Potency-sparing radical perineal prostatectomy: anatomy, surgical technique and initial results

By integrating a re-examination of perineal anatomy with the recently described anatomy of the pelvic nerve plexus and the cavernous nerves, a modification of radical perineal prostatectomy that can preserve potency has been developed. In 16 patients who underwent this procedure immediately after bilateral pelvic lymphadenectomy the traditional low morbidity of radical perineal prostatectomy was retained, and potency was preserved in 5 of 9 patients (56 per cent), including all whose tumor was confined within the specimen margins. Review of the anatomy of the pelvic fascia also demonstrates that additional fascia around the lateral and dorsal surfaces of the prostate can be removed during radical perineal prostatectomy when one is willing to sacrifice the cavernous nerves to achieve a more radical excision of the prostate.     

Laparoendoscopic single-site radical nephrectomy for renal cancer: technique and surgical outcomes

Background

Laparoendoscopic single-site (LESS) surgery has been developed in attempt to further reduce the morbidity and scarring associated with surgical intervention.

Objective

To describe the technique and report the surgical outcomes of LESS radical nephrectomy (RN) in the treatment of renal cell carcinoma.

Design, setting, and participants

LESS-RN was performed in 33 patients with renal tumours. The indications to perform a LESS-RN were represented by renal tumours not greater than T2 and without evidence of lymphadenopathy or renal vein involvement.

Surgical procedure

The Endocone (Karl Storz, Tuttlingen, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and bent grasper and scissors was used. The sequence of steps of LESS-RN was comparable to standard laparoscopic RN.

Measurements

Demographic data and perioperative and postoperative variables were recorded and analysed.

Results and limitations

The mean operative time was 143.7 ± 24.3 min, with a mean estimated blood loss of 122.3 ± 34.1 ml and a mean hospital stay of 3.8 ± 0.8 d. The mean length of skin incision was 4.1 ± 0.6 cm and all patients were discharged from hospital with minimal discomfort, as demonstrated by their pain assessment scores (visual analogue scale: 1.9 ± 0.8). The definitive pathologic results revealed a renal cell carcinoma in all cases and a stage distribution of four T1a, 27 T1b, and 2 T2 tumours. All patients were very satisfied with the appearance of the scars, and at a median follow-up period of 13.2 ± 3.9 mo, all patients were alive without evidence of tumour recurrence or port-site metastasis.

Conclusions

LESS is a safe and feasible surgical procedure for RN in the treatment of renal cell carcinoma and has excellent cosmetic results.     

Medullary thyroid carcinoma: results of a standardized surgical approach in a contemporary series of 80 consecutive patients

BACKGROUND: The surgical management and follow-up strategy in patients with medullary thyroid carcinoma (MTC) remain controversial because of the lack of data on the natural history of these tumors and their patterns of progression. METHODS: We reviewed the records of all patients who underwent a cervical operation for MTC between 1991 and 2002. Compartment-oriented surgery (COS) was performed to minimize the risk of cervical recurrence. RESULTS: We identified 92 consecutive patients who underwent a cervical operation for MTC: 80 had invasive MTC, and 12 had C-cell hyperplasia after prophylactic thyroidectomy for familial MTC. Ten (13%) of the 80 patients with invasive MTC presented with distant metastases and underwent COS to achieve local-regional control; cervical recurrence developed in none, but three have died of MTC. The remaining 70 patients underwent COS for primary (n=23) or recurrent (n=47) MTC. Disease recurred in 18 (26%) of these 70 patients at a median follow-up of 35 months, with 10 (14%) of the recurrences being cervical. Recurrent disease was associated with a basal calcitonin level of >250 pg/mL in all but four patients, two of whom showed tumor dedifferentiation. In contrast, only 5 (11%) patients without evidence of recurrence had basal calcitonin levels of >250 pg/mL at last follow-up. CONCLUSIONS: Complete COS minimizes cervical recurrence. Radiographic evidence of recurrent disease is unlikely when the calcitonin level is < or =250 pg/mL. These data could be used to develop a logical, cost-effective treatment and follow-up strategy for patients with MTC.     

Outcome after radical prostatectomy depends on surgical technique but not approach

Conclusions The results after radical prostatectomy currently are very good but could be better. There is no question that surgical technique is important in decreasing morbidity and improving outcomes. The same principles apply regardless of surgical approach. Ultimately, there may be little difference in the important outcome measures regardless of the approach used. Exploration of innovative approaches and techniques should be encouraged but measured by their effect on outcome rather than assumed improvements or promotional efforts.     

Cervico-mediastinal extension of thyroid cancer

A surgical series of 30 cervico-mediastinal thyroid cancer patients operated on has been retrospectively reviewed. Results were compared with those obtained in patients operated on for benign cervico-mediastinal goiter and thyroid cancer confined to cervical region. Of 4688 thyroidectomies performed, 30 patients were operated on for thyroid carcinoma with cervico-mediastinal extension. There were 15 males and 15 females. The mean age was 67 years (range, 21-86 years). Patients with cervico-mediastinal cancer were significantly older than patients with benign cervico-mediastinal goiter (P < 0.0001). Time between onset of first symptoms and surgery was significantly longer in patients with cervico-mediastinal cancer than in those with benign cervico-mediastinal goiter (P < 0.0001) and cervical thyroid cancer. Signs and symptoms at the time of surgery were cervical mass in 28 patients (93%), cervical lymphadenopathy in 20 patients (66%), dyspnea in 21 (70%), dysphagia in 9 (30%), dysphonia in 2 (7%), and venous stasis in 1 (3%). None of the patients was asymptomatic. Total thyroidectomy with functional lymphectomy was performed in 16 cases. Seven of these patients were operated on in 2 stages. In 8 cases the operation was a debulking procedure, and in 6 it was a near-total thyroidectomy. Sternotomy was performed in two cases. A differentiated thyroid cancer was found in 21 patients (70%), medullary in 5 (17%) and undifferentiated in 4 (13%). The incidence of medullary carcinoma was significantly higher compared with cervical cancer (P < 0.008). Postoperative complications were higher than those occurring in benign cervico-mediastinal goiter and similar to those occurring in cervical cancer. The actuarial survival was similar to that of cervical cancer matched for age and sex. This analysis shows that the longer clinical history of goiter is related to its endothoracic development and its neoplastic transformation. This finding should further encourage surgeons to treat any cervico-mediastinal goiter as promptly as possible.     

Influence of surgical approach on cancer control following radical prostatectomy

Pathologic T3 prostate cancer (extraprostatic spread) detected following radical prostatectomy reduces the likelihood of cure. We conducted this study to determine the impact of the surgical approach (retropubic versus perineal) on risk and location of pT3 disease. A retrospective analysis of 287 consecutive radical prostatectomies [III retropubic (RRP) and 176 perineal (RPP)] was conducted. Specimens were pathologically examined for presence or absence of pT3 disease. A greater rate of pT3 disease was found with RRP than with RPP, which was likely due to patient selection. Of specimens with a single positive surgical margin, the positive margin was more common at the base of the gland with RPP than with RRP (38.5% versus 9.3%). Conversely, the percentage of specimens with a positive apical margin only was less with RPP than with RRP (12.8% versus 44.2%) (Chi-square, p ≤ 0.025). These results lead us to conclude that RPP may achieve superior cancer control for tumors located at the prostate apex, while the retropubic approach may be preferred for tumors located at the prostatic base.     

Undifferentiated thyroid cancer: improved therapeutic results following initial radical intervention and early postoperative radiotherapy

During a 16-year period (1972-1988), 40 out of 477 thyroid cancer patients underwent thyroidectomy for undifferentiated thyroid carcinoma. To analyse the significance of "radical" versus "palliative" surgical procedures with regard to early postoperative course, operative complications and survival, all patients records were reviewed and actually followed up. A significant better survival was correlated with radical (n = 17) versus palliative tumor resection (n = 23) (p less than 0.001), and total thyroidectomy (n = 22) versus subtotal thyroidectomy (n = 18) (p less than 0.006). Radical surgery with early postoperative external irradiation revealed no postoperative mortality and only one symptomatic cervical tumor recurrence. In contrast, palliative surgery, particularly in the case of synchronous tracheotomy, was attended with a relatively high mortality (30%) and symptomatic local recurrences. The results of this study suggest that in undifferentiated thyroid carcinoma without infiltration of the esophageal or tracheal mucosa an attempt of radical tumor resection should be undertaken, since palliative surgical procedures revealed a significantly lower survival due to complications of persistent or recurrent cervical tumor infiltration and frequently were accompanied by local complications during the postoperative course.     

Routine level VI lymph node dissection for papillary thyroid cancer: surgical technique

Total thyroidectomy is the treatment of choice for clinically significant papillary thyroid cancer (PTC); however, 10-15% develop palpable local recurrence in the cervical lymph nodes. Metastases in the cervical lymph nodes account for 75% of loco-regional recurrence and up to 50% of these patients eventually die of their disease. It is generally accepted that surgical excision of grossly involved lymph node disease should be carried out. The role of routine lymph node dissection, however, is greeted with far more controversy. Regional lymph node metastases have been shown to be associated with more frequent tumour recurrence. Not only is recurrence associated with increased disease-related mortality, but recent data have shown that the presence of involved lymph nodes is associated with adverse survival. Additionally, there have been significant changes to the way patients are managed after treatment for PTC in recent years. Surveillance previously relied on clinical assessment and radioiodine scans whereas now the use of serum thyroglobulin and high-resolution ultrasound are the standard as evidenced by recommendations by the American Thyroid Association. These techniques have greater sensitivity and subsequently lymph node metastases are being detected earlier and more frequently. This has led to a paradigm shift in the aims of treatment of PTC, from a focus on survival data to a focus on disease-free status. Routine central neck lymph node dissection can be carried out with no increased morbidity and can achieve lower 6-month stimulated thyroglobulin levels when compared with total thyroidectomy alone. Routine ipsilateral level VI lymph node dissection in addition to total thyroidectomy should be carried out for the management of clinically significant PTC.     

The orbitozygomatic infratemporal approach: a new surgical technique

Lesions in the parasellar region and the interpeduncular fossa, including medial-third sphenoid wing meningiomas, petroclival meningiomas, trigeminal neurinomas, and basilar tip aneurysms, are very difficult to approach for radical procedures. To minimize brain retraction and achieve excellent exposure in the shortest possible distance for safe manipulation within these regions, the authors have developed a new surgical technique, an orbitozygomatic infratemporal approach. Sixteen patients with parasellar tumors, nine patients with basilar tip aneurysms, and one patient with a P-1 distal aneurysm were operated on using this orbitozygomatic infratemporal approach, with excellent results. The operative technique and its results are detailed.     

Locoregionally advanced rectosigmoid cancer: diagnosis, surgical approach, late results

The colorectal cancer continues to be diagnosed in advanced stages in our country, mainly due to unapplying of a programmer of active diagnosis through screening on the population with risk for colorectal cancer, and inefficiency of primary care system. In the department of General Surgery CFR Craiova Hospital between 1991-2001 were operated a number of 231 patients with colon cancer and 104 patients with rectal cancer. The results, showing an increased number of recurrences in cases of resection performed for advanced loco-regional tumors of rectosigmoid, made us to reconsider the attitude of avoiding the abdominoperineal resection even when the distance between the inferior limits of the tumors and the anal edge exceeded the distance considered being standard for a low anastomosis performing. The follow-up of the patients with paraclinic technique that didn't prove efficient led in the most cases to a delaying in diagnosis of local recurrences until the moment of resectability was exceeded. The applying of efficient methods in early diagnosis of colorectal cancer and follow-up could provide in the future better results for anterior resections with low anastomosis.     

Gastric per-oral endoscopic myotomy: Indications,technique, results and comparison with surgical approach

Gastroparesis is a chronic disease of the stomach that causes a delayed gastric emptying, without the presence of a stenosis. For 30 years the authors identified pylorospasm as one of the most important pathophysiological mechanisms determining gastroparesis. Studies with EndoFLIP, a device that assesses pyloric distensibility, increased the knowledge about pylorospasm. Based on this data, several pyloric-targeted therapies were developed to treat refractory gastroparesis: Surgical pyloroplasty and endoscopic approach, such as pyloric injection of botulinum and pyloric stenting. Notwithstanding, the success of most of these techniques is still not complete. In 2013, the first human gastric per-oral endoscopic myotomy (GPOEM) was performed. It was inspired by the POEM technique, with a similar dissection method, that allows pyloromyotomy. Therapeutical results of GPOEM are similar to surgical approach in term of clinical success, adverse events and post-surgical pain. In the last 8 years GPOEM has gained the attention of the scientific community, as a minimally invasive technique with high rate of clinical success, quickly prevailing as a promising therapy for gastroparesis. Not surprisingly, in referral centers, its technical success rate is 100%. One of the main goals of recent studies is to identify those patients that will respond better to the therapies targeted on pylorus and to choose the better approach for each patient.     

Smiley incision: a direct surgical approach for retropubic radical prostatectomy

Two standard incisions are used for retropubic radical prostatectomy, a midline vertical and a transverse Pfannenstiel incision. Both of these incisions have their advantages and disadvantages. A geometric union of these two standard incisions has been devised and tried on 45 patients with very desirable results.     

The transcaruncular approach: surgical anatomy and technique

With a detailed understanding of the pertinent surgical anatomy, the transcaruncular approach provides safe access and excellent exposure of the medial orbit and orbital apex. We herein describe our technique of the transcaruncular approach and delineate the pertinent associated surgical anatomy via dissection, magnetic resonance imaging, and histologic examination. The isolated transcaruncular approach provides exposure of the medial orbital floor from the region of the maxilloethmoidal strut to the orbital roof area superior to the frontoethmoidal suture. When combined with an inferior fornix incision, the transcaruncular approach allows for continuous exposure from the frontozygomatic suture laterally to the frontoethmoidal suture medially. Attention to anatomical details promotes creation of an effective and safe caruncular incision. The conjunctival incision should be ample. The orbital septum should be carefully dissected from the posterior surface of the Horner muscle to minimize fat spillage, and the periosteum should be opened widely at the beginning of surgery.     

Renal-cell carcinoma with intracaval neoplastic extension: stratification and surgical technique

Summary Surgical removal continues to be the mainstay in the treatment of renal-cell carcinoma with neoplastic venous extension. The steady improvement of surgical and anesthesiological techniques and the introduction of complete circulatory arrest has dramatically improved the morbidity even of patients with extensive thrombi. If ultrasound or computerized tomography (CT) scanning suggests the presence of a venous extension in a patient with renal-cell carcinoma, cavography, magnetic resonance imaging (MRI), transesophageal color-coded ultrasound, and echocardiography may be needed to resolve the questions of cranial extension and vascular wall infiltration. Surgical stratification and, thus, classification of the venous extension depend on the potential need for complete circulatory arrest. Surgical removal is done en bloc for smaller venous extensions and in a two-step procedure (radical nephrectomy followed by thrombectomy) for more extensive thrombi. In patients with infiltration of the suprahepatic inferior vena cava, the hepatic veins or atrium, pending thrombotic embolism, or large masses of suprahepatic thrombotic material, the use of cardiopulmonary bypass and complete circulatory arrest is recommended.