Percutaneous radio frequency ablation of small renal tumors: initial results.

PURPOSE: Thermal tissue ablation with radio frequency energy is an experimental treatment of renal tumor. We report early results of an ongoing trial of percutaneous radio frequency ablation for small renal tumors. MATERIALS AND METHODS: Patients with percutaneously accessible renal tumors were evaluated for radio frequency ablation. Tumors were solid on computerized tomography (CT), 3 cm. or less in diameter and enlarging during at least 1 year. Ablation was performed at the Interventional Radiology suite under ultrasound and/or CT guidance. A 50 W., 460 kHz. electrosurgical generator delivered radio frequency energy via a percutaneously placed 15 gauge coaxial probe. At least 2, 10 to 12-minute ablation cycles were applied to each lesion. Patients were observed overnight before discharge from hospital and reevaluated 2 months later. RESULTS: A total of 24 ablations were performed in 21 patients with renal tumor, including solid von Hippel-Lindau clear cell tumor in 19 and hereditary papillary renal cancer 2. Most (22 of 24) procedures were performed with patients under conscious sedation. At 2 months postoperatively mean tumor diameter plus or minus standard deviation decreased from 2.4 +/- 0.4 to 2.0 +/- 0.5 cm. (p = 0.001), and a majority of tumors (19 of 24, 79%) ceased to be enhanced on contrast CT. Mean serum creatinine plus or minus standard deviation was unchanged during this interval (1.0 +/- 0.2 mg./dl.). No major and 4 minor complications were encountered, including 2 episodes each of transient psoas pain and flank skin numbness. CONCLUSIONS: Percutaneous radio frequency ablation of small renal tumor is well tolerated and minimally invasive. It will remain experimental until procedural and imaging parameters that correlate with tumor destruction are validated.     

Transurethral ethanol injection therapy for prostatic hyperplasia: 3-year results

PURPOSE: We assessed the medium-term (3-year) efficacy of transurethral ethanol injection therapy of the prostate (EIP) for benign prostatic hyperplasia. MATERIALS AND METHODS: A total of 34 patients were followed for a median of 4.3 years after EIP. Mean age was 68.1 years and mean baseline prostate volume was 49.3 ml. With the patient under combined sacral and urethral anesthesia, dehydrated ethanol was injected into the prostate with endoscopic guidance. A urethral catheter was inserted postoperatively. RESULTS: Mean total ethanol dose was 6.4 ml and a catheter was required for a mean of 7.6 days postoperatively. Mean International Prostate Symptom Score was 21.8 points before EIP (in 34 patients), and decreased to 13.1 points after 3 years (in 17, p <0.01). Mean quality of life index decreased from 5.0 points before EIP to 2.8 points after 3 years (p <0.001). Mean peak urine flow rate was 8.3 ml per second before EIP and increased to 12.7 ml per second after 3 years (p <0.01). Mean residual urine volume decreased from 93 ml before EIP to 28 ml after 3 years (p <0.01). Mean prostate volume decreased from 49.3 ml before EIP to 45.7 ml after 1 year (p <0.001), but increased to 51.4 ml after 3 years. No major complications were experienced. By 3 years after surgery 59.0% of patients had not required further treatment. CONCLUSIONS: Transurethral EIP caused minimal complications while maintaining improvement of the prostate symptom score and an increased peak urine flow after 3 years.     

Vattikuti Institute prostatectomy: technique

PURPOSE: We have performed more than 250 radical prostatectomies using the da Vinci (Intuitive Surgical, Mountain View, California) surgical system. Our initial cases were done using the classic Montsouris approach. However, after gaining familiarity with the robot we modified our technique to reflect our experience with open radical retropubic prostatectomy. We detail the Vattikuti Institute prostatectomy technique that we currently use. MATERIALS AND METHODS: The robotic technique requires 2 teams, namely a skilled laparoscopic team at the patient and a skilled open surgeon at the console. Dissection is started anterior to the bladder and it continues extraperitoneally. The endopelvic fascia is opened and the dorsal vein complex is secured. The apex of the prostate is dissected free, releasing the neurovascular bundles at the apex. The bladder neck is then incised, and the seminal vesicles and vasa are transected. Posterior dissection is done within the posterior layer of Denonvilliers' fascia, preserving the neurovascular bundles and lateral prostatic fascia. The apex is transected and frozen sections are obtained from the parietal margins. Vesicourethral anastomosis is formed with 2 continuous sutures. RESULTS: In the last 100 cases mean operative time was 2.5 hours and average blood loss was 150 ml. (range 25 to 525 cc.). Median specimen Gleason score was 7 and mean tumor volume was 7 cc. Four patients had a positive surgical margin, which was focal in 3. Of the patients 95% were discharged home within 23 hours. Mean catheterization time was 4.2 days. CONCLUSIONS: Vattikuti Institute prostatectomy is a precise and safe minimally invasive technique of radical retropubic prostatectomy.     

Pilot study of radiofrequency interstitial tumor ablation (RITA) for the treatment of radio-recurrent prostate cancer

BACKGROUND: To prospectively evaluate the feasibility, safety, morbidity, and preliminary efficacy of radiofrequency interstitial tumor ablation (RITA) for the focal treatment of patients with local prostate cancer recurrence. METHODS: Eleven patients with biopsy-proven, hormone-na?ve, clinically localized prostate cancer were enrolled in a prospective phase I/II trial. Eight patients had failed prior radiation therapy and three were not candidates for curative primary therapy (median Gleason score 7 and 6, respectively). Median follow-up was 20 months. All patients were treated with RITA in an office setting, under intravenous sedation and were discharged after the procedure. Radiofrequency energy was applied via needles placed transperineally under transrectal ultrasound guidance. RESULTS: The placement of 1/4 lesions was aborted in two patients due to increasing rectal temperature. Complications included transient macrohematuria (19%), bladder spasms (9%), and dysuria (9%). Serum PSA levels decreased after RITA >50% in 90% of patients, > 70% in 72% of patients, and > 80% in 46% of patients. The mean PSA doubling time after RITA was slower than that before RITA (37 +/- 22 months vs. 14 +/- 13 months, P = 0.008). At 12 months after RITA, 50% of patients with sufficient follow-up had no residual cancer on repeat systematic 12-core biopsy cores and 67% were cancer-free in biopsy cores sampled from the RITA-treated areas. CONCLUSIONS: RITA treatment is a minimal invasive, rapid, user-friendly, office-based procedure that is well tolerated. Focal ablation with RITA results in effective local disease control in patients with non-metastatic prostate cancer recurrence. Larger, prospective, multicenter clinical studies are needed to confirm these findings.     

Self-retaining barbed suture for parenchymal repair during laparoscopic partial nephrectomy; initial clinical experience

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? This paper reports on outcomes for SRBS during conventional laparoscopic partial nephrectomy. In addition to an improvement in warm ischaemia time, we found that SRBS use during LPN may be beneficial in reducing rates of clinically significant haemorrhage.

OBJECTIVES

• ? To evaluate the efficacy of a self‐retaining barbed suture (SRBS) in achieving a secure and haemostatic renorrhaphy during laparoscopic partial nephrectomy (LPN).
• ? To compare perioperative outcomes for LPN with SRBS with those for LPN with conventional polyglactin suture, with specific attention to warm ischaemia time, blood loss and need for postoperative bleeding interventions.

PATIENTS AND METHODS

• ? Patients who underwent LPN between June 2007 and October 2010 were identified through an Institutional Review Board approved registry of oncological patients.
• ? Before July 2009, parenchymal repair after tumour excision was performed using absorbable polyglactin suture (Group 1), and subsequently, using SRBS (Group 2).
• ? Demographic, clinical, intraoperative and postoperative outcomes were compared for each group.

RESULTS

• ? LPN was performed in 49 patients in Group 1 and 29 in Group 2.
• ? Baseline demographic and clinical features, estimated blood loss, and transfusion and embolization rates were statistically similar for the cohorts.
• ? Mean warm ischaemia time (±SD) was significantly shorter for the SRBS group (26.4 ± 8.3 vs 32.8 ± 7.9; P= 0.0013).
• ? Bleeding requiring intervention (open conversion or transfusion ± embolization) was more common for Group 1 (9/49, 18.4% vs 1/29, 3.4%; P= 0.06).

CONCLUSIONS

• ? The use of SRBS for parenchymal repair during LPN in humans is safe and is associated with a significant reduction in warm ischaemia time.
• ? SRBS use during LPN may also reduce rates of clinically significant bleeding.
• ? Prospective, larger studies to confirm the value of SRBS use in minimally invasive partial nephrectomy are warranted.

     

Endoscopic extraperitoneal radical prostatectomy: initial experience after 70 procedures

PURPOSE: After our initial experience with 70 transperitoneal laparoscopic radical prostatectomies we developed a totally extraperitoneal retropubic approach to radical prostatectomy using laparoscopic instruments. We report our initial experience with 70 endoscopic extraperitoneal radical prostatectomy procedures. MATERIALS AND METHODS: A total of 70 patients underwent endoscopic extraperitoneal radical prostatectomy. Mean patient age was 63.4 years (range 49 to 76). Mean preoperative prostate specific antigen was 12.48 ng./ml. (range 1.4 to 50.7). There were no specific selection criteria for the procedure. The steps of the procedure are preparation of the preperitoneal space with the help of a balloon trocar, trocar placement (a 3 x 5 and a 2 x 12 mm. port), pelvic lymph node dissection, exposure of the prostate and the bladder neck, incision of the endopelvic fascia, ligation of Santorini's plexus, bladder neck dissection, mobilization of the seminal vesicles, incision of Denonvilliers' fascia, sectioning of the prostatic pedicles with or without preservation of the neurovascular bundles, dissection of Santorini's plexus and apex, urethrovesical anastomosis with 7 to 9 interrupted sutures and removal of the specimen via an extraction bag. During the 70 endoscopic prostatectomies 11 hernia defects were treated in 9 patients concomitantly. RESULTS: There was no conversions and no re-interventions. Mean operative time was 155 minutes (range 90 to 260). One patient required transfusion with 2 units of blood cells. Pathological stage was pT2a in 19 patients, pT2b in 14, pT3a in 25, pT3b in 9 and pT4 in 3. Positive surgical margins were found in 2 of the 33 patients (6.1%) with pT2 tumors and in 13 of the 37 (35.1%) with pT3 and pT4 tumors. Postoperatively edema and hematoma of the penis in 10 cases was treated conservatively. Furthermore, 4 patients had asymptomatic lymphoceles, 1 required lymphocele drainage and 2 had partial obturator nerve paralysis, which resolved spontaneously. In 1 patient deep venous thrombosis developed. CONCLUSIONS: The preliminary results of this series are promising. Operative and perioperative morbidity was low. Functional results and oncological control were similar to the results of laparoscopic radical prostatectomy. The data demonstrate that endoscopic extraperitoneal radical prostatectomy can be performed with efficacy and results equal to those of laparoscopic radical prostatectomy, while providing the benefits of a totally extraperitoneal approach. Therefore, totally endoscopic extraperitoneal radical prostatectomy represents a technical improvement of laparoscopic technique because it completely obviates intra-abdominal complications and combines the advantages of minimally invasive laparoscopy and the retropubic open approach.     

Saturation technique does not improve cancer detection as an initial prostate biopsy strategy

PURPOSE: We reported on the results of a sequential cohort study comparing office based saturation prostate biopsy to traditional 10-core sampling as an initial biopsy. MATERIALS AND METHODS: Based on improved cancer detection of office based saturation prostate biopsy repeat biopsy, we adopted the technique as an initial biopsy strategy to improve cancer detection. Two surgeons performed 24-core saturation prostate biopsies in 139 patients undergoing initial biopsy under periprostatic local anesthesia. Indication for biopsy was an increased PSA of 2.5 ng/dl or greater in all patients. Results were compared to those of 87 patients who had previously undergone 10-core initial biopsies. RESULTS: Cancer was detected in 62 of 139 patients (44.6%) who underwent saturation biopsy and in 45 of 87 patients (51.7%) who underwent 10-core biopsy (p >0.9). Breakdown by PSA level failed to show benefit to the saturation technique for any degree PSA increase. Men with PSA 2.5 to 9.9 ng/dl were found to have cancer in 53 of 122 (43.4%) saturation biopsies and 26 of 58 (44.8%) 10-core biopsies. Complications included 3 cases of prostatitis in each group. Rectal bleeding was troublesome enough to require evaluation only in 3 men in the saturation group and 1 in the 10-core group. CONCLUSIONS: Although saturation prostate biopsy improves cancer detection in men with suspicion of cancer following a negative biopsy, it does not appear to offer benefit as an initial biopsy technique. These findings suggest that further efforts at extended biopsy strategies beyond 10 to 12 cores are not appropriate as an initial biopsy strategy.     

Intermediate results of laparoscopic cryoablation in 59 patients at the Medical College of Wisconsin

PURPOSE: We report our experience with LC for small renal tumors. MATERIALS AND METHODS: Patients who underwent LC at our institution between February 2000 and September 2004 were included in the study. A retrospective chart review was done for perioperative and postoperative parameters as well as clinical outcomes. RESULTS: A total of 65 LCs were performed in 59 patients during the period reviewed. Overall 81 renal tumors were cryoablated. Median patient age was 62 years. Median tumor size was 2.5 cm. Median operative time was 190 minutes. Median estimated blood loss was 50 ml. Median hospital stay was 2 days. Conversion to open surgery occurred in 2 patients. Nephrectomy for bleeding occurred in 1 patient. Median followup was 26.8 months. Two recurrences were identified after LC. CONCLUSIONS: LC is an alterative modality to laparoscopic partial nephrectomy or open partial nephrectomy for small renal tumors. Tumor recurrence rates in the studies published to date are comparable to those of partial nephrectomy, although longer followup is needed.     

胸部小切口微创手术治疗先天性心脏病的早期结果

目的 总结右或左前外胸部小切口治疗先天性心脏病的早期结果.方法 2010年4月到2012年12月,63例先天性心脏病患者采用右或左前外胸部小切口的方法完成手术,其中男22例,女41例;年龄30.6岁.手术包括房间隔缺损修补术38例,室间隔缺损修补术19例,部分心内膜垫缺损矫治术3例,肺静脉异位引流矫治术1例,Ebstein畸形矫治术1例,主动脉窦瘤破裂修补术1例.结果 手术切口长度2.5～7.0 cm,平均(4.76±0.95) cm.全组无中转大切口开胸手术,无手术死亡.体外循环36～209 min,平均(76.38 ±29.97) min;主动脉阻断0～ 138 min,平均(33.49±31.50) min.气管插管2～37 h,平均(10.53±6.13)h;监护室停留4～42 h,平均(14.93±7.65)h;术后住院2～ 14天,平均(5.42±1.98)天.9例输血,54例未输血.随访1 ～32个月,平均(13.75 ±8.91)个月,超声心动图提示所有患者无残余漏,一般情况佳.结论 胸部小切口微创治疗先天性心脏病安全、可行.     

巨大型垂体腺瘤的显微外科手术治疗

目的 探讨扩大前颅底经纵裂经平台蝶窦入路手术治疗巨大垂体腺瘤的疗效。方法 1999年12月～2004年12月，对21例巨大型垂体腺瘤采用扩大前颅底经纵裂经平台蝶窦入路进行显微外科手术治疗，术前均经MRI检查，肿瘤最长径平均4、8（4．0～7．5）cm。结果 肿瘤全切除18例（85．7％），次全切除3例（14．3％），无手术死亡病例。术后患者症状均有所改善，但发生脑脊液漏1例，短时尿崩4例，2例未能保留嗅神经，1例仅保留1侧。术后平均随访2．5（0．5～5．5）年，复查内分泌检查、MRI未见复发。结论 此入路视野广阔、暴露良好、无严重并发症，可提高巨大垂体腺瘤的手术效果。     

恶性输尿管梗阻的腔内微创治疗(附85例报告)

目的探讨盆腔肿瘤或盆腔转移性肿瘤及放疗等引起的恶性输尿管梗阻的腔内微创治疗方法和效果。方法2004年1月-2007年1月收治恶性输尿管梗阻病人85例,采用腔内泌尿外科微创治疗,其中72例经尿道膀胱镜下（25例）或输尿管镜下（47例）留置双J管,单侧42例,双侧30例,13例经皮肾穿刺微造瘘顺行放置2根双J管。结果所有病例均获随访,平均9（6-24）个月。术后下腹不适15例,排尿时腰部胀痛22例,肉眼血尿3例,均自行缓解。腹平片未发现双J管移位。术后3个月更换双J管时,未发现导管周围结石形成。71例患者留置双J管后引流通畅,尿量明显增加,肾功能复查,肌酐5-7 d恢复正常或接近正常,B超示置管侧肾积水减轻。14例患者术后B超示肾积水无明显改变,肾功能改善不明显,改行经皮肾穿刺微造瘘术后肾功能恢复正常。8例术后9-15月再发梗阻,经皮肾穿刺微造瘘术后肾功能恢复正常。结论恶性输尿管梗阻的腔内治疗创伤小,疗效确切,可以为患者解除痛苦,提高生活质量。     

单孔腹腔镜与非单孔腹腔镜胆囊切除术安全性及有效性的荟萃分析

目的系统评价单孔腹腔镜与非单孔腹腔镜胆囊切除术安全性及有效性。方法计算机检索Pubmed和万方数据库中有关单孔腹腔镜与非单孔腹腔镜胆囊切除术的随机对照实验(RCT)文献,依据Cochrane评价手册评价偏倚风险,并提交手术时间、术后疼痛评分、术后并发症发生率及术后美容评分等的相关数据进行荟萃分析。结果纳入4篇RCT文献,共236例患者。荟萃分析结果显示相比非单孔腹腔镜胆囊切除术,单孔腹腔镜技术不会显著性影响手术并发症的发生(OR 1.47;95%CI 0.73～2.97;P=0.28),且具有更高的术后美容评分(SMD 0.70;95%CI 0.40～0.99;P<0.00 001)。结论单孔腹腔镜胆囊切除术具有更好的美容效果和一定的安全性。但评价该术式和非单孔腹腔镜胆囊切除术在其他发面的优劣势,仍需要更多设计严谨和大样本的随机对照研究。