forty-seven consecutive men undergoing radical prostatectomy had preoperative determination of the seminal vesicle volume by TRUS. The volume was determined for each individual seminal vesicle as well as the total seminal vesicle volume. Asymmetry was defined as one seminal vesicle having twice the volume of the other. RESULTS: Average total seminal vesicle volume was statistically greater for patients with Stage C disease as opposed to those with organ-confined tumors. Seminal vesicle asymmetry was also present statistically more often in Stage C patients than Stage B men. The combination of total seminal vesicle volume less than 15 cc and symmetrical seminal vesicles yielded a possibility of only 18% of extraprostatic extension of tumor. CONCLUSIONS: We believe that seminal vesicle volume as determined by TRUS can aid in the staging of adenocarcinoma of the prostate and should be considered along with other parameters, such as prostate-specific antigen, acid phosphatase, and Gleason score, when planning therapy for this disease.
Diagnosis, Differential↗
Endocavitary (laparoscopic) pelvic lymphadenectomy with specific indications in urologic surgery.
Recent reports have established the feasibility and minimal morbidity of laparoscopic pelvic lymph node dissection in the staging of prostate and bladder cancer. In addition, a prospective study recently published established the completeness and efficacy of this form of endocavitary surgical lymphadenectomy with respect to the standard modified open procedure. The method's utility prior to definitive radiation therapy or radical perineal prostatectomy is obvious. However, clear indications of its utility in identifying men with positive nodes prior to radical retropubic prostatectomy are less clear. A description of the surgical technique as well as a review of the existing literature, and our present indications for its use are presented. In addition, possible future applications of endocavitary node dissection will be put in context.
Biomarkers, Tumor↗
Endocavitary bladder surgery.
The advent of laparoscopy has expanded the horizon for endocavitarily approaching urologic disorders, otherwise managed by open surgical procedures. In this article we will review our experience with this new modality as applied to the urinary bladder, and put into perspective future applications.
Adult↗
The titanium intraprostatic stent: the United States experience.
This multicenter, cooperative study represents the initial United States experience using an expandable, titanium intraprostatic stent in 68 patients (60 to 93 years old). The stents were inserted under direct vision and expanded to 33F using a balloon catheter. All patients had a symptom score analysis, and underwent measurement of peak urine flow and rate and post-void residual urine volume as part of the initial evaluation. Patients were seen at approximately 1, 3, 6 and 18 months after stent insertion (mean followup 16 months). Of the 68 patients 38 presented in urinary retention. The type of anesthesia used included general anesthesia in 6 patients, spinal or epidural anesthesia in 24, intravenous sedation in 20 and intraurethral lidocaine only in 18. All patients were able to void spontaneously within 36 hours after stent insertion. Symptom scores decreased from 16.8 to 3.9, 6.3, 5.0, 5.7 and 3.2 at approximately 1, 3, 6, 12 and 18 months, respectively. Peak urine flow rate increased from 3.9 to 13.8, 11.5, 11.2, 12.4 and 14.4 ml. per second at approximately 1, 3, 6, 12 and 18 months, respectively. Post-void residual urine volume decreased from 74.4 to 30.1, 29.2, 19.8 and 40.2 ml. at approximately 1, 3, 6 and 12 months, respectively. Of the initial 68 patients 5 died of the underlying disorder (all voiding satisfactorily with the stent in place) and 17 underwent uneventful stent removal (10 for technical failure and 7 for treatment failure). Technical failures were secondary to either inaccurate positioning or improper stent sizing. Of the 58 patients with proper placement of the stent and no technical failures 46 (79%) had improvement in symptom scores and urine flow rate. Transient hematuria was noted in 43 patients (63%) and usually resolved within 48 hours. None of the 6 urinary tract infections (9%) was recurrent. In conclusion, the titanium intraprostatic stent, when properly placed, is a promising therapeutic alternative to prostatectomy or long-term catheterization in high risk obstructed patients or those in urinary retention. Studies are currently in progress to determine the long-term efficacy of this therapeutic modality.
Aged↗
Transrectal ultrasound in the evaluation of men with low volume azoospermia.
The evaluation of the subfertile man has changed with the advent of noninvasive imaging techniques. We used high resolution transrectal ultrasound early in the evaluation of 25 men 24 to 35 years old with probable ductal obstruction represented by azoospermia or severe oligospermia (less than 1 million sperm per cc) and low volume ejaculate. Of these patients 13 were found to have a post-testicular obstructive cause including ejaculatory duct obstruction (5), voluminous seminal vesicle dilatation with obstruction (3), seminal vesicle aplasia (2), nonpalpable vas (2) or epididymal obstruction (1). The other 12 men had either a varicocele (8) or testicular failure (4). Except for vasal or epididymal pathology, the other causes of post-testicular azoospermia presented with an ejaculate volume consistently less than 1.0 cc. All 10 patients with low volume and an abnormal ultrasound had normal follicle stimulating hormone levels and testicular biopsy findings. Sonography not only was helpful in establishing the diagnosis but also in determining the distal extent of the obstruction. Transrectal ultrasound is an important noninvasive diagnostic tool that minimizes the need for more invasive studies in the evaluation of azoospermia, particularly when associated with low ejaculate volume.
Adult↗
Endoluminal urethral stents: a review.
Although Fabian first introduced the concept of an endourethral stent in 1980, recent developments in biomedical technology and the treatment philosophy of urethral obstruction has led to a resurgence of this concept. We review the past and current literature with regard to both temporary and permanent stents. Available stents are described, clinical results summarized, and indications discussed.
Equipment Design↗