Laparoscopic lymph node dissection in urology.
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Humans↗
Biomedical subjects
Günter Janetschek
Publications and source records attributed to Günter Janetschek.
Indications and contraindications for the use of laparoscopic surgery for renal cell carcinoma.
Surgery remains the only treatment with a chance of cure for renal cell carcinoma. Laparoscopic radical nephrectomy (LRN) has developed to be a standard treatment for the management of suspected renal malignancy in many centers worldwide, with oncologic efficacy equal to that of open radical nephrectomy. LRN has considerable advantages over open surgery, such as decreased postoperative morbidity, decreased analgesic requirements, and shorter hospital stay and convalescence. Current indications for LRN include all patients with localized stage T1-2 renal tumors. LRN for stage T3 renal tumors may be technically feasible in individual situations, but cannot be considered standard treatment. Open radical nephrectomy is reserved for advanced renal tumors, according to the surgeon's judgment. Partial nephrectomy is well established and considered to be the standard management for all organ-confined tumors of <or=4 cm in diameter. The scope of partial nephrectomy, however, is expanding, and now includes patients with organ-confined renal tumors of <or=7 cm. Laparoscopic partial nephrectomy is a continuously evolving technique. Continuing developments allow the experienced laparoscopist to use laparoscopic surgery for virtually all patients who are eligible for elective partial nephrectomy. This review evaluates the current indications and contraindications for laparoscopic radical and partial nephrectomy.
Carcinoma, Renal Cell↗
Technology insight: radioguided sentinel lymph node dissection in the staging of prostate cancer.
Pelvic lymph node dissection is the only reliable method of staging for clinically localized prostate cancer. Despite the obvious prognostic advantages conferred by accurate staging, pelvic lymph node dissection is associated with significant morbidity and prolonged operative time. A substantial decrease in the sensitivity to lymph node metastasis occurs by simple reduction of the dissection area to the obturator fossa. Radioguided sentinel lymph node dissection provides accurate staging despite use of a minimal-area dissection template. Results from studies in prostate cancer indicate that this method has a high sensitivity for very early detection of lymphatic spread. A substantial number of the detected metastases are of a small size, solitary and widely distributed throughout the pelvic lymph nodes. These features make metastases undetectable by preoperative imaging modalities, and by the current, standard method of lymph node dissection limited to the obturator fossa.
Humans↗
Long-term functional outcome of renal units after laparoscopic nephron-sparing surgery under cold ischemia.
BACKGROUND AND PURPOSE: Renal-artery occlusion is used to control bleeding during laparoscopic nephronsparing surgery, but there are worries about ischemic damage. We compared the functional outcomes of kidneys treated under warm and cold ischemia. PATIENTS AND METHODS: Twelve patients treated with warm ischemia and 14 treated with cold ischemia had renal function investigation 3 to 6 months postoperatively. Four and ten patients, respectively, also had preoperative studies. RESULTS: In patients treated with warm ischemia, two kidneys had evidence of possible damage, but the kidney with the longest ischemia (56 minutes) was normal. Among patients treated with cold ischemia, function was lost in one case. Parenchymal transit time was prolonged in five patients, but in four cases, this probably was attributable to performance of a contrast-enhanced CT scan the same day. In the fifth patient, an ischemic injury is possible. CONCLUSION: The parenchymal transit time is a good indicator of ischemic damage. Nephron-sparing surgery can lead to damage even if the ischemia time is short and cold ischemia is used. More data are needed on the factors determining such injury.
Aged↗
Laparoscopic nephron sparing surgery: ischemic renal damage.
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Carcinoma, Renal Cell↗
Laparoscopic nephron sparing surgery: evolution in a decade.
OBJECTIVE: To present our experience with laparoscopic nephron sparing surgery (NSS) over a decade. METHODS: Seventy-eight patients underwent NSS since 1994. Two techniques were used-partial nephrectomy without ischemia (group 1) in 29 patients, and with ischemia (group 2) which was in cold or warm ischemia in 24 and 25 patients respectively. The mean tumour size was 1.97 and 2.2 cm in groups 1 and 2 respectively. Renal reconstruction evolved in our hands during this period. We changed many technical details and now we depend more on clips for securing the sutures rather than free hand knotting. RESULTS: The mean operative time was 162 and 216 minutes in groups 1 and 2 respectively. Mean ischemia time for patients with cold and warm ischemia was 44.9 and 33.8 minutes respectively. 3 patients in group 2 were converted to open surgery. Mean blood loss was 254 and 212 ml for group 1 and 2 respectively with two major bleedings in group 2. Minor intra-operative complication occurred in 3 patients, and major and minor postoperative complication in 15 patients. At a mean follow-up of 23.9 and 12.2 months for groups 1 and 2 respectively there was no recurrence. CONCLUSION: Warm and cold ischemia have widened the indications for laparoscopic NSS to more complex tumours and allow renal reconstruction with acceptable complication rate.
Female↗
Laparoscopic adrenal surgery for recurrent tumours in patients with hereditary phaeochromocytoma.
OBJECTIVE: To report our experience with Laparoscopic Partial Adrenalectomy (LPA) for recurrent tumours in patients with hereditary phaeochromocytoma. PATIENTS AND METHODS: Five patients with hereditary phaeochromocytoma (4 with von Hippel-Lindau disease and 1 with Multiple Endocrine Neoplasia 2B), who had undergone adrenal surgery previously, presented with recurrent adrenal tumours. One patient was pregnant at 20 weeks of gestation. All patients underwent hormonal evaluation, genetic screening and imaging with CT or MRI, metaiodobenzylguanidine (MIBG) scintigraphy. RESULTS: Of the 7 attempted LPA in five patients, five procedures (71%) were successfully completed and total adrenalectomy was needed on two occasions. The adrenal vein could be spared in all patients except one. There were no intra-operative complications. The adrenal function was adequate in all patients without need for steroid supplementation except one patient who lost both adrenals eventually. There was no correlation between the preservation of adrenal vein and adrenocortical function. CONCLUSION: Laparoscopic partial adrenalectomy is feasible, safe and effective in recurrent phaeochromocytoma, despite previous adrenal surgery and is technically easier if the previous approach had been laparoscopic as well. Patients with hereditary phaeochromocytoma are prone for recurrent tumours and may need repeated surgical procedures. Hence, minimally invasive approach is ideal for these patients.
Adolescent↗
Role of laparoscopy in management of renal stones: single-center experience and review of literature.
BACKGROUND AND PURPOSE: Laparoscopy can be an alternative modality in the management of renal stones. We present our experience with laparoscopic renal stone surgery. PATIENTS AND METHODS: Eighteen patients (4 males, 14 females) with mean age of 51 years (range 18-86 years) underwent 19 laparoscopic procedures. The mean stone number and size, excluding five patients who had nephrectomy/heminephrectomy, were 1.9 (range 1-5) and 1.3 cm (range 0.5-4.5 cm), respectively. Three patients with ureteropelvic junction obstruction underwent pyeloplasty and concomitant pyelolithotomy. Three patients with upper-pole caliceal-diverticular stones had nephrolithotomy and fulguration of the diverticular mucosa. Three patients with stones and hydrocalix with scarred cortex had partial nephrectomy, two under cold and one under warm ischemia. Five patients, including one with a horseshoe kidney (who had one procedure on each kidney), had pyelolithotomy as an alternative to percutaneous nephrolithotomy. Patients with stones in a nonfunctioning kidney underwent nephrectomy (three patients) or heminephrectomy (one patient). RESULTS: All procedures were completed laparoscopically. The operative time was variable depending on the complexity of the procedures, from 115 minutes for Fengerplasty to 315 minutes for partial nephrectomy under cold ischemia (mean 178 minutes). The estimated blood loss was 53.2 mL (range 20-120 ml), and none of the patients received a blood transfusion. Complete stone clearance was achieved in 93% of the procedures. The mean hospital stay was 10.5 days (range 5-35 days). Three patients needed temporary pigtail-catheter drainage for obstruction after pyelolithotomy. One patient with a solitary kidney and infected staghorn calculus had prolonged urinary leak, which stopped with conservative management. One nephrectomy for nephrocutaneous fistula was complicated by a late colonic perforation necessitating colostomy. CONCLUSION: Laparoscopic surgery is effective for complex renal stones and allows for adjunctive procedures. It can also be an alternative to percutaneous nephrolithotomy. It complements other minimally invasive procedures, and a need for open stone surgery should be rare in the future.
Adolescent↗
Detection of early lymph node metastases in prostate cancer by laparoscopic radioisotope guided sentinel lymph node dissection.
PURPOSE: Radioisotope guided sentinel lymph node (SLN) dissection (SLND) for prostate cancer has been shown to increase the sensitivity of detecting early metastases in open pelvic lymph node dissection. We developed a technique that allows SLND to be performed by laparoscopy in conjunction with laparoscopic radical prostatectomy. MATERIALS AND METHODS: In 71 consecutive patients SLND was performed by 1 surgeon preceding laparoscopic radical prostatectomy. Mean preoperative prostate specific antigen was 8.88 ng/ml (range 2.1 to 25.4). At 24 hours prior to surgery 3 ml (200 MBq) Tc labeled human albumin colloid were injected into the prostate gland under transrectal ultrasound guidance. An especially designed laparoscopic gamma probe was used to measure radioactivity during surgery. SLNs were identified and removed. If frozen section analysis showed metastases, extended pelvic lymph node dissection was performed. RESULTS: Radioactivity was detected on 2, 1 and no sides in 50 (70.4%), 19 (26.7%) and 2 patients (2.8%), respectively. In 81 of the 142 pelvic side walls (54.7%) SLNs were exclusively outside of the obturator fossa. Histopathological examination showed metastases to SLNs in 9 patients (12.9%). Eight of the 11 detected metastases (72.7%) were outside of the obturator fossa. Lymph node metastases were exclusively found in Tc marked lymph nodes. Mean tumor size was 1.7 mm (range 0.2 to 3.9). CONCLUSIONS: SLND is feasible by laparoscopy. It detects micrometastases outside of the obturator fossa in a significant number of patients. We noted that the transperitoneal approach allowing wide exposure and a gamma probe with a 90-degree lateral energy window is the most important factor to enable successful laparoscopic SLND.
Aged↗
Pelvic lymph node dissection in prostate cancer: editorial review.
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Humans↗
Laparoscopic partial nephrectomy.
PURPOSE OF REVIEW: This review defines the current role, indications, contraindications, advances, complications, and outcomes of laparoscopic partial nephrectomy in the management of renal tumors. RECENT FINDINGS: Recent publications have widened the scope for the application of this technology. The new advances in the management of renal tumors and the tools for tumor excision, renal parenchymal reconstruction, hemostasis, renal vascular control to establish renal ischemia, and the ability to avoid positive surgical margins have made the procedure safe and feasible in the hands of an experienced laparoscopist. SUMMARY: The trend toward nephron-sparing surgery has become stronger even in the presence of normal contralateral functioning kidney. Data on oncologic efficacy are promising, and partial nephrectomy is becoming a standard therapy for renal tumors less than 4 cm in size in many centers. Laparoscopic partial nephrectomy has evolved significantly during the past 10 years in our experience as well as that of others. It cannot be considered as a standard yet, but it is being performed in rapidly increasing numbers with good surgical efficiency and oncologic efficacy parallel to that of open surgery.
Hemostasis, Surgical↗
Laparoscopic approaches in urology.
The use of laparoscopy was one of the most important steps in the progress of medicine, and has developed through the 20th century. Gynaecologists took the initial lead in introducing this technology, followed by general surgeons. Since the first laparoscopic nephrectomy in 1990, most ablative and reconstructive urological surgery has been attempted laparoscopically. Laparoscopic urological surgical approaches include conventional transperitoneal and extraperitoneal; in this review the different approaches, with the relevant anatomical considerations, are discussed.
Humans↗
Hematuria due to an intrapelvically intruding total hip replacement.
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Aged, 80 and over↗
Long-term results of laparoscopic retroperitoneal lymph node dissection: a single-center 10-year experience.
OBJECTIVES: To evaluate the feasibility, morbidity, and long-term oncologic efficacy of laparoscopic retroperitoneal lymph node dissection (L-RPLND) in patients with nonseminomatous germ cell tumor (NSGCT). METHODS: L-RPLND was performed 188 times in 185 patients; 114 procedures were performed for Stage I NSGCT and 6 procedures for tumor marker-negative clinical Stage IIA disease. In the case of positive lymph nodes, adjuvant cisplatin-based chemotherapy was administered. After chemotherapy, L-RPLND was performed for retroperitoneal Stage IIA (10 patients), IIB (43 patients), and IIC lesions (15 patients). RESULTS: The mean operative time was 256 minutes for Stage I and 243 minutes for Stage II; the conversion rate was 2.6%. The mean blood loss was 159 mL in patients with Stage I and 78 mL in those with Stage II disease. Active tumor was found in 19.5% of patients with Stage I lesions and in 50% of patients with tumor marker-negative clinical Stage IIA disease. After chemotherapy, active tumor was found in 1 patient with Stage IIC disease and mature teratoma in 38.2% of patients. The mean postoperative hospital stay for those with Stage I and II disease was 4.1 and 3.7 days, respectively. Antegrade ejaculation was preserved in 98.4% of patients. The mean follow-up was 53.7 months for those with Stage I and 57.6 months for those with Stage II disease. All but 6 patients have remained free of relapse, and no patient died of tumor progression. CONCLUSIONS: The rate of tumor control after L-RPLND and the diagnostic accuracy of L-RPLND were equal to the open procedure, and the morbidity was significantly lower. Therefore, L-RPLND for Stage I and low-volume retroperitoneal Stage II disease can be performed at centers with experience in urologic laparoscopy and oncology.
Combined Modality Therapy↗
Prospective, randomized controlled study: transperitoneal laparoscopic versus retroperitoneoscopic radical nephrectomy.
OBJECTIVES: To evaluate the transperitoneal and retroperitoneal approaches for endoscopic radical nephrectomy in a prospective randomized manner to assess the possible differences in the outcome related to patients' morbidity and technical difficulty for the surgeon. METHODS: A total of 40 patients with Stage cT1-T2 were randomized into two equal groups: laparoscopic radical nephrectomy (LRN) and retroperitoneoscopic radical nephrectomy (RRN). The patient demographics and tumor characteristics were comparable. Two surgeons with differing experience performed an equal number of procedures in both treatment arms. The outcome was compared, and the technical difficulty for the surgeon and assistant was assessed with the European scoring system. RESULTS: All procedures were completed without a need for conversion. No statistically significant differences were found between the two approaches in terms of the number and size of the trocars used, length of incision, specimen weight, pathologic stage, operative time, need for additional procedures such as adrenalectomy and/or lymph node sampling, estimated blood loss, need for blood transfusions, analgesic requirement, length of hospital stay, or the incidence of minor or major complications. All patients in the LRN group resumed oral intake on postoperative day 1, but only 75% did so in the RRN group. The technical difficulty score for either the surgeon or the assistant did not differ significantly between the two groups. Both approaches allowed complete tumor excision. The robotic assistance system (AESOP) was more difficult with RRN compared with LRN. CONCLUSIONS: This first prospective randomized study comparing LRN and RRN did not find any real difference between the two approaches in relation to patient morbidity or the technical difficulty for the surgeon.
Adult↗
Laparoscopic partial adrenalectomy for recurrent pheochromocytoma in a boy with Von Hippel-Lindau disease.
We describe a case of a boy with Von Hippel-Lindau disease who presented with recurrent right adrenal pheochromocytoma 4.5 years after laparoscopic bilateral partial adrenalectomy. The boy had a second laparoscopic adrenal-sparing removal of the tumor. By this technique, not only the recurrent tumor was successfully removed but also the unaffected adrenal cortex could be preserved for the second time. To our knowledge, this is the first published case of its type.
Adrenal Gland Neoplasms↗