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G Janetschek

Publications and source records attributed to G Janetschek.

At least 19 recordsLinked to original sources
PubMed2000

Laparoscopic retroperitoneal lymph node dissection.

INTRODUCTION: Retroperitoneal lymph node dissection (RPLND) is the most accurate method for evaluating the presence of retroperitoneal metastases from clinical Stage I nonseminomatous testicular tumors. We have introduced laparoscopy to reduce the morbidity of open RPLND, which is too high for a diagnostic procedure. As the next step, we replaced open surgery with the laparoscopic approach for Stage IIb tumors to remove residual tumor after chemotherapy. TECHNICAL CONSIDERATIONS: One prerequisite for laparoscopic RPLND is free access to the retroperitoneum, which can be achieved by wide dissection of the colon and duodenum. The borders of the dissection are the same as with open surgery, and complete dissection can be achieved. Bipolar coagulation and the harmonic scalpel have proved very helpful in achieving adequate hemostasis, a crucial point. Venous lesions can be sealed with fibrin glue. CONCLUSIONS: Laparoscopic RPLND is superior to open surgery with regard to morbidity and complication rates, and operative times are equal once enough experience has been collected. The diagnostic accuracy is the same for both methods, and tumor control is not compromised by the laparoscopic approach. The only drawback of laparoscopy is the long and steep learning curve.

Humans↗
PubMed2000

Laparoscopic surgery in urology.

Not more than 10 years ago, laparoscopy was introduced to the armamentarium of urology. The start was slow, with pelvic lymphadenectomy, nephrectomy and varicocelectomy being about the only indications. However, very soon great enthusiasm developed, and almost every urological operation was performed by means of laparoscopy. For several reasons this exaggerated enthusiasm had to be followed by disappointment. First of all, laparoscopy turned out not to be as easy as many would have liked it to be. Due to a low frequency of operations, many surgeons were never able to overcome their learning curve, and the early literature reflects this problem. Unlike general surgery where cholecystectomy developed into a pacemaker operation, which forced everybody to go ahead with laparoscopy, urology was long searching for good and frequent indications for this new technique. Within the last few years, the pendulum has swung back to the other side. Adrenalectomy was one of the first indications where laparoscopy proved superior to open surgery in every aspect. Several other good indications have followed, some of which, namely cryptorchidism, nephrectomy and pyeloplasty, will be presented in detail to give an example. But the breakthrough that recently occurred is due to the success of laparoscopy in the field of oncologic surgery. Laparoscopic radical nephrectomy has shown its surgical efficiency as well as its oncologic efficacy. However, the main interest is now focused on radical prostatectomy, since this is the most frequently performed operation in urology by now. Recently this operation could be developed to a standardized technique, but only time will tell its true impact. Several indications will change in the future, but laparoscopy is here to stay.

Adrenalectomy↗
PubMed2000

Laparoscopic surgery for stage T1 renal cell carcinoma: radical nephrectomy and wedge resection.

OBJECTIVES: Renal cell carcinoma (RCC) is likely to become one of the most important indications for laparoscopic surgery. We herein report our experience. METHODS: From April 1994 until April 1999, 98 patients presenting with RCC were treated laparoscopically by either radical nephrectomy (RN; n = 73) or wedge resection (WR; n = 25). The mean age was 62.3 years. The mean tumour diameters were 3.8 cm (RN) and 1.9 cm (WR). All tumours were clinical stage T1 lesions. The transperitoneal approach was used for RN in all patients. For WR either the transperitoneal or the retroperitoneal approach was used. In 15 patients, the adrenal gland was removed simultaneously. The specimen was entrapped in an organ bag and removed intact through a small muscle-splitting incision in the lower abdominal wall. RESULTS: RN: The mean operating time was 142 (range 86-230) min, the mean blood loss was 170 (range 0-1,500) ml, and the mean postoperative hospital stay was 7.4 (range 3-32) days. Minor complications occurred in 4.0% of the patients, while major complications were seen in 8.0% of them. WR: The mean operating time was 163.5 (range 90-300) min, the mean blood loss was 287 (range 20-800) ml, and the postoperative hospital stay was 8.0 (range 3-8) days. Minor complications: 4%, major complications: 8%. Histology revealed RCC stage T1 in 77 patients, stage T3a in 7, and stage T3b in 3 patients, oncocytoma in 2 patients, angiomyolipoma in 2, renal adenoma in 1, renal metastasis in 1, multilocular cysts in 4, and renal abscess in 1 patient. Over mean follow-up periods of 13.3 and 22.2 months for RN and WR, respectively, neither local recurrences nor metastases have been observed among patients with histologically confirmed RCC. CONCLUSIONS: Laparoscopic surgery for clinical stage T1 RCC is safe and efficient. Excellent tumour control can be achieved. However, longer follow-up periods will be necessary to confirm these results.

Adult↗
PubMed2000

Laparoscopic partial adrenalectomy for bilateral pheochromocytomas in a boy with von Hippel-Lindau disease.

OBJECTIVES: In adults, increasing numbers of adrenalectomies for pheochromocytomas are performed laparoscopically. We report for the first time laparoscopic bilateral subtotal adrenalectomy for pheochromocytomas in an 8-year-old boy with von Hippel-Lindau disease. METHODS: In July 1998, an 8-year-old boy with von Hippel-Lindau disease underwent laparoscopic adrenal-sparing surgery for bilateral pheochromocytomas. The boy presented with severe hypertension and two pheochromocytomas on both sides. RESULTS: The child could be solely treated with laparoscopic adrenal-sparing surgery. The procedure was completed as planned. There were absolutely no intraoperative or postoperative complications. Postoperatively, catecholamine levels and hypertension went back to normal. At follow-up no residual tumor could be detected and no steroid replacement therapy was necessary. CONCLUSIONS: In experienced hands, laparoscopic adrenal-sparing surgery for pheochromocytomas is feasible and safe. Moreover, this minimal invasive approach represents an exceptional improvement in life quality, especially in children with von Hippel-Lindau disease since surgery will probably be necessary again and again in their future life.

Adrenal Gland Neoplasms↗
PubMed2000

Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular carcinoma: long-term outcome.

PURPOSE: We report the long-term oncological efficacy and morbidity of laparoscopic retroperitoneal lymph node dissection for testicular carcinoma. MATERIALS AND METHODS: From August 1992 to September 1999, 73 consecutive patients underwent laparoscopic retroperitoneal lymph node dissection with modified unilateral template dissection. All lumbar vessels within the template were routinely transected in the initial 29 cases only. Patients with positive lymph nodes received 2 cycles of chemotherapy. RESULTS: Operative time ranged from 150 to 630 minutes (mean 221) in our most recent 28 cases. All but 2 operations were completed as planned for a conversion rate of 2.7%. Minor intraoperative complications developed in only 6.8% of cases. In our last 44 patients there was no major and only 1 minor (2.3%) postoperative complication. Mean postoperative hospitalization was 3.3 days. Ejaculation was preserved in all patients. Lymph nodes were positive in 19 cases (26%). Mean followup in 47 patients with pathological stage I disease was 43.3 months (range 7 to 84). We noted 1 retroperitoneal recurrence due to false-negative histological findings but there were no other relapses. At a mean followup of 42.7 months (range 6 to 86) 17 patients with pathological stage II carcinoma treated with 2 cycles of adjuvant chemotherapy were also free of disease. CONCLUSIONS: In our hands laparoscopic retroperitoneal lymph node dissection has not only proved its surgical efficiency, but also its oncological efficacy. Patient satisfaction is high. During long-term followup of more than 3 years not a single recurrence developed due to surgical failure.

Adolescent↗
PubMed1999

Extracorporeal shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective randomized study.

PURPOSE: We performed a prospective randomized study to determine appropriate first line treatment for distal ureteral stones. MATERIAL AND METHODS: Between January 1996 and October 1997, 80 patients with distal ureteral stones (40 smaller than 5 mm. and 40 larger than 5 mm.) were randomized and treated with extracorporeal shock wave lithotripsy or ureteroscopy with a 9.5 or 6.5F semirigid ureteroscope. RESULTS: Ureteroscopy was significantly better in terms of operative time, fluoroscopy time and time to achieve a stone-free state. The smaller the stones, the greater the difference between the 2 treatment modalities. CONCLUSIONS: For distal ureteral stones we recommend ureteroscopy as first line treatment.

Adult↗
PubMed1999

Surgical options in adrenalectomy: laparoscopic versus open surgery.

Small hormone-active benign tumors are considered as clear indication for laparoscopic adrenalectomy. Laparoscopy resection of pheochromocytomas is still a controversial issue, but recent data have shown that the specific risks of pheochromocytoma surgery are not increased by the laparascopic approach. The majority of endoscopic adrenalectomies are performed via the transperitoneal route, but there is growing interest in the retroperitoneoscopic approach. The advantages and disadvantages of each endoscopic approach have to be weighed carefully, but the final decision will also depend on the experience of the surgeon. Several retrospective studies have compared laparoscopy with open surgery. There is general agreement that laparoscopy is superior to open surgery since it is associated with less pain, a shorter hospital stay, and more rapid return to normal activities, and also yields the best cosmetic and long-term results. Partial adrenalectomy may be indicated for bilateral pheochromocytoma, and also has advantages for patients with aldosterone-producing adenomas. The feasibility of laparoscopic partial adrenalectomy has been demonstrated. Laparoscopic intraoperative ultrasonography is valuable in selected cases. The already low morbidity of laparoscopic adrenalectomy can be reduced further by using needlescopic techniques.

Adrenal Gland Neoplasms↗
PubMed1999

Crossing vessels at the ureteropelvic junction: detection with contrast-enhanced color Doppler imaging.

PURPOSE: To investigate the feasibility of imaging crossing vessels at the ureteropelvic junction (UPJ) preoperatively by means of contrast agent-enhanced color Doppler imaging (CDI). MATERIALS AND METHODS: Twenty-nine patients (13 female patients, 16 male patients; age range, 17-76 years; mean age, 45 years) with symptomatic UPJ obstruction were examined with CDI before and after intravenous infusion of the contrast agent. The type (i.e., arterial or venous) and position of the vessel relative to the UPJ (i.e., anterior or posterior) were assessed. The CDI findings were correlated with the surgical findings at laparoscopic pyeloplasty. RESULTS: Among the 29 patients, crossing vessels were detected with nonenhanced CDI in 15 patients, with enhanced CDI in 22 patients, and with laparoscopy in 23 patients. Enhanced CDI depicted crossing vessels in 22 (96%) of the 23 laparoscopically confirmed cases compared with nonenhanced CDI, which depicted 15 (65%) of the 23 cases. The rate of detecting crossing vessels increased significantly with use of the contrast agent (P < .016, McNemar test). CONCLUSION: Compared with nonenhanced CDI, contrast-enhanced CDI significantly improves the detection of crossing vessels at the UPJ and is useful in the presurgical evaluation of UPJ obstruction.

Adolescent↗
PubMed1999

Cryptorchidism, open processus vaginalis, and associated hernia: laparoscopic approach to the internal inguinal ring.

OBJECTIVES: A nonpalpable testis was the first indication for laparoscopy in urology. This primarily diagnostic procedure has evolved to complete laparoscopic orchidopexy. An associated inguinal hernia due to an open processus vaginalis is reported in 26% of cryptorchidism cases. Simultaneous laparoscopic orchidopexy and herniorrhaphy are therefore the next logical step. METHODS: Between 1992 and 1998, 61 children underwent laparoscopy for pathology of the internal inguinal ring. In 48 boys the operation was performed for a nonpalpable testis and in 13 boys laparoscopic transection of the processus vaginalis was performed because of clinical hydrocele. RESULTS: In 25 of the 48 cases an intra-abdominal location was found with 18 existing and 7 vanishing testicles. Laparoscopic orchidopexy was performed either as a two-stage Fowler-Stephens technique (n = 6) or as a direct one-stage repair (n = 12). In 6 boys with cryptorchidism a direct inguinal hernia was associated, which received simultaneous laparoscopic herniorrhaphy. In 23 cases of cryptorchidism with an inguinal location of the testis, 3 vanishing testicles were found. In 20 cases with normal testicular vessels, an inguinal exploration followed. In 4 of the hydrocele cases additional herniorrhaphy had to be performed. In all cases the operation could be performed as planned without complications. After orchidopexy all testicles were in the normal position and well perfused as revealed by flow Doppler sonography. All hydroceles disappeared within several days. There was no inguinal hernia recurrence. CONCLUSIONS: Laparoscopic dissection of the internal inguinal ring allows perfect delineation of the anatomic structures and their relationship. Transection of the processus vaginalis can be performed without disturbance of the inguinal canal. Hernias can be closed with essentially the same technique as used in open surgery. Morbidity was minimal in all patients.

Child, Preschool↗
PubMed1999

Preserved adrenocortical function after laparoscopic bilateral adrenal sparing surgery for hereditary pheochromocytoma.

BACKGROUND: Familial pheochromocytoma, increasingly diagnosed in asymptomatic subjects with inherited syndromes such as multiple endocrine neoplasia type 2 and Von Hippel-Lindau disease, is frequently bilateral and multifocal, but very rarely malignant. Therefore, bilateral adrenalectomy and subsequent lifelong steroid replacement, with its attendant side effects, is not desirable. Minimally invasive adrenal sparing surgery by means of laparoscopy was explored for the treatment of bilateral pheochromocytoma. We report on the cure rate and adrenocortical function in a series of patients treated accordingly. PATIENTS AND METHODS: Four patients (three male, one female, ages 9-60 yr) with hereditary bilateral adrenal pheochromocytoma were treated by laparoscopic surgery in an organ sparing fashion. Postoperatively, all patients were reevaluated for complete tumor removal and for adrenocortical function. RESULTS: Two to 24 months after surgery, all patients were normotensive, had normal sodium potassium, glucose, aldosterone, renin, and cortisol serum concentrations, 24-h excretion of norepinephrine, epinephrine, and vanillylmandelic acid. Abdominal magnetic resonance imaging (n = 3) and computed tomographic scan (n = 1) disclosed no remnant or relapsing tumor tissue. ACTH stimulation testing resulted in normal cortisol responses. CONCLUSION: By adrenal sparing laparoscopic surgery not only bilateral pheochromocytoma can be successfully removed, but also adrenocortical function preserved. This may become the treatment of choice for familial pheochromocytoma.

Adrenal Cortex↗
PubMed1999

Laparoscopic retroperitoneal lymphadenectomy after chemotherapy for stage IIB nonseminomatous testicular carcinoma.

PURPOSE: We investigated laparoscopic retroperitoneal lymphadenectomy after chemotherapy for stage IIB testicular carcinoma in terms of operative feasibility, overall morbidity and tumor control. MATERIALS AND METHODS: Between February 1995 and April 1998, 24 patients underwent laparoscopic retroperitoneal lymphadenectomy following initial chemotherapy for stage IIB (2 to 5 cm.) solitary or unilateral lymph node metastases. Mean tumor diameter was 2.4 cm. before and 1.1 cm. after chemotherapy. Laparoscopic retroperitoneal lymphadenectomy was performed in all patients, including those with complete remission. RESULTS: Laparoscopic retroperitoneal lymphadenectomy could be completed as planned in all patients and there was no need for conversion to open surgery. Operative time was 150 to 300 minutes (mean 240). Blood loss was minimal and no blood transfusions were required. The only postoperative complications were chylous ascites (5 patients) which resolved with conservative management (low fat diet) and a small asymptomatic lymphocele. Histological examination revealed necrosis in 71%, mature teratoma in 25% and active tumor in 4% of patients. Antegrade ejaculation was preserved in all patients. Mean postoperative hospital stay was 4 days, return to normal activities between 1 and 3 weeks, and time to complete recovery between 5 and 10 weeks. All patients were well without evidence of disease at a mean followup of 24.4 months. CONCLUSIONS: Laparoscopic retroperitoneal lymphadenectomy after chemotherapy proved feasible in select patients presenting with solitary or unilateral lymph node metastases and was associated with a low morbidity. Tumor control was not compromised by the laparoscopic approach.

Adolescent↗
PubMed1998

A novel method of surgical instruction: international telementoring.

Telemedicine is the use of communication technologies to deliver health care. Telesurgical telementoring represents an advanced form of telemedicine, whereby an experienced surgeon can guide and teach practicing surgeons new operative techniques utilizing current video technology, medical robots, and high-band-width telecommunications. This technology can potentially enhance surgeons' education, increase patients' access to experienced surgeons, and decrease the likelihood of complications due to inexperience with new techniques. A personal computer-based system was developed to immerse a surgical specialist into a distant operating room utilizing public telephone lines. Telesurgical laparoscopic telementoring has successfully been implemented in 27 prior operations between the Johns Hopkins Bayview Medical Center and the Johns Hopkins Hospital, whereby the two institutions were separated by 3.5 miles. We report our experience in performing three successful international surgical telementoring operations, one in Innsbruck, Austria, and two in Bangkok, Thailand.

Adrenalectomy↗
PubMed1998

Laparoscopic surgery for pheochromocytoma: adrenalectomy, partial resection, excision of paragangliomas.

PURPOSE: Surgical treatment of pheochromocytoma includes adrenalectomy, adrenal sparing surgery and excision of extraadrenal paragangliomas. We report our experience using laparoscopy for these procedures. MATERIALS AND METHODS: Between June 1992 and November 1997, 19 patients underwent laparoscopic surgery for pheochromocytoma. Of the patients 14 had solitary tumors, and 4 presented with bilateral pheochromocytomas and 1 or 2 additional paragangliomas. In 1 patient a recurrent pheochromocytoma was found in the contralateral adrenal following previous right adrenalectomy. One patient each had myocardiopathy, amaurosis and stroke secondary to severe hypertension. Two patients were pregnant. RESULTS: All solitary tumors were treated with laparoscopic adrenalectomy. Laparoscopic adrenal sparing surgery (4 cases, 2 bilateral) and bilateral adrenalectomy (1) were performed for multiple familial pheochromocytoma, and all paragangliomas were excised simultaneously. The pregnant patients underwent surgery at 16 and 20 weeks of gestation, respectively. All procedures were completed as planned. The rate of minor intraoperative and postoperative complications was 11% and 16%, respectively, and there were no major complications. In all patients the catecholamine levels returned to normal and no residual tumors were found at followup. None of the patients undergoing partial resection required steroid replacement therapy. CONCLUSIONS: In experienced hands, laparoscopic surgery for solitary and multiple pheochromocytoma and paraganglioma is feasible and safe, and does not increase the specific risks associated with pheochromocytoma surgery.

Adrenal Gland Neoplasms↗
PubMed1998

Laparoscopic nephrectomy: the experience of the laparoscopy working group of the German Urologic Association.

PURPOSE: The centers of the laparoscopy working group of the German Urologic Association collected data to prove the efficacy, safety and reproducibility of laparoscopic nephrectomy. MATERIALS AND METHODS: At 14 centers 482 laparoscopic nephrectomies have been performed until December 1996 via a transperitoneal approach in 344 (71%) and a retroperitoneal approach in 138 (29%). All 482 laparoscopic nephrectomies were performed by a total of 20 surgeons with an average of 24 procedures per surgeon (range 4 to 105). The indications for nephrectomy were benign renal pathology in 444 patients (92%), including renovascular disease in 28%, hydronephrosis in 20%, reflux nephropathy in 15%, chronic pyelonephritis in 12%, end stage nephrolithiasis in 11%, renal dysplasia in 4% and renal tuberculosis in 1%. Of the remaining 38 patients (8%) laparoscopic radical nephrectomy was performed for renal cell carcinoma in 5% and for upper tract transitional cell carcinoma in 3%. RESULTS: Operating time depended mainly on the pathology of the kidney (that is small dysplastic organ versus large hydronephrosis) and the learning curve of the surgeon. However, the average operating time did not vary significantly among the different centers (maximum 277.6 and minimum 81.9 minutes). Intraoperative or perioperative complications were noted in 29 patients (6.0%), including bleeding in 22 (4.6%), bowel injury in 3, hypercarbia in 2 and pleura lesion in 1 and pulmonary embolism in 1. The conversion rate was 10.3% (bleeding, bowel injury, difficult dissection), including 4 patients with renal tuberculosis, 2 with xanthogranulomatous nephritis, and 1 each following renal trauma and embolization. The re-intervention rate was 3.4% due to bleeding in 6 cases, abscess formation in 3, intestinal stenosis in 2 and a pancreatic fistula and port hernia in 1. Mean hospital stay was 5.4 days. CONCLUSIONS: Laparoscopic nephrectomy has become a well established procedure in those urology departments focusing on laparoscopy. The indications and results are reproducible at these centers. However, for patients with severe perinephritis (that is renal tuberculosis, xanthogranulomatous nephritis, posttraumatic atrophy) a higher likelihood of open conversion must be considered.

Adolescent↗
PubMed1998

Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective.

OBJECTIVES: To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy. METHODS: A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed. RESULTS: Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51. CONCLUSIONS: Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Humans↗
PubMed1998

Laparoscopic nephrectomy for renal cell cancer: evaluation of efficacy and safety: a multicenter experience.

OBJECTIVES: Although laparoscopic radical nephrectomy is a safe and minimally invasive alternative to open surgery, the long-term disease-free outcome of this procedure has not been reported. We evaluated our experience with the laparoscopic management of renal cell carcinoma to assess the clinical efficacy of this surgical modality. METHODS: Between February 1991 and June 1997, 157 patients at five institutions were retrospectively identified who had clinically localized, pathologically confirmed, renal cell carcinoma and had undergone laparoscopic radical nephrectomy. Operative and clinical records were reviewed to determine morbidity, disease-free status, and cancer-specific survival. Of the patients followed up for at least 12 months (n = 101), 75% had an abdominal computed tomography scan at their last visit. RESULTS: The mean age at surgery was 61 years (range 27 to 92) and all patients were clinical Stage T1-2,NO,MO. Fifteen patients (9.6%) had perioperative complications. During a mean follow-up of 19.2 months (range 1 to 72; 51 patients with 2 years or more of follow-up), no patient developed a laparoscopic port site or renal fossa tumor recurrence. Four patients developed metastatic disease, and 1 patient developed a local recurrence. The 5-year actuarial disease-free rate was 91%+/-4.8 (SE). At last follow-up, there were no cancer-specific mortalities. CONCLUSIONS: The laparoscopic surgical management of localized renal cell carcinoma is feasible. Short-term results indicate that laparoscopic radical nephrectomy is not associated with an increased risk of port site or retroperitoneal recurrence. Longer follow-up is necessary to compare long-term survival and disease-free rates with those of open surgery.

Adult↗