Abdominal aortic laparoscopic surgery: retroperitoneal or transperitoneal approach?

Objective: to define the respective advantages and pitfalls of the trans- or retroperitoneal approaches in laparoscopic abdominal aortic reconstruction (LAOR). DESIGN: prospective study. MATERIAL: ten patients (8 males; average age 58) underwent an aortouni- (n=2) or bifemoral bypass (n=8) to treat aortoiliac occlusive disease (n=8) or an aortic aneurysm (n=2). METHODS: a retroperitoneal approach (the "apron" technique) was used in the first 5 cases (Group I) and a transperitoneal approach in the last 5 cases (Group II). RESULTS: no early or late death occurred, and all bypasses remain patent after a mean follow-up of 5.7 months. Mean surgical and clamping times are similar in both groups (370 and 126 min in Group I; 324 and 137 min in Group II). One intraoperative conversion to open surgery and two postoperative surgical complications occurred in Group I. Four minilaparotomies of 8-10 cm were necessary in Group II. Two patients were discharged on postoperative day 6 in Group I and five in Group II. CONCLUSION: this preliminary study shows the feasibility of LAOR through both approaches. In Group II, a better exposure of the right aortic wall and of the right iliac axis was noted and division of the inferior mesenteric artery was not always necessary.     

Laparoscopic radical nephrectomy for T1 renal cancer: the gold standard? A comparison of laparoscopic vs open nephrectomy

OBJECTIVE: To evaluate the complication rate and clinical follow-up of patients treated for T1 renal cancer by open or laparoscopic nephrectomy at the same institution, as this approach appears to be attractive for treating small renal cancers. PATIENTS AND METHODS: Between 1995 and 2002, 39 patients underwent retroperitoneal laparoscopic and 26 transperitoneal open radical nephrectomy for T1 renal cancer (TNM 1997). Variables before during and after surgery, e.g. cancer recurrence, were compared between the groups. RESULTS: There were no differences between the laparoscopic and open groups in age, sex ratio, weight, height, fitness score, operative duration (134 vs 133 min), minor or major complications, tumour diameter, Fuhrman grade or length of follow-up. Patients who underwent laparoscopic surgery had less blood loss (133 vs 357 mL, P < 0.001), less need for transfusion (none vs 150 mL, P = 0.04), a lower consumption of analgesia drugs, and shorter hospitalization (5.5 vs 8.8 days, P < 0.001). With a mean follow-up of 20.4 months there was no recurrence or tumour progression. CONCLUSION: Laparoscopic radical nephrectomy for patients with T1 renal cancer is a safe, reliable procedure that decreases hospitalization time and bleeding, and ensures the same cancer control as open nephrectomy.     

Laparoscopic radical prostatectomy: transperitoneal versus retroperitoneal approach: is there an advantage for the patient?

PURPOSE OF REVIEW: Radical prostatectomy is the standard treatment for localized prostate cancer; its translation to a laparoscopic approach is considered today not only as feasible and reproducible but also as a valid and teachable alternative to its open counterpart. Beyond the "classical" transperitoneal antegrade route codified by the Montsouris group, several extraperitoneal approaches were developed, claiming clinical equivalence and reduced risks of morbidity and operative times. This article summarizes various aspects of different approaches and their outcome. RECENT FINDINGS: Complications reported about transperitoneal procedures definitely further the discovery or learning curves of the pioneering teams; the groups who developed extraperitoneal alternatives established their "new approaches" on a solid base of technical skills, acquired transperitoneally. Beyond the unsurpassed qualities of visual and working spaces belonging to the transperitoneal route, which should be taken into account with respect to teaching, transperitoneal antegrade approach to the prostate enables the surgeon with early hemostatic control and essential tactical choices to achieve negative surgical margins. SUMMARY: So far, as oncological and functional results of both approaches seem equivalent, both approaches should be further developed and remain available for teaching purposes. The true benefit for patients lies more in global quality control of surgery than in an obsessional search for alternatives to established techniques that have already stood the proof of time.     

Should laparoscopy be the standard approach used for radical nephrectomy?

Since its inception in June 1990, laparoscopic radical/total nephrectomy for renal tumor has been successfully applied worldwide to hundreds of patients. Recent 5-year follow-up data have shown this procedure to produce cancer control identical to that of open radical/total nephrectomy. Although in most centers the cost of the procedure remains higher than open surgery, the patient benefits of decreased pain, reduced hospitalization, less blood loss, and more rapid convalescence appear to be universal. At this time, we believe that laparoscopic radical/total neph-rectomy for the treatment of renal tumors should become the new standard of care.     

Is robotically assisted laparoscopic radical prostatectomy less invasive than retropubic radical prostatectomy? Results from a prospective,unrandomized, comparative study

OBJECTIVES

To evaluate whether robotically assisted laparoscopic prostatectomy (RALP) is less invasive than radical retropubic prostatectomy (RRP), as experimental studies suggest that the acute phase reaction is proportional to surgery‐induced tissue damage.

PATIENTS AND METHODS

Between May and November 2006, all patients undergoing RRP or RALP in our department were prospectively assessed. Blood samples were collected 24 h before (T0), during surgery (T1), at the end of anaesthesia (T2), and 12 (T3) and 24 h after surgery (T4), and assayed for interleukin(IL)‐6 and IL‐1α, C‐reactive protein (CRP), and lactate. The Mann‐Whitney U‐, Student’s t‐ and Friedman tests were used to compare continuous variables, and the Pearson chi‐square and Fisher test for categorical variables, with a two‐sided P < 0.05 considered to indicate significance.

RESULTS

In all, 35 and 26 patients were assessed for RALP and RRP, respectively; the median (interquartile range) age was 62 (56–68) and 68.5 (59.2–71.2) years, respectively (P < 0.009). Baseline levels (T0) of IL‐1, IL‐6, CRP and lactate were comparable in both arms. IL‐6, CRP and lactates levels increased during both kinds of surgery. The mean IL‐6 and CPR values were higher for RRP at T1 (P = 0.01 and 0.001), T2 (P = 0.001 and <0.001), T3 (P = 0.002 and <0.001) and T4 (P < 0.001 and 0.02), respectively. Lactate was higher for RRP at T2 (P = 0.001), T3 (P = 0.001) and T4 (P = 0.004), although remaining within the normal ranges. IL‐1α did not change at the different sample times.

CONCLUSIONS

This study showed for the first time that RALP induces lower tissue trauma than RRP.     

Does the extraperitoneal laparoscopic approach improve the outcome of radical prostatectomy?

Laparoscopic radical prostatectomy (LRPE) became the operative procedure of choice for patients with clinically localized prostate cancer in selected urologic centers around the world. Principal advantages are the minimal invasive nature of the procedure, a superior visualization of the operative field because of the magnification of the optical system, an exact and watertight anastomosis, the possibility of early catheter removal, and a potentially reduced amount of blood loss. Recent data show that oncologic outcome is not compromised by the minimal invasive nature of the procedure. However, a major drawback of LRPE is the transperitoneal route of access to the extraperitoneal organ of the prostate. Therefore, principal disadvantages of LRPE are potential intraperitoneal complications. Endoscopic extraperitoneal radical prostatectomy is a further advancement of minimal invasive surgery because it overcomes the limitations of LRPE by the strictly extraperitoneal route of access, combining the advantages of minimal invasive surgery with the advantages of an extraperitoneal procedure. This article reviews the literature on minimally invasive (laparoscopic and endoscopic-extraperitoneal) radical prostatectomy.     

Does the medical evidence justify robotic assisted laparoscopic radical prostatectomy as the new gold standard for radical prostatectomy?

Today, over 70% of radical prostatectomies (RP) are performed using the daVinci robot. The robot has been heavily promoted and marketed to both the urologic community and the lay public as a minimally invasive and superior alternative to open radical prostatectomy. The robot has also been heavily promoted to hospitals as a means to increase market share by advertising “cutting edge” technology. Web sites promoting this new technology have consistently failed to legitimize claims of superiority with credible medical evidence. The time has come to critically examine whose interests have been best served by the robot: the patients, the surgeons, or the health care delivery system? As physicians who have taken the Hippocratic oath, it is the interest of the patient we must pursue and defend.     

Which is the best laparoscopic approach for inguinal hernia repair: TEP or TAPP? A systematic review of the literature with a network meta-analysis

Background

Totally extraperitoneal (TEP) repair and transabdominal preperitoneal (TAPP) repair are the most used laparoscopic techniques for inguinal hernia treatment. However, many studies have shown that laparoscopic hernia repair compared with open hernia repair (OHR) may offer less pain and shorter convalescence. Few studies compared the clinical efficacy between TEP and TAPP technique. The purpose of this study is to provide a comparison between TEP and TAPP for inguinal hernia repair to show the best approach.

Methods

We performed an indirect comparison between TEP and TAPP techniques by considering only randomized, controlled trials comparing TEP with OHR and TAPP with OHR in a network meta-analysis. We considered the following outcomes: operative time, postoperative complications, hospital stay, postoperative pain, time to return to work, and recurrences.

Results

The two techniques improved some short outcomes (such as time to return to work) with respect to OHR. In the network meta-analysis, TEP and TAPP were equivalent for operative time, postoperative complications, postoperative pain, time to return to work, and recurrences, whereas TAPP was associated with a slightly longer hospital stay compared with TEP.

Conclusions

TEP and TAPP improved clinical outcomes compared with OHR, but the network meta-analysis showed that TEP and TAPP efficacy is equivalent. TAPP was associated with a slightly longer hospital stay compared with TEP.     

Does the extent of lymphadenectomy in radical cystectomy for bladder cancer influence disease-free survival? A prospective single-center study

Background

Controversy exists regarding the optimal extent of lymphadenectomy and the number of lymph nodes to be retrieved at radical cystectomy (RC).

Objective

To compare the disease-free survival of patients with standard lymphadenectomy (endopelvic region composed of the internal, external iliac, and obturator groups of lymph nodes) versus extended lymphadenectomy (up to the level of origin of the inferior mesenteric artery) at RC in a prospective cohort of patients at a single, high-volume center.

Design, setting, and participants

Prospective data were collected from 400 consecutive patients treated with RC for bladder cancer by two high-volume surgeons at Mansoura Urology and Nephrology Center. Of the 400 patients, 200 (50%) received extended lymphadenectomy and the other 200 (50%) underwent standard lymphadenectomy at RC. The patients did not receive any neoadjuvant or adjuvant therapy.

Measurements

Patient characteristics and outcomes are evaluated.

Results and limitations

Median patient age for the entire group was 53.0 yr. Ninety-six patients (24.0%) had lymph node metastases. Median follow-up was 50.2 mo. Estimates of 5-yr disease-free survival in the extended lymphadenectomy group were 66.6% compared with 54.7% for patients with standard lymphadenectomy (p = 0.043). Extended lymphadenectomy was associated with better disease-free survival after adjusting for the effects of standard pathologic features (p = 0.02). When restricting the analyses to lymph node-positive patients, patients with extended lymphadenectomy had much better 5-yr disease-free survival compared with patients with standard lymphadenectomy (48.0% vs 28.2%; p = 0.029). The study was nonrandomized.

Conclusions

Extended lymphadenectomy is associated with better disease-free survival for bladder cancer patients with endopelvic lymph node involvement and should be considered in these patients.     

Is the outcome of laparoscopic incisional hernia repair affected by defect size? A prospective study

BackgroundThis study was performed to determine if defect size after laparoscopic incisional hernia repair is predictive of recurrence during the long-term follow-up evaluation.MethodsWe performed a prospective clinical study on 310 patients who underwent laparoscopic incisional hernia repair to identify predictable risk factors for hernia recurrence. Univariate and multivariate Cox regression analysis were used. The defect size was analyzed with curve receiver operating characteristic curve.ResultsThe overall recurrence rate was 6% after an average follow-up period of 60 months. On univariate analysis of the defect size (categories: <10 cm, 10–12 cm, and >15 cm), obesity, previous repairs, hernia location, surgical time, hospital stay, morbidity, and recurrences were significantly different (P < .001). By multivariate analysis, only obesity and defect size were independent prognostic factors (P < .001).ConclusionsThe predictive value of defect size is shown. Patients with large defects have a higher risk of recurrence. Our study recommends reserving the laparoscopic technique for hernias not exceeding 10 cm in size, where it can be put to better use.     

T1 adenocarcinoma of the rectum: transanal excision or radical surgery?

BACKGROUND: Recent studies suggest local excision may be acceptable treatment of T1 adenocarcinoma of the rectum, but there is little comparative data with radical surgery to assess outcomes and quantify risk. We performed a retrospective evaluation of patients with T1 rectal cancers treated by either transanal excision or radical resection at our institution to assess patient selection, cancer recurrence, and survival. METHODS: All patients who underwent surgery for T1 adenocarcinomas of the rectum (0-15 cm from anal verge) by either transanal excision (TAE) or radical resection (RAD) between January 1987 and January 2004 were identified from a prospective database. Data were analyzed using Fisher exact test, Kaplan-Meier method, and log-rank test. RESULTS: Three hundred nineteen consecutive patients with T1 lesions were treated by transanal excision (n = 151) or radical surgery (n = 168) over the 17-year period. RAD surgery was associated with higher tumor location in the rectum, slightly larger tumor size, a similar rate of adverse histology, and a lymph node metastasis rate of 18%. Despite these features, patients who underwent RAD surgery had fewer local recurrences, fewer distant recurrences, and significantly better recurrence-free survival (P = 0.0001). Overall and disease-specific survival was similar for RAD and TAE groups. CONCLUSION: Despite a similar risk profile in the 2 surgical groups, patients with T1 rectal cancer treated by local excision were observed to have a 3- to 5-fold higher risk of tumor recurrence compared with patients treated by radical surgery. Local excision should be reserved for low-risk cancers in patients who will accept an increased risk of tumor recurrence, prolonged surveillance, and possible need for aggressive salvage surgery. Radical resection is the more definitive surgical treatment of T1 rectal cancers.     

Laparoscopic radical nephrectomy for renal cell carcinoma: the standard of care already?

PURPOSE OF REVIEW: Laparoscopic radical nephrectomy has been developed and applied for patients with renal cell carcinoma since 1992. The number of patients undergoing laparoscopic radical nephrectomy has increased explosively worldwide in recent years, and laparoscopy is now extended to patients with advanced disease. It is very important to clarify the present status of laparoscopic radical nephrectomy among the treatment modalities for patients with renal cell carcinoma. RECENT FINDINGS: Laparoscopic radical nephrectomy has a minimally invasive nature as well as comparable long-term cancer control in patients with pT1-3a renal cell carcinoma to open surgery. It is technically applicable for N1-2 disease and T3b disease if the tumor thrombus is within the renal vein. Also, it is feasible as a cytoreductive surgery for patients with M1 disease. SUMMARY: Laparoscopic radical nephrectomy is a standard treatment modality for T1-3a renal cell carcinoma patients. It is also available for treating patients with N1-2 disease, and for patients with M1 disease as a cytoreductive surgery.     

Robot‐assisted or pure laparoscopic nerve‐sparing radical prostatectomy: What is the optimal procedure for the surgical margins? A single center experience

Objectives: To compare positive surgical margin rates after robot‐assisted and pure laparoscopic radical prostatectomy when neurovascular bundles are preserved, and to identify parameters affecting surgical margin status. Methods: From March 2004 to January 2009, 279 consecutive prostatectomies with preservation of neurovascular bundles were carried out by the same surgeon: 175 robot‐assisted radical prostatectomies and 104 laparoscopic radical prostatectomies. An intraperitoneal Montsouris's technique was used for all cases. Patient's age, body mass index, prostate weight, prostate‐specific antigen level, clinical stage, preoperative and postoperative Gleason score, percentage of positive biopsies, pathological stage, and positive surgical margin status were prospectively recorded in an institutional database. The two groups were retrospectively analyzed and compared. Results: Positive surgical margin rates were 17% and 13% for the robot‐assisted radical prostatectomy and laparoscopic radical prostatectomy group (P = 0.4), respectively. At multivariable analysis, only prostate‐specific antigen level and prostate weight significantly affected the surgical margin status, where the type of procedure (robotic vs laparoscopic) did not have any effect. Conclusion: In our single‐surgeon experience, prostate‐specific antigen levels and prostate weight are predictive of positive surgical margin in patients undergoing nerve‐sparing radical prostatectomy, whereas there seems to be no difference between the robot‐assisted radical prostatectomy and the laparoscopic radical prostatectomy techniques.