Videolaparoscopic Radical Hysterectomy Approach: a Ten-Year Experience

Background:

Because of the advancements in surgical techniques and laparoscopic instruments, total laparoscopic radical hysterectomy can now be performed for the treatment of uterine cervical carcinoma. We assessed the feasibility, complications, and survival rates of patients who underwent total laparoscopic radical hysterectomy with pelvic lymphadenectomy.

Methods:

We retrospectively collected data from the medical charts of 29 patients who had undergone surgery between 1998 and 2008. The following data were assessed: age, staging, histological type, number of lymph nodes retrieved, parametrial measures, operative time, length of hospital stay, surgical complications, and disease-free time.

Results:

The mean patient age was 37.07±10.45 years. Forty percent of the patients had previously undergone abdominal or pelvic surgeries. Mean operative time was 228.96±60.41 minutes, and mean retrieved lymph nodes was 16.9±8.12. All patients had free margins. No conversions to laparotomy were necessary. Median time until hospital dismissal was 6.5 days (range 3–38 days). Four patients had intraoperative complications: 2 lacerations of the rectum, 1 laceration of the bladder, and 1 lesion of the ureter. Three patients developed bladder or ureteral fistulas postoperatively that were successfully corrected surgically.

Conclusion:

Laparoscopic radical hysterectomy is feasible and has acceptable complications. The radicalism of the surgery must be considered, bearing in mind the parametrial measures and the number of lymph nodes retrieved.     

Laparoscopic Radical Hysterectomy after Preoperative Brachytherapy for Stage IB1 Cervical Cancer: Feasibility, Results, and Surgical Implications in a Large Bicentric Study of 162 Consecutive Cases

Purpose

To examine the feasibility and to report the results of laparoscopic radical hysterectomy (LRH) after initial uterovaginal brachytherapy (BT) for stage IB1 cervical cancer.

Methods

We retrospectively reviewed patients at 2 comprehensive cancer centers who underwent initial BT followed 6–8 weeks later by LRH and lymph node dissection.

Results

Between 2003 and 2010, a total of 162 patients underwent LRH. The procedure was feasible via this approach in 160 cases (98.8 %) (2 conversions to laparotomy). Eight perioperative complications occurred. Nineteen patients had nodal involvement. Peri- or postoperative ureteral morbidity occurred in 10 patients (6 %). Twenty-four patients (15 %) experienced postoperative dysuria. Histologically, only 9 patients had residual cervical disease ≥5 mm, and only 1 patient had parametrial lymphovascular space involvement (associated with nodal spread). No patient had vaginal disease or involved surgical margins. After a median follow-up of 39 (range 3–118) months, 9 patients experienced relapse. Five-year overall survival was 95 % (range 88.2–97.9 %).

Conclusions

Radical hysterectomy using a laparoscopic approach is feasible and reproducible after initial BT for stage IB1 cervical cancer and is associated with excellent survival. Morbidity is close to that reported in patients treated with up-front surgery. In this large series, the morbidity associated with parametrial dissection and the fact that parametrial spread was observed in only 0.6 % of the patients suggest that a simple extrafascial hysterectomy is perhaps sufficient in this context; the rate of urinary tract morbidity would then be reduced.     

Completion Surgery After Concomitant Chemoradiation in Locally Advanced Cervical Cancer: A Comprehensive Analysis of Pattern of Postoperative Complications

Background

We provided a comprehensive analysis of rate, pattern, and severity of early and late postoperative complications in a very large, single-institution series of locally advanced cervical cancer (LACC) patients administered CT/RT plus radical surgery (RS).

Methods

A total of 362 consecutive LACC (FIGO stage IB2-IVA) patients were submitted to RS after CT/RT at the Gynecologic Oncology Unit of the Catholic University (Rome/Campobasso). At 4 weeks after CT/RT, patients were evaluated for objective response and triaged to radical hysterectomy and pelvic ± aortic lymphadenectomy. Surgical morbidity was classified according to the Chassagne’s grading system.

Results

Most cases underwent type III–IV radical hysterectomy (N = 313, 86.5 %); pelvic lymphadenectomy was performed in all patients, while 116 patients (32.1 %) were also submitted to aortic lymphadenectomy. A total of 93 patients (25.7 %) experienced any grade postoperative complications, and 60 (16.6 %) had ≥grade 2 complications; grade 3–4 complications occurred in 21 patients (5.8 %). Of all early postoperative complications (N = 100), 31 (31.0 %) were urinary, 9 (9.0 %) were gastrointestinal, and 45 (45.0 %) were vascular. Of all late complications (N = 31), 20 (64.5 %) were urinary, 7 (22.6 %) gastrointestinal, and 2 (6.4 %) were vascular. Multivariate analysis showed that not complete clinical response to treatment retained an independent, unfavorable association with risk of development of postoperative morbidity, while advanced stage, and aortic lymphadenectomy showed only a borderline value.

Conclusions

Failure to achieve clinical complete response to treatment and, to a lesser extent, more advanced stage, and aortic lymphadenectomy, were associated with a higher risk of developing any grade as well as ≥grade 2 complications.     

Ureterovaginal fistula: a case series

Introduction and hypothesis

We describe the presentation, diagnosis, and management of ureterovaginal fistula over a 7-year period at a tertiary care center.

Methods

A retrospective review of ureterovaginal fistula cases between 2003 and 2011 was performed. Demographic information, antecedent event, symptoms, diagnostic modalities, and management strategies were reviewed.

Results

Nineteen ureterovaginal fistulas were identified during the 7-year study period. One fistula followed a repeat cesarean section and 18 fistulas followed a hysterectomy (9 total abdominal, 6 total laparoscopic, 3 vaginal hysterectomies). Ureteral injuries were not recognized in any of the patients at the time of index surgery. Computed tomography (CT) urography was the most commonly utilized diagnostic modality (58 %). Primary non-surgical management with ureteral stents was attempted and successful in 5 out of 7 cases (71 %). There were 14 total surgical repairs, including 2 cases in which stents were successfully placed, but the fistula persisted, and 6 additional cases where attempted stent placement failed. Surgical repair consisted of 10 ureteroneocystostomies performed via laparotomy and 4 performed laparoscopically, 3 of which were robotically assisted.

Conclusions

Despite being uncommon, ureterovaginal fistula should remain in the differential diagnosis of new post-operative urinary incontinence after gynecological surgery. Conservative management with ureteral stent appears to be the best initial approach in selected patients, with a success rate of 71 %. Minimally invasive approaches to performing ureteroneocystostomy have high success rates, comparable to those of open surgical repair.     

Laparoscopic Ureteroneocystostomy for Ureteral Injuries After Hysterectomy

Objectives:

To examine the feasibility of early laparoscopic ureteroneocystostomy for ureteral obstruction due to hysterectomy injury.

Methods:

We retrospectively reviewed a 10-y experience from 2 institutions in patients who underwent early (<30 d) or late (>30 d) laparoscopic ureteroneocystostomy for ureteral injury after hysterectomy. Evaluation of the surgery included the cause of the stricture and intraoperative and postoperative outcomes.

Results:

A total of 9 patients with distal ureteral injury after hysterectomy were identified. All injuries were identified and treated as early as 21 d after hysterectomy. Seven of 9 patients underwent open hysterectomy, and the remaining patients had vaginal and laparoscopic radical hysterectomy. All ureteroneocystostomy cases were managed laparoscopically without conversion to open surgery and without any intraoperative complications. The Lich-Gregoir reimplantation technique was applied in all patients, and 2 patients required a psoas hitch. The mean operative time was 206.6 min (range, 120–280 min), the mean estimated blood loss was 122.2 cc (range, 25–350 cc), and the mean admission time was 3.3 d (range, 1–7 d). Cystography showed no urine leak when the ureteral stent was removed at 4 to 6 wk after the procedure. Ureteroneocystostomy patency was followed up with cystography at 6 mo and at least 10 y after ureteroneocystostomy.

Conclusion:

Early laparoscopic ureteral reimplantation may offer an alternative surgical approach to open surgery for the management of distal ureteral injuries, with favorable cosmetic results and recovery time from ureteral obstruction due to hysterectomy injury.     

Robotic-Assisted Repair of Iatrogenic Ureteral Ligation Following Robotic-Assisted Hysterectomy

Background and Objectives:

Ureteral injuries, while rare, do occur during gynecologic procedures. The expansion of laparoscopic and robotic pelvic surgical procedures increases the risk of ureteral injury from these procedures and suggests a role for minimally invasive approaches to the delayed repair of ureteral injuries. We present, to our knowledge, the first case of delayed robotic-assisted ureteral deligation and ureterolysis following iatrogenic ureteral injury occurring during a robotic abdominal hysterectomy.

Methods:

We present a case report and review of the literature.

Results:

A 57-year-old female underwent a seemingly uncomplicated robotic-assisted laparoscopic total abdominal hysterectomy and bilateral oophorectomy for symptomatic fibroids. On postoperative day 8, she presented with persistent right flank pain. Imaging studies revealed high-grade ureteral obstruction consistent with suture ligation of the right ureter. She underwent successful robotic-assisted ureteral deligation and ureterolysis. Her postoperative course was unremarkable, and she was discharged home on postoperative day 1 from the deligation.

Conclusion:

Robotic-assisted management of complications from urologic or gynecologic surgery is technically feasible. This can potentially preserve the advantages to the patient that are being seen from the initial less-invasive surgery.     

Die Duplex-Doppel-J-Schiene bei intrinsischen und extrinsischen Harnleiterengen

Background

Duplex or twin ureteral stenting has previously been described as a viable option for patients where single double-J ureteral stenting has failed in order to avoid nephrostomies or further surgical intervention. We assessed a series of 20 patients at our institution after unsuccessful primary single ureteral stenting where parallel ureteral stents were inserted.

Methods

Between 2003 and 2009, 20 patients underwent double-J ureteral stenting for ureteral compression or ureteral strictures. After failure of single stenting two ureteral stents were consecutively inserted into the ureter in a parallel fashion after dilating the ureter up to 14 F. The second stent was passed over a hydrophilic guidewire while holding the first stent secure to prevent dislocation.

Results

In all patients the insertion of two parallel stents was technically possible. In 8 of 12 patients with extrinsic tumor compression the stents provided sufficient drainage (67%). When the stricture was due to surgery or radiation two of three patients were successfully diverted with twin stents. In five patients with a ureteral stricture due to malignant disease the stenting did not provide sufficient drainage and a nephrostomy had to be placed after a mean duration of 19 days. Two of those patients were later managed with a pyelovesical bypass. Three patients were later managed with a ureterocystoneostomy (psoas hitch). In four of five patients with benign disease a long-term management was feasible. The patient with retroperitoneal fibrosis developed immediate hydronephrosis and severe flank pain and ultimately underwent an ileal ureter replacement. In three patients with a benign ureteral stenosis after stone therapy, hysterectomy, or colon ureter replacement, a temporary duplex stenting sufficiently resolved the hydronephrosis for spontaneous urine passage. In one patient the duplex stenting prevented a kidney stone from dislocating into the ureter during lithotripsy.

Conclusions

Duplex or twin (double) ureteral stenting is a valid option in selected patients to avoid the placement of a nephrostomy. Severe stenosis may however demand a nephrostomy insertion or more invasive procedures in the later course. For certain benign ureteral strictures a therapeutic dilating effect of the two ureteral stents that makes further intervention unnecessary can be discussed.     

Vaginal-assisted laparoscopic radical hysterectomy: rationale, technique, results

Objective:

Total laparoscopic radical hysterectomy (TLRH) makes it difficult to resect adequate vaginal cuff according to tumor size and to avoid tumor spread after opening the vagina. Laparoscopic-assisted radical vaginal hysterectomy (LARVH) is associated with higher risk for urologic complications.

Methods:

The vaginal-assisted laparoscopic radical hysterectomy (VALRH) technique comprises 3 steps: (1) comprehensive laparoscopic staging, (2) creation of a tumor-adapted vaginal cuff, and (3) laparoscopic transsection of parametria. We retrospectively analyzed data of 122 patients who underwent VALRH for early stage cervical cancer (n=110) or stage II endometrial cancer (n=12) between January 2007 and December 2009 at Charité University Berlin.

Results:

All patients underwent VALRH without conversion. Mean operating time was 300 minutes, and mean blood loss was 123cc. On average, 36 lymph nodes were harvested. Intra- and postoperative complication rates were 0% and 13.1%, respectively. Resection was in sound margins in all patients. After median follow-up of 19 months, disease-free survival and overall survival for all 110 cervical cancer patients was 94% and 98%, and for the subgroup of patients (n=90) with tumors ≤pT1b1 N0 V0 L0/1 R0, 97% and 98%, respectively.

Conclusion:

VALRH is a valid alternative to abdominal radical hysterectomy and LARVH in patients with early-stage cervical cancer and endometrial cancer stage II with minimal intraoperative complications and identical oncologic outcomes.     

Robotic radical nephrectomy for renal cell carcinoma: a systematic review

Background

The reporting of post-operative complications in the urological field is lacking of a uniform quantitative measure to assess severity, which is essential in the analysis of surgical outcomes. The purpose of this study was to evaluate the feasibility of estimating quantitative severity weighing of post-operative complications after common urologic procedures.

Methods

Using a large healthcare system’s quality database, complications were identified in eleven common urologic procedures (e.g., insertion or replacement of inflatable penile prosthesis, nephroureterectomy, partial nephrectomy, percutaneous nephrostomy tube placement, radical cystectomy, radical prostatectomy, renal/ureteral/bladder extracorporeal shockwave lithotripsy (ESWL), transurethral destruction of bladder lesion, transurethral prostatectomy, transurethral removal of ureteral obstruction, and ureteral catheterization) from January 1, 2011 to December 31, 2011. Complications were classified by the Expanded Accordion Severity Grading System, which was then quantified by validated severity weighting scores. The Postoperative Morbidity Index (PMI) for each procedure was calculated where an index of 0 would indicate no complication in any patient and an index of 1 would indicate that all patients died.

Results

This study included 654 procedures of which 148 (22%) had one or more complications. As would be expected, a more complex procedure like radical cystectomy possessed a higher PMI (0.267), while a simpler procedure like percutaneous nephrostomy tube placement possessed a lower PMI (0.011). The PMI of the additional nine procedures fell within the range of these PMIs. These PMIs could be used to compare surgeons, hospitals or procedures.

Conclusions

Quantitative severity weighing of post-operative complications for urologic procedures is feasible and may provide exceptionally informative data related to outcomes.     

Laparoscopic radical cystectomy: initial experience using the single-incision triangulated umbilical surgery (SITUS) technique

Introduction

As could be demonstrated for simple and radical nephrectomy, single-incision triangulated umbilical surgery (SITUS) is an interesting alternative to laparoscopic single-site surgery. We present our initial experience with the SITUS technique in radical cystectomy.

Materials and methods

Between September 2010 and September 2011, eight patients underwent SITUS radical cystectomy (SITUS Cx), pelvic lymph node dissection and extracorporeal urinary diversion. A cutaneous ureterostomy was performed in three, an ileum conduit in one and an ileal neobladder in four patients. Data were collected prospectively, including patients’ characteristics, intraoperative parameters, pathological stage and postoperative outcome.

Results

Mean age of the patients was 67?years and the mean body mass index 24?kg/m². SITUS Cx was successfully completed in all patients without conversion to conventional laparoscopic or open surgery. Mean surgical time was 434?min and mean estimated blood loss 643?ml. No major intra- or postoperative surgical complications occurred. All patients recovered quickly reporting low postoperative pain levels. Mean hospital stay was 16 (7–24?days). Histopathological evaluation revealed a mean of 16 (6–33) retrieved lymph nodes and no positive margins.

Conclusion

In the present experience, SITUS Cx proved to be feasible with surgical outcome comparable to conventional techniques. Because SITUS Cx combines the advantages of traditional laparoscopy (straight instruments and triangulation) with those of single-port surgery (superior cosmesis and minimal invasiveness), it presents an attractive alternative to other minimally invasive techniques.     

Short-Term Outcomes of Totally Laparoscopic Total Gastrectomy: Experience With the First Consecutive 112 Cases

Introduction

Although laparoscopic distal gastrectomy has become a viable treatment option for gastric cancer, laparoscopic total gastrectomy remains in limited use.

Purpose

The present study was designed to evaluate the short-term outcomes of totally laparoscopic total gastrectomy (TLTG).

Methods

The records of 112 consecutive patients who underwent TLTG for gastric cancer between September 2006 and November 2012 were reviewed, and surgical outcomes were retrospectively investigated.

Results

Neoadjuvant chemotherapy was given to 21 patients (18.8 %). The degree of lymphadenectomy was D1+ in 83 patients (74.1 %) and D2 in 29 (25.9 %). The operation time was 359 min, median intraoperative blood loss was 85 ml, and median total number of harvested lymph nodes was 64. Grade II or higher postoperative complications developed in 25 patients (22.3 %). On univariate analysis, pathologic stages IB to IV (versus stage IA) overlapped esophagojejunostomy (versus functional end-to-end esophagojejunostomy) and operation time >360 min (versus ≤360 min) were related to postoperative morbidity. In the multivariate analysis, operative time and pathologic stage were independent risk factors for postoperative complications.

Conclusions

TLTG is feasible and can be performed with acceptable postoperative morbidity. A longer operating time and more advanced pathologic stage were significantly associated with higher postoperative morbidity.     

Laparoscopic, minilaparoscopic and single-port hysterectomy: perioperative outcomes

Objective

This study was designed to compare perioperative outcomes and postoperative pain of standard laparoscopic (S-LPS), minilaparoscopic (M-LPS), and laparoendoscopic single-site (LESS) hysterectomy.

Methods

A single-institutional, matched, retrospective, cohort study was performed. Between May 2010 and March 2011, 85 consecutive women were submitted to a total laparoscopic hysterectomy by S-LPS, M-LPS, and single-port LESS. Perioperative outcomes of these three techniques were analyzed and compared.

Results

Demographics and baseline characteristics of each group were absolutely comparable. The median operative time was longer [105 (range, 75?C125) min] in the LESS group compared with the M-LPS group [90 (range, 60?C120) min; p?<?0.011] and S-LPS [80 (range, 50?C110) min; p?<?0.001]. No statistically significant differences have been reported for estimated blood loss or intra- and early postoperative complications. Postoperative pain control was better for LESS and M-LPS than S-LPS.

Conclusions

M-LPS and LESS hysterectomy can be performed safely, and both seem to be associated with a halving of early postoperative pain with a lower request of analgesics.     

Laparoscopic inguinal hernioplasty after radical prostatectomy: is it safe? Prospective clinical trial

Introduction

Despite inguinal hernia repair being one of the most common elective operations performed in general surgical practice, there are many controversies including indications for repair and selection of the surgical technique. In recent years, laparoscopic repair has gained wider acceptance because it is associated with fewer postoperative complications and less chronic pain when compared with conventional approaches with similar recurrence rate. However, patients with lower abdominal surgery are contraindicated for laparoscopic approach. There are few studies that evaluated whether patients who have been subjected to radical prostatectomy might be subjected to laparoscopic hernia repair with the same benefits as those without previous radical prostatectomy.

Methods

Between March 2010 and March 2013, 20 consecutive patients, who had been subjected to prior radical prostatectomy, underwent laparoscopic transabdominal inguinal repair and were followed prospectively. Surgical procedure was performed using a standard technique.

Results

Mean operative time was 67.5 min. There was only one (5 %) intraoperative minor complication, an injury to the inferior epigastric vessels, which was managed by clipping of the vessels. There were no major postoperative complications. After 24 h and on the seventh postoperative day, 85 and 90 % of patients had no pain or only complained of discomfort, respectively. Nine patients (45 %) did not need any analgesics postoperatively. The mean time to return to leisure activities and to work was 3.1 and 5.6 days, respectively. There was no conversion to open surgery. All patients were discharged within 24 h. After a mean follow-up of 14 months, none of the patients presented recurrence.

Conclusion

TAPP after prostatectomy is safe and effective. It seems that patients undergoing laparoscopic repair after radical prostatic resection have the same benefits as those without prostatectomy.     

Analysis of intraoperative difficulties and management of operative complications in revision anterior exposure of the lumbar spine: a report of 25 consecutive cases

Purpose

After a first anterior approach to the lumbar spine, formation of adhesions of soft tissues to the spine increases the surgical difficulties and potential for iatrogenic injury during the revision exposure. The objective of this study was to identify the intraoperative difficulties and postoperative complications associated with revision anterior lumbar spine procedures in a single institution.

Methods

This is a retrospective review of 25 consecutive anterior revision lumbar surgeries in 22 patients (7 men and 15 women) operated on between 1998 and 2011. Patients with trauma or malignancies were excluded. The mean age of the patients at the time of revision surgery was 56 years (range 20–80 years). The complications were analyzed depending on the operative level and the time between the index surgery and the revision.

Results

Six major complications (five intraoperatively and one postoperatively) occurred in five patients (20 %): three vein lacerations (12 %) and two ureteral injuries (8 %), despite the presence of a double-J ureteral stent. The three vein damages were repaired or ligated by a vascular surgeon. One of the two ureteral injuries led to a secondary nephrectomy after end-to-end anastomosis failure; the other necessitated secondary laparotomy for small bowel obstruction.

Conclusions

Anterior revision of the lumbar spine is technically challenging and is associated with a high rate of vascular or urologic complications. Therefore, the potential complications of the procedure must be weighted against its benefits. When iterative anterior lumbar approach is mandatory, exposure should be performed by an access surgeon in specialized centers that have ready access to vascular and urologic surgeons.     

Laparoscopic ureterocalicostomy for complicated upper urinary tract obstruction: mid-term follow-up

Purpose

To report on the largest series of laparoscopic ureterocalicostomies done for complicated upper urinary obstruction.

Methods

We retrospectively reviewed the data from 6 transperitoneal laparoscopic ureterocalicostomies performed in our institution from January 2008 to January 2012. Symptomatic complicated upper urinary obstruction was the main reason for all the procedures. The recorded data included age, gender, clinical presentation, duration of symptoms, laterality, mean operative time, hospital stay, complications and clinical and functional outcomes.

Results

The median patient age was 20.1 (2–44) years, and all patients were females. Patients underwent laparoscopic ureterocalicostomy due to previous failed procedures (3 patients), anatomic abnormalities (2 patients) and a severe upper ureteral stenosis (1 patient). The median operative time was 215 (180–270) min. There were no major complications. There were no conversions to open surgery. In a median follow-up of 30 (8–56) months, all patients presented with clinical and radiological improvement with no signs of obstruction. In all cases, the postoperative renal scintigraphy revealed a T1/2 lower than 10 min.

Conclusion

Laparoscopic ureterocalicostomy is feasible and associated with high success rate in well-selected cases with complicated upper urinary obstructions.     

Esophagogastric tube reconstruction with stapled pseudo-fornix in laparoscopic proximal gastrectomy: a novel technique proposed for Siewert type II tumors

Purpose

The incidence of adenocarcinoma of the esophagogastric junction is increasing, but laparoscopic proximal gastrectomy is not widely accepted due to the absence of a standardized technique of reconstruction. This report describes a novel technique of esophagogastric tube reconstruction in laparoscopic proximal gastrectomy for Siewert type II tumors.

Methods

Laparoscopic proximal gastrectomy, sometimes with transhiatal distal esophagectomy, was performed. After a perigastric, suprapancreatic, and lower thoracic paraesophageal lymphadenectomy, a gastric tube of 35-mm width was prepared. An esophagogastric tube anastomosis with pseudo-fornix was made with a no-knife linear stapler to prevent postoperative reflux esophagitis.

Results

Fifteen patients with Siewert type II tumors underwent this operation. They included six patients with early-stage cancer, six at high risk for transhiatal total gastrectomy due to several comorbidities, and three who needed palliative tumor resection. The mean operation time was 315 min. One postoperative anastomotic leak was treated conservatively, and three anastomotic stenoses were resolved with endoscopic balloon dilatation. Postoperative 1-year follow-up endoscopy revealed four cases of reflux esophagitis that were well controlled by medication.

Conclusions

This new technique of reconstruction was feasible. With the advantage of a gastric tube, a tension-free anastomosis was possible even for bulky tumors that needed lower esophagectomy. Although long-term follow-up and a larger number of patients are required to evaluate long-term functional outcomes and oncological adequacy, our procedure has the potential of becoming a treatment of choice for early-stage Siewert type II tumors and/or for some selected high-risk patients who need tumor resection.     

Radical resection of gallbladder cancer: could it be robotic?

Background

The only potentially curative option for patients with gallbladder cancer is radical resection. This is the first report that describes the successful application of a minimally invasive, robot-assisted radical resection, including lymphadenectomy, in five gallbladder cancer patients.

Methods

Medical records of patients who underwent radical resection of gallbladder cancer via the da Vinci robotic surgical system in the Hepato-Bilio-Pancreatic Surgical Department of the Shanghai Ruijin Hospital, China, between March 2010 and July 2011 were reviewed and analyzed.

Results

Robot-assisted radical resection was successful in all five patients. The mean number of excised lymph nodes was 9 (range?=?3–11), mean operative time was 200?min (range?=?120–300?min), mean intraoperative blood loss was 210?ml (range?=?50–400?ml), and mean length of hospital stay was 7.4?days (range?=?7–8?days). All patients were discharged with no reported complications. Mean postoperative follow-up was 11?months (range?=?1–17?months). One patient died due to tumor recurrence 10?months postsurgically, but there was no recurrence in the remaining four patients during the follow-up period.

Conclusions

Robot-assisted radical resection for gallbladder cancer is both feasible and safe. Compared to laparoscopic surgery, the robotic surgery system is better suited for subtle dissection in a narrow, deep space. This is advantageous for both the removal of lymph nodes near the pancreas and hepatoduodenal ligament and the skeletonization of the hepatoduodenal ligament, the hepatic artery, and the celiac axis. The long-term outcome and direct comparisons to laparotomy in a larger patient cohort are needed to provide more clinical data supporting the superiority of this approach.     

Feasibility of laparoscopic gastrectomy for advanced gastric cancer with positive peritoneal cytology

Purpose

The role of gastrectomy for patients with positive peritoneal cytology, but a negative macroscopic peritoneal implant (P?/cy+), remains unclear. The aim of this study was to evaluate laparoscopic gastrectomy for P?/cy+ patients.

Methods

This study reviewed a prospectively maintained gastric cancer database of gastric-cancer patients those underwent surgical resection. P?/cy+ gastric cancer that had invaded the subserosa, or deeper layers, of the stomach wall without distant organ metastases was considered operable in this institution. P?/cy+ patients underwent either open or laparoscopic gastrectomy with D2 lymphadenectomy. The short-term results were examined to assess differences in outcome between the two groups.

Results

Eighteen P?/cy+ patients without distant organ metastases underwent surgery between 2000 and 2010. Laparoscopic gastrectomy was performed in nine patients and open gastrectomy in nine patients. The estimated blood loss was significantly smaller, the resumption of food intake earlier, and the length of postoperative hospital stay shorter in the patients that underwent laparoscopic gastrectomy than in the patients that underwent open gastrectomy. There were no significant differences in the 2-year survival rates between the groups.

Conclusion

Laparoscopic gastrectomy for P?/cy+ patients is a minimally invasive and safe oncologic procedure with good short-term results.     

Plasmadeponierte Kohlenstoffbeschichtung auf urologischen Verweilkathetern

Background

Any material placed in the urinary tract is susceptible to the formation of encrustations of crystalline bacterial biofilms. These biofilms cause severe complications in some cases. The strategies used so far for reduction of these complications by surface modifications of the implant material failed to show the expected results.

Patients and methods

In this study, we investigated amorphous carbon coatings (a-C:H) for their ability to effectively reduce or to repress the progressive formation of infection-enhancing crystalline biofilms as new functional surface coatings. In nine patients suffering for several years from stenting, a-C:H-coated ureteral stents were tested in treatment attempts. The current replacement intervals amounted to a mean of 77 days; the principle cause for early replacement was massive stent encrustations associated with symptomatic urinary tract infections.

Results

In total, 20 coated ureteral stents were tested spanning indwelling times between 3 and 4 months. No stent-related complications occurred. In all cases extraordinarily facile handling, less pain during replacement, and markedly increased tolerance were observed. Symptomatic urinary tract infections were reduced by more than 50%. The stents remained virtually free of encrustations.

Conclusion

a-C:H coatings are a novel strategy leading to an enhancement of long-term applicability of ureteral stents and catheters and to improved patient comfort.     

Technical Improvement of Total Pharyngo-Laryngo-Esophagectomy for Esophageal Cancer and Head and Neck Cancer

Purpose

Total pharyngo-laryngo-esophagectomy (PLE) is highly invasive, and the subsequent reconstruction is difficult. The purpose of this study was to clarify the techniques that can decrease the surgical stress and allow for safe reconstruction after this operation.

Methods

The surgical method and clinical outcomes of total PLE were reviewed in 12 patients with either cervicothoracic esophageal cancer or double cancer of the esophagus and pharynx. Microscopic venous anastomosis was principally performed, and arterial anastomosis was added, if needed.

Results

A narrow gastric tube was used in ten patients, including two patients who underwent free jejunal interposition, while the colon was used as the main reconstructed organ in two other patients. Staged operations were performed in three high-risk patients. All six patients treated after 2010 were able to undergo thoracoscopic and/or laparoscopic surgery. No critical postoperative complications developed, although minor anastomotic leakage developed in two patients who were successfully treated conservatively.

Conclusion

When performing PLE, it is important to decrease the surgical stress and ensure a reliable reconstruction by adopting techniques that are appropriate for each case, such as thoracoscopic and laparoscopic surgery, staged operations, microvascular anastomosis, and muscular flaps.