Carcinomatosis peritoneal tras nefrectomía parcial laparoscópica en carcinoma de células renales: nuestra experiencia y revisión de la literatura

ObjectivePeritoneal carcinomatosis associated with renal cell carcinoma is an infrequent entity, usually associated with large renal masses, and with a very rare presentation after surgery of localized renal tumors. Our objective is to review the literature and analyze the factors involved in the development of peritoneal carcinomatosis after laparoscopic partial nephrectomy in localized tumors.Material and methodsWe present our experience with two cases of peritoneal carcinomatosis after laparoscopic partial nephrectomy. We reviewed the literature and analyzed the factors associated with the development of peritoneal carcinomatosis after laparoscopic partial surgery in renal cell carcinoma.ResultsBetween 2005-2018, 225 patients underwent laparoscopic partial nephrectomy for localized renal neoplasia in our service. Two patients developed peritoneal carcinomatosis during follow-up, at 1.5 and 7 years after surgery. Few cases of postoperative peritoneal carcinomatosis for renal neoplasia have been described in the literature, being more frequently associated with large renal masses, with multiple metastases at diagnosis, with a poor prognosis. The dissemination of tumor cells during surgery, direct tumor extension or metastasis by hematogenous route, are among the factors involved in the development of this condition.ConclusionsPeritoneal carcinomatosis after laparoscopic partial nephrectomy constitutes a very rare event. However, it should be taken into consideration, and, since it is the only factor we can influence, we must maximize precautions during the surgical act, following oncological principles.     

Adenomectomía laparoscópica: 10 años de experiencia

Introduction

Lower urinary tract symptoms secondary to increased prostate volume are associated with ageing and are becoming more prevalent due to increased life expectancy. We present our experience with transperitoneal laparoscopic adenomectomy for the management of bladder outlet obstruction caused by benign prostatic enlargement.

Estudio comparativo de la extracción de la pieza de nefrectomía laparoscópica mediante una incisión de tipo Pfannenstiel

ObjectivesThe aim of our study is to demonstrate that the Pfannenstiel incision is a reliable option in terms of postoperative complications compared to other types of incisions usually performed for kidney extraction after laparoscopic nephrectomy.Materials and methodsRetrospective and comparative study of 256 patients who underwent laparoscopic nephrectomy or nephroureterectomy. Patients were divided into two groups: specimen extraction by Pfannenstiel incision (group 1) and specimen extraction by way of other incisions (group 2). Incisional hernia, surgical site infection, pain score, seroma, haematoma/bleeding, wound dehiscence and muscle paralysis were analyzed in each patient.ResultsPatients in Pfannenstiel group presented a rate of wound complications of 11.72% vs 27.34% with other incisions, p = 0.002, it was significantly inferior the rate of wound dehiscence (5.5% vs 12.5%, p = 0.047) and seroma (3.1% vs 7.8%, p = 0.022). Using multivariate logistic regression, Pfannenstiel incision was a significant protective predictor factor for wound complications (OR = 0.34, p = 0.005).ConclusionsThe Pfannenstiel incision allowed the extraction of bigger kidney masses with less incidence of dehiscence, seroma and in general wound complications. The hospital stay was lower in Pfannenstiel extraction group. These results present this incision as a reliable and safe option in the decision of which incision to select.     

Nefrectomía parcial laparoscópica: estudio comparativo entre la vía transperitoneal y la vía retroperitoneal

Introduction

Laparoscopic partial nephrectomy is the recommended treatment for tumours smaller than 4 cm in cases where it is feasible. Depending on the location of the tumour, the transabdominal or direct retroperitoneal pathway may be considered.

Nefrectomía parcial laparoscópica off-clamp tras la embolización del tumor en sala híbrida frente a nefrectomía parcial convencional: un análisis de pares emparejados por puntuación de propensión

ObjectiveOff-clamp laparoscopic partial nephrectomy in a hybrid operating room after superselective arterial embolization (hLPN) is a promising minimally invasive approach. In this study, we compared the perioperative surgical outcomes of this innovative technique with the conventional standard of care laparoscopic partial nephrectomy (cLPN) technique.Patients and methodsOverall, 86 and 127 patients treated with hLPN and cLPN, respectively, were included. These two techniques were compared in terms of surgical complications, estimated blood loss (EBL), operative time, length of stay (LOS), surgical margins, and Trifecta achievement rate (defined as warm ischemia duration < 25 min, negative surgical margins and absence of complications). A propensity score based on age, gender, BMI, preoperative eGFR and tumor size was used for a 1:1 matching of patients of each group. After matching, two groups of 67 patients with similar characteristics were obtained.ResultsConversion rate to open surgery, complications and EBL were similar in both groups. Conversely, operative time, LOS and Trifecta rates favored hLPN. The multivariate analysis showed that hLPN had a 70% higher chance of Trifecta achievement than cLPN in all age groups and for all tumor size across the study population.ConclusionCompared to a conventional approach, off-clamp laparoscopic partial nephrectomy in a hybrid room after superselective arterial embolization showed satisfying immediate surgical outcomes and reached a higher rate of Trifecta achievement. Mid and long-term functional and oncological results are needed to establish this minimally invasive surgical alternative.     

Desarrollo y validación de una herramienta de entrenamiento y evaluación para la nefrectomía radical laparoscópica

Introduction

Laparoscopic radical nephrectomy(LRN) is a cornerstone in managing renal cancer and small renal masses. Twenty-first century surgical training faces challenges, thus must be efficient and safe so surgeons attain relevant skills, protecting patients and operative outcomes. This study aimed to systematically develop a tool for training and assessment in LRN and validate the developed tool for use by trainee urologists.

Donante vivo renal. experiencia de cirugía abierta y laparoscópica. hospital la paz

Laparoscopic live donor nephrectomy is a rare operation in our country because the complexity of the technique and the expansion of the cadaveric donor. We present our open and laparoscopic live donor nephrectomy from 1984.Material and MethodsFrom 1984 to 2007 we have done 84 live donor nephrectomies; 64 open, 20 laparoscopic surgeries. The transperitoneal approach is preferred in laparoscopy and lumbotomy for the open surgery.ResultsIn the open technique the operating time is 112min (70-155), ischaemia time 20 seconds (15-47) and postoperative hospital stay 4,8 days (3-9). Laparoscopic cases, the operating time is 146 min (90-210), ischaemia time 3 min 15 sec (2-3,25 min) and postoperative hospital stay 3,4 days (2-9).ConclusionsThe laparoscopic live donor nephrectomy is a difficult and demanding technique. It should be done by experienced team in laparoscopic renal surgery. The kidney from a live donor is a very good alternative for the cronic renal failure. It should be offered in our main hospitals.     

Nefrectomía parcial laparoscópica previa embolización supraselectiva como tratamiento de angiomiolipomas renales gigantes

Objective

Cases of giant renal angiomyolipoma (> 9 cm) are a therapeutic challenge due to their low frequency and large size. The treatment objective for patients with renal angiomyolipoma should be complete tumour extirpation, with a nephron-sparing surgical technique, without complications and using a minimally invasive approach.

Luces y sombras de la duodenopancreatectomía cefálica laparoscópica

IntroductionLaparoscopic pancreaticoduodenectomy (PD) is not widely accepted, and its use is controversial. Only correct patient selection and appropriate training of groups experienced in pancreatic surgery and laparoscopy will be able to establish its role and its hypothetical advantagesMethodsOut of 138 pancreatic surgeries performed in a two-year period (2017-2019), 23 were laparoscopic PD. We evaluate its efficacy and safety compared to 31 open PD.ResultsThere were no cases of B/C pancreatic or biliary fistula, nor any cases of delayed gastric emptying in the laparoscopic group, but hemorrhage required one reoperation. The conversion rate was 21% (five cases): one due to bleeding, and the remainder for non-progression. The converted patients showed no differences compared to those completed by laparoscopy. There were no differences between laparoscopic and open PD in surgical time, postoperative complications, reintervention rate, readmissions or mortality. R0 resection in tumor cases was 85% for laparoscopy and 69% in open surgery without statistical significance. The postoperative hospital stay was shorter in the laparoscopic PD group (eight vs. 15 days).ConclusionsIn a selected group, laparoscopic PD can be safely and effectively performed if carried out by groups who are experts in pancreatic surgery and advanced laparoscopy. The technique has the same postoperative results as open surgery and is oncologically adequate, with less hospital stay. Proper patient selection, a step-by-step program and a lax and early conversion prevents serious operating accidents.     

Experiencia y resultados en la suprarrenalectomía laparoscópica transperitoneal

IntroductionLaparoscopic adrenalectomy is currently the gold standard in surgical management of adrenal pathology.ObjectivesTo analyze our results after 12 years of experience in this surgery and to compare with the main published series.Material & methodswe describe retrospectively 100 adrenalectomies performed between 1997–2009. Analized variables: age, size, side, preoperative diagnosis, operative time, blood loss, reconversion, hospital stay and histopathologic report. We utilized Fisher test and chi square test to compare categoric data. We utilized t-Student test to compare means from independents groups with normal distribution. We considered statistical significance when p<0.05.Resultsmean age was 53,1 years (±14,4). Mean size was 3,7 cm (±2,2). In 51% of cases it was the left side. Mean follow-up was 15 months (±11,9). Preoperative diagnosis was: functional mass (44%), pheocromocytome (17%), incedentaloma >4 cm (20%), metastasis (10%) and adrenal carcinoma (5%). Mean operative time was 145,1 min (±55,6). Mean hematocrite loss was 6,26 points (±3,3). Reconversion rate was 9,6%. 2 cases of prolonged postoperative ileus. 2 patients required transfusion. 1 patient death because of an descompensation of liver cirrhosis. 80% of complications were on right side. Mean hospital stay was 6 days (±5,6). In last 30 procedures we realized statistical differences with first group, in terms of operative time (119,1 min vs 171,2 min) and hospital stay (4,1 days vs 6,1) (p<0,05).ConclusionsTransperitoneal laparoscopic adrenalectomy is a surgical feasible and safe procedure in urological groups with previous laparoscopic experience. Our results are similar with the published series and confirm the efficacy, security and reproducibility of this technique.     

Límites de la cirugía laparoscópica en el tratamiento del tumor renal

Laparoscopic radical nephrectomy is considered to be the technique of choice in the mangement of stage T1 and T2 renal cancer, though increased mastery of this alternative type of surgery has served to expand its indications. In any case, these procedures have a series of limitations which are tied to the intrinsic characteristics of laparoscopic surgery, and which are associated with the patient and tumor characteristics, and the experience of the surgeon. The present study discusses the different indications and establishes the current limits of laparoscopic surgery applied to the management of renal tumors. Its role in cell-reducing therapy in metastatic disease, and the methods available for reducing tumor implantation in the surgical ports are also commented.     

Comparación entre prostatectomía laparoscópica y abierta: análisis de la continencia urinaria poscirugía

IntroductionThere are very few articles comparing open radical prostatectomy (ORP) vs. laparoscopic radical prostatectomy (LRP) and their functional results or urinary continence (UC), which is one of the most important objectives to pursue after oncological results.ObjectivesTo compare postoperative UC in patients with localized prostatic adenocarcinoma treated with OPR or LRP.Material and methodsComparison between two patient cohorts (312 for ORP and 206 for LRP) between 2007-2015. The UC was evaluated at 3, 6, 12, 18 and 24 months. Continence was defined and classified as follows: a) UC, no need of pads, and b) urinary incontinence (UI), use of pads.To compare the qualitative variables, we employed the chi-squared test and ANOVA for quantitative variables. We performed a multivariate analysis using logistic regression with dependent qualitative variable UI. Statistical significance when P < .05.ResultsNerve-sparing was performed in 51.7% cases. At 24 months after surgery, 72.4% patients had UC, of which 87.7% were from the ORP group and 78.1% in the LRP group (P = .004). 22,7% of patients experienced biochemical recurrence (BR), with 83% treated with salvage radiotherapy (SRT), presenting greater UI percentage (P = .036). ORP patients showed a higher percentage of anastomosis stricture (P = .03).ConclusionsLRP, non-nerve sparing, and SRT were directly related to postoperative UI.     

Revisión sistemática del tratamiento activo de la fístula urinaria después de la nefrectomía parcial

IntroductionUrinary fistula is expected to become more frequent in urological practice as a result of expanding indication of partial nephrectomy given it?s oncological results equivalent to those of radical nephrectomy but at a lower risk of progression to chronic kidney disease, lower cardiovascular morbidity, and overall mortality.ObjectivesReview and compare different techniques of contemporary active management for urinary fistula after partial nephrectomy.MethodsA systematic literature search on the MEDLINE database was conducted in March 2020, combining the terms: «urine leak», «urine leakage», «urinary leak» and «urinary fistula», with: «partial nephrectomy», «nephron sparing surgery» and «renal sparing surgery». The review of the literature was performed accordingto the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Only articles related to active treatment were eligible. Abstracts in English and Spanish from the last two decades were screened. No restriction based on study design nor the length of follow-up. Primary outcomes: 1) Leak resolution rate 2) Time course of leak resolution and 3) Number of interventions needed for resolution.ResultsMultiple studies were found. There were no randomized controlled trials. Urinary fistula can be solved in many ways with active treatment, with a high success rate (97.5%), an average of 1.4 intervention-per-patients and a mean time for leak resolution of 11 days (median of 3 days).ConclusionThere is a high risk of bias due to the study's methodology. There is a broad range of effective alternatives and various approaches to solve urinary fistula in an appropriate timing.     

Evolución de la función renal en pacientes con cáncer renal cT1 después de nefrectomía parcial y radical laparoscópica. Factores predictores de deterioro de función renal

Introduction and objectivesTo analyze the evolution of kidney function after laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) and to identify predictive factors for deterioration in kidney function.Material and methodRetrospective study of patients with two kidneys, glomerular filtration rate (GFR) > 60 mL/min/1.73 m², and single renal tumor cT1, treated in our center between 2005 and 2018.ResultsA total of 372 patients met the inclusion criteria for the study; 156 (41.9%) were treated by RN and 216 (58.1%) by PN. There was a difference of 26.75 mL/min/1.73 m² in GFR between RN and PN at discharge. Age > 60 years, postoperative complications (OR 2.97, p = 0.005) and RN (OR 10.03, p = 0.0001) were predictors of GFR<60 mL/min/1.73 m² at discharge. Only RN (OR 7.69, p = 0.0001) behaved as an independent prognostic factor for GFR<45 mL/min/1.73m2 at discharge. The median follow-up of the series was 57 (IQR 28-100) months. At the end of the follow-up period, nine (6%) patients treated with RN developed severe chronic kidney disease (CKD) and three (2%) developed end stage renal disease (ESRD). Age > 70 years, diabetes mellitus (DM) (HR 2.12, p = 0.001), arterial hypertension (AHT) (HR 1.73, p = 0.01) and RN (HR 2.88, p = 0.0001) behaved as independent predictors of GFR<60 mL/min/1.73 m². The independent predictors for GFR< 45 mL/min/1.73m2 were age >70 years, DM (HR 1.99 CI 95% 1.04-3.83, p = 0.04) and RN (HR 5.88 CI 95% 2.57-13.45, p = 0.0001).ConclusionsRN is a short- and long-term risk factor for CKD, although with a low probability of severe CKD or ESRD in patients with preoperative GFR > 60 mL/min/1.73 m². Age, DM and AHT contribute to worsening renal function during follow-up.     

Simulación sanitaria durante la COVID-19: una experiencia con los residentes de Anestesiología

BackgroundThe restrictions to stop COVID-19 pandemic have had a negative impact in simulation. However, it is imperative to develop new strategies that facilitate healthcare education.ObjectiveTo describe a simulation in healthcare based on the learning of non-technical skills and performed under the restrictions of COVID-19 pandemic.MethodsQuasi-experimental study of an educational activity performed through simulation with Anaesthesiology residents in November 2020. Twelve residents participated in 2 consecutive days. A questionnaire was filled related to the performance of non-technical skills that encompasses leadership, teamwork and decision making. The complexity of the scenarios and the non-technical skills results obtained between the 2 days were analysed. Advantages and challenges were documented when a clinical simulation is performed under COVID-19 restrictions.ResultsThe global performance of the teams improved when comparing first and second day (79.5 vs. 88.6%, P < .01). Leadership was the worst section rated, however, was the one that showed the best improvement (70 vs. 87.5%, P < .01). The complexity of the simulation cases had no relation with the group performance in leadership and teamwork but affected task management results. General satisfaction was over 75%. The main challenges to develop the activity were the technology required to adapt virtuality to simulation and the time spent for the preparation of it. No cases of COVID-19 were reported within the first month after the activity.ConclusionClinical simulation can be done in the context of COVID-19 pandemic, obtaining satisfactory learning results but requiring the adaptation of institutions to the new challenges it implies.     

¿Existe alguna indicación de colocación de drenaje en la colecistectomía laparoscópica electiva?

IntroductionClassically, a sub-hepatic drain was inserted routinely in a cholecystectomy to prevent intra-abdominal abscesses, possible post-surgical bleeding, and biliary fistulas. Over the years, it has been demonstrated that the systematic use of a drain does not have any benefits, and many studies conclude that, in special circumstances (bleeding, signs of gallbladder inflammation, incidental opening, or suspected bile leak), and depending on the experience of the individual surgeon, the insertion of a drain may be of use.Material y methodsA prospective study was conducted on 100 elective laparoscopic cholecystectomies performed due to symptomatic cholelithiasis or gallbladder polyps. A sub-hepatic drain was inserted in 15 of them. The indications for inserting it were: in 11 patients as a “control” due to a gallbladder bed bleed controlled during surgery, and in 4 due to a gallbladder opening with the excretion of turbid-purulent bile. The main outcomes investigated were the clinical benefit achieved by the insertion of the drain, the hospital stay, and the quantifying of the pain by the patients 24 h after surgery, using a visual analogue scale.ResultsThe insertion of a drain was of no benefit to any patient. The median hospital stay increased by 1 day in patients with a drain (P=.002). The median pain score at 24 h was higher in patients with a drain inserted (P=.018).ConclusionThe insertion of a sub-hepatic drain after elective laparoscopic cholecystectomy increases post-surgical pain and prolongs hospital stay, and does not prevent the occurrence of intra-abdominal abscesses.