Partial laparoscopic adrenalectomy in primary hyperaldosteronism

Introductionprimary hyperaldosteronism is one of the few potentially curable causes of secondary arterial hypertension. One of the most important variants is the adenoma of the adrenal cortex that produces aldosterona (Conn's Syndrome). The treatment of choice in this subgroup of patients was the removal of the lesion. An initial series of patients with aldosteronoma subjected to partial laparoscopic adrenalectomy is presented.Materials and methodWe examined the case selection and methods applied to hypertensive patients subjected to partial laparoscopic adrenalectomy between November 2001 and March 2004 due to primary hyperaldosteronism. They all presented an imaging study (CT scan) compatible with a tumour of the adrenal cortex and, in two patients the lesion was bilateral. One patient had a history of incidental adrenalectomy during and open colecistectomy performed some years previously.Resultswe operated on 16 patients, 13 of them women and 3 men, with a mean age of 55.4 years. We performed 18 laparoscopic adrenalectomies: 17 conservative operations and one total adrenalectomy of a 4.3 cm tumour in a patient with bilateral lesion. The mean duration of the operations was 70.9 minutes, with a mean bleeding rate of 30 ml. There were no complications or the need to resort to open surgery. Postoperative hospital stay was 2.8 days. In all the cases, the hypertension improved totally or partially.Conclusionalthough small, the series confirmed that partial laparoscopic suprarenalectomy can be performed with good results and with the advantages of minimally invasive surgery.     

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.     

Robotic partial nephrectomy: an initial experience in 25 consecutive cases

ObjectiveTo report our initial experience with robotic partial nephrectomy (RPN) in a series of 25 consecutively-operated patients.Material and methodsA series of 25 consecutive patients who underwent RPN from April 2010 to February 2011 were studied. We used the da Vinci S HD robotic system with transperitoneal approach. Total renal hilum control was used 22 cases and 3 patients underwent selective renal parenchymal compression with an ad-hoc device.ResultsMean age was 55.8 years (26-77) with a male/female ratio of 2:1. Mean operative time was 117.6 minutes (54-205) and the warm ischemia time was 20.2 minutes (9-34). Mean estimated blood loss was 440 ml (20-2000) and the mean tumor size was 3.25 cm (1-5.3). Five patients (20%) had complications, the most frequent being intraoperative bleeding (Clavien II). There was no conversion to open or laparoscopic surgery. Mean hospital stay was 3.5 days (1-7). The pathological study revealed renal cell carcinoma in 19 cases and benign lesions in 6 patients. There were no positive surgical margins and no mortality.ConclusionsOur preliminary results show that RPN is a feasible surgical approach in small-sized renal tumors.     

Experiencia inicial con una serie de adrenalectomía laparoscópica asistida por robot

ObjectivesWe present our initial experience using robotic-assisted laparoscopic adrenalectomy in the surgical treatment of adrenal masses.Material and methodsA total of 18 patients (11 women and 7 men) diagnosed of a functioning or non-functioning adrenal tumor mass were operated on in our facilities between October 2009 and October 2011. Surgical variables, intra-hospital recovery time, pathological findings and peri- and post-operatory findings were evaluated.ResultsMean age of the population intervened was 51.2 years (range 18-81), average ASA score 2.11 (range 1-4) and BMI 27.0 (range 18.8-36.1). Of the 18 patients, 11 were operated on the left side and 7 on the right. Mean surgery time was 150 (range 84-329) min and intra-operatory bleeding 121 (range 10-1500) ml, with a mean loss of hemoglobin and hematocrits of 2.11 g/dl and 6.33%, respectively. Two patients were converted to conventional surgery. The factors influencing surgical conversion were: normal size (> 10 cm), tumor weight (> 100 g.), active pheochromocytoma and left localization of the tumor. Seven functioning cortical adenomas, 6 metastatic adrenal tumors, 3 pheochromocytoma and 2 incidental tumors were excised. Mean tumor size was 5.39 (range 3-15) cm. Median hospital stay was 6 days (range 4-14). Five patients had peri-operatory complication. Of these, only one (5%) had major complications (Clavien III). Mean follow-up was 6 months (range 2-24).ConclusionsRobotic technology for laparoscopic adrenalectomies is a valid option for adrenal tumor treatment. In our experience with a relatively short learning curve, it makes it possible to reduce hospital treatment times and the intra- and post-operatory complications, without affecting the oncological and post-operatory functional results.     

Cirugía conservadora de parénquima renal laparoscópica. Cinco años de experiencia

IntroductionLaparoscopic nephron-sparing surgery is among the most complex urological procedures currently performed. Open surgery continues to be the gold standard of care, but the laparoscopic approach is gaining ground slowly but surely. Our 5 years’ experience is reported.Materials and MethodsFrom September 2004 to March 2009, 38 laparoscopic nephron-sparing procedures were performed at our hospital. A transperitoneal laparoscopic approach was used in all cases, with en bloc clamping of renal hilum in most patients.ResultsMean operating time was 141 min, mean intraoperative bleeding 130 mL, mean warm ischemia time 24 min, and mean hospital stay 3.3 days. Bleeding was the most common complication (requiring transfusion in 13.5% of patients). Positive surgical margins were found in 5.4% of patients.ConclusionsAdequate selection of the patient (tumor size, location) and the procedure to be used, surgeon experience, and surgical skills are essential for achieving good oncological results and for minimizing the complications of this demanding procedure.     

Laparoscopic nephrectomy in children

IntroductionLaparoscopic nephrectomy in children, not as in the adult population, has evolved more slowly due to the misleading concept that children require small incisions and recover faster. The aim of this article is to present our experience in laparoscopic renal surgery in a paediatric population.Material and methodsWe checked the clinical records of children that were subjected to laparoscopic renal surgery at our institution between May 1993 and September 2010. We recorded the data prospectively and analysed it retrospectively. The variables we studied were surgical indication, age, sex, procedure and approach, surgery time, hospital stay, intraoperative bleeding, perioperative complications, conversion to open surgery, reintervention and blood transfusion rates.ResultsBetween May 1993 and September 2010, we operated a total of 72 patients, 45 nephrectomies (62.5%), 13 nephroureterectomies (18%) and 14 heminephrectomies (19.4%). The mean age was 68 months (range 3-168). The mean surgery time was 80.4 min. (range: 25-270 min.) with a estimated mean blood loss of 37.5 ml (range: 0 -1.000 ml). There were 3 (4.1%) conversions to open surgery. One was due to intraoperative bleeding and the other two were secondary to a difficult dissection due to a history of prior renal surgical interventions. The mean hospital stay was 3.17 days (range: 1-30 days) and there were 7 (9.72%) postoperative complications. There were no deaths.ConclusionsWe consider the laparoscopic approach for renal surgery in paediatric patients to be a feasible, safe and effective procedure that must be considered as the first option for the treatment of benign pathology in this population group.     

Adrenalectomía laparoscópica bilateral sincrónica: técnica quirúrgica y resultados perioperatorios en 13 años de experiencia

Introduction and objectivesLaparoscopic surgery is the standard approach for the treatment of adrenal glands. Bilateral synchronous adrenalectomy is rarely performed, and evidence about this procedure is limited. Our objective is to report our 13-year experience with synchronous laparoscopic bilateral adrenalectomy, evaluating its feasibility, safety, and perioperative outcomes.Patients and methodsA total of 23 consecutive patients undergoing synchronous bilateral laparoscopic adrenalectomy between 2007 and 2020 in a single academic center were included. Variables evaluated were operative time, estimated blood loss, conversion to open surgery, postoperative complications, mortality, and postoperative length of stay.ResultsMean operative time was 189.3 ± 48.9 min. Mean estimated blood loss was 163.0 ± 201.3 ml. There were no conversions to open surgery. Five patients had postoperative complications, three of those were major. No patient died in the perioperative period. Median postoperative length of stay was three days (range 1-30). At pathology analysis, 15 patients had bilateral adrenal hyperplasia, 2 unilateral adrenal hyperplasia and a contralateral benign tumor, 1 unilateral adrenal hyperplasia and a normal contralateral gland, 1 unilateral adenoma, 3 bilateral pheochromocytomas and 1 bilateral myelolipoma.ConclusionSynchronous bilateral laparoscopic adrenalectomy is a feasible and safe technique. A multidisciplinary and experienced team involving anesthesiologists and endocrinologists is required.     

Removal of an entrapped large metallic dilator from the sigmoid neovagina in a male-to-female transsexual using a laparoscopic approach

IntroductionTo describe the role of laparoscopy for removal of entrapped vaginal metallic dilator (20 cm in length and 3.5 cm in diameter) in a case of male-to-female transsexual.Presentation of the caseThe patient was a 24-year old male-to-female transsexual, presented with entrapment and upward migration of the vaginal metallic dilator 1 week before admission. She underwent gender reassignment surgery with sigmoid vaginoplasty 8 month before admission. After 3-port transperitoneal laparoscopic abdominopelvic exploration, through an incision over the sigmoid vagina the dilator was extracted. The sigmoid vagina was repaired with free-hand intracorporeal laparoscopic suturing and knot-tying techniques in two layers and the dilator was removed by extending the site of umbilical port. The operative time was 70 min.DiscussionUp to 60% of rectosigmoidal or vaginal foreign bodies can be extracted transanally or transvaginally with adequate sedation. When surgical exploration is indicated, a longitudinal laparatomy is performed to extract the foreign body. To reduce the associated morbidity of an open procedure in our patient, we performed a laparoscopic approach for complete abdominal exploration for possible presence of intestinal or sigmoidal injuries together with removal of this large metalic dilator.ConclusionLaparoscopic approaches in cases of neovaginal foreign body are useful when the endovaginal approaches have failed, especially in transsexual patients, to prevent another major open surgery.     

Laparoendoscopic single-site retroperitoneoscopic adrenalectomy compared with conventional laparoscopy and open surgery

ObjectiveLaparoendoscopic single-site surgery (LESS) is a new laparoscopy development that avoids the use of multiple ports and minimizes morbidity. Combined with retroperitoneoscopy, LESS is suitable for adrenalectomy. We compared open, conventional laparoscopic, and LESS-retroperitoneoscopic adrenalectomy (LESS-RA) surgeries for adrenal tumor removal. Furthermore, we analyzed the conventional retroperitoneoscopic adrenalectomy (CRA) and LESS-RA outcomes.Materials and MethodsWe examined 178 patients who underwent adrenalectomy: 43 by open surgery, 72 by conventional laparoscopy, and 63 by LESS-RA. We analyzed the outcomes of operative time, estimated blood loss (EBL), complications, postoperative convalescence, time to resuming oral intake, analgesics on demand, and hospital stay.ResultsWe found that the open surgery group had a significantly greater mean EBL than the conventional laparoscopy or LESS-RA group (353.1 ± 313.6 mL vs. 62.3 ± 76.9 mL vs. 60.9 ± 64.3 mL, respectively; p < 0.0001). Open surgery was lengthier than LESS-RA. Both hospital stay and time to resuming oral intake were shortest in the LESS-RA group, followed by conventional laparoscopy and open surgery. CRA and LESS-RA did not differ significantly in mean tumor size, operation time, or EBL. However, there were significant differences in postoperative hospital stay length (6.4 ± 3.4 days vs. 3.6 ± 1.3 days, respectively; p < 0.0001), time to resuming oral intake (1.2 ± 0.5 days vs. 0.4 ± 0.5 days, respectively; p < 0.0001), and number of on-demand intravenous or intramuscular analgesics needed (0.5 ± 0.8 ampoules/vial vs. 0.3 ± 0.6 ampoules/vial, respectively; p = 0.0484).ConclusionThe standard approach to adrenalectomy recently improved from open to laparoscopic surgery, transperitoneal to retroperitoneal access, and multiple ports to a single port. Here we found that laparoscopic surgery had better intra- and postoperative outcomes than open surgery. Furthermore, patients treated with LESS-RA required less postoperative recovery time and less analgesic use than those treated with CRA.     

Adrenal giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy

IntroductionGiant cystic pheochromocytoma (>10 cm) is rare with only a few cases described in the literature. Preoperative diagnosis is very difficult because clinical, biochemical and radiologic finds are usually not consistent with a pheochromocytoma. Open surgery is traditionally the gold standard.Case presentationA 51 year-old male patient resorted to surgery department with an adrenal cystic incidentaloma. He was asymptomatic, mild hypertension easily controlled, with increased plasma fractionated metanephrines. MRI and MIBG scans confirmed the presence of a right adrenal giant cystic pheochromocytoma (14 cm). A right posterior retroperitoneoscopic adrenalectomy was performed, complicated with an unintended disruption. At follow-up he was asymptomatic and with plasma fractionated metanephrines normalized.DiscussionAlthough laparoscopic surgery is effective and safe, traditional open surgery is the gold standard in the presence of adrenal tumours with suspicion of malignancy, like masses larger than 8 cm (including giant cystic pheochromocytomas). Minimal invasive techniques have the advantages of less postoperative pain and ileus, less morbidity, improved cosmetics, and faster recovery, but with the negative impact in R0 resection and probably a higher risk of cystic rupture. However comparisons between open and minimally invasive surgery are lacking. Additionally posterior retroperitoneoscopic approach has several advantages over laparoscopic transperitoneal method.ConclusionThis is the first case report of a giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy, but the occurrence of the unintended rupture may be a factor against this approach. More studies are needed to compare open and minimally invasive techniques in terms of resectability and cystic rupture rate.     

Clinical outcomes of laparoscopic adrenalectomy according to tumor size

Objectives: In order to evaluate the indication and usefulness of laparoscopic adrenalectomy, clinical outcomes of laparoscopic adrenalectomy for patients with adrenal tumors were examined. Whether tumor size affects surgical outcome was analysed, along with the long-term clinical outcome for these patients.
Patients and methods: A total of 63 patients with adrenal tumor underwent laparoscopic adrenalectomy in our institute between 1999 and 2003. A laparoscopic transperitoneal approach was used in all cases. Underlying pathologies comprised Cushing syndrome ( n  = 12), pheochromocytoma ( n  = 13), primary aldosteronism ( n  = 21), non-functioning adenoma ( n  = 12) and others ( n  = 5).
Results: No open conversion was performed. Mean operative duration was 239 min, and mean estimated blood loss was 134 mL. Tumor diameter was significantly smaller for primary aldosteronism than for Cushing syndrome, which in turn was significantly smaller than for adrenocorticotropic hormone-independent macronodular hyperplasia (AIMAH). No significant differences in surgical outcome and postoperative recovery were noted between large (≥5 cm) and small (<5 cm) tumors. Long-term clinical outcome was better for patients with pheochromocytoma or primary aldosteronism than for patients with Cushing syndrome.
Conclusions: Laparoscopic adrenalectomy for benign tumor offers excellent surgical outcomes and convalescence. This is true for both small and large tumors.     

Laparoscopic simple prostatectomy (adenomectomy): experience in 59 consecutive patients

ObjectiveLaparoscopic adenomectomy 150 is a minimally invasive alternative to open surgery in large prostates. Our aim is to discuss our series of 59 patients treated by means of laparoscopic adenomectomy with precise vascular control.Materials and methodsBetween June 2003 and June 2006, a total of 59 patients with a mean age of 65.5 years (51 to 82), underwent laparoscopic extraperitoneal adenomectomy. All the patients had a history of lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH). The mean International Prostate Symptom Score (IPSS) was 20 points (16-22). The information was collected prospectively in a database. The analysis was performed subsequently.ResultsAll 59 adenomas were completely removed laparoscopically without conversion to open surgery. The mean preoperative prostate volume by ultrasound was 108.5 cc (75-150). The average operating time was 123 minutes (90-180). The mean loss of blood was 415 ml (50-1500) and 4 patients (14.8%) required a blood transfusion. Two (7.4%) of the patients presented perioperative complications. The mean hospital stay and the bladder catheterization time were 3.5 (2-7) and 4.2 (3-7) days respectively.ConclusionsLaparoscopic extraperitoneal simple prostatectomy is an effective procedure for the treatment of large prostatic adenomas. There seems to be less perioperative morbidity and, in our experience, this technique seems to be feasible and reproducible; however, its learning curve is a complicated matter to deal with.     

Robotic-assisted laparoscopic radical cystectomy: evaluation of functional and oncological results

Purposeradical cystectomy remains the most effective treatment for patients with localized, invasive bladder cancer and recurrent noninvasive disease. We report our experience with 84 consecutive cases of robotic assisted laparoscopic radical cystectomy with regard to perioperative results, pathological outcomes and surgical complications.Materials and methodsa total of 84 consecutive patients (70 male and 14 female) underwent robotic radical cystectomy and urinary diversion at our institution from January 2007 to August 2010 for clinically localized bladder cancer. Outcome measures evaluated included operative variables, hospital recovery, pathological outcomes and complication rate.Resultsmean age of this cohort was 65.5 years (range 28 to 82). Of the patients 62 underwent ileal conduit diversion, 22 received a neobladder. Mean operating room time for all patients was 261 min. (range: 243-618 min.) and mean surgical blood loss was 298 ml (range: 50-2000 ml). 29% of the cases were pT1 or less disease, 38% were pT2, 26% and 7% were pT3 and T4 disease respectively, 15% were node positive. Mean number of lymph nodes removed was 15 (range 1 to 33). In 2 cases (2.4%) there was a positive surgical margin. Mean days to flatus were 2.12, bowel movement 2.87 and discharge home 17.7 (range: 10-33). There were 45 postoperative complications with 11.9% having a major complication (Clavien grade 3 or higher). At a mean followup of 16.7 months 10 patients (11%) had disease recurrence and 2 died of disease.Conclusionsour experience with robotic radical cystectomy for the treatment of bladder cancer suggests that in proper hands this procedure provides acceptable surgical and pathological outcomes.     

Transfusion requirements, morbidity and mortality in cardiac surgery and the use of antifibrinolytic agents: a comparison of aprotinin and tranexamic acid

ObjectiveTo evaluate transfusion requirements, morbidity and mortality when 2 antifibrinolytic agents (aprotinin and tranexamic acid) were used in patients undergoing cardiac surgery.Patients and methodsComparison of the effects of 2 antifibrinolytic agents in 243 patients undergoing cardiac surgery between December 2006 and June 2008. We recorded the surgical procedures used, blood product transfusions required, complications (particularly renal), mortality, and length of hospital stay.ResultsThe patients were distributed into 2 groups to receive tranexamic acid (n = 144) or aprotinin (n = 99). The incidence of transfusion in the tranexamic acid group (31.94%) was nonsignificantly lower than in the aprotinin group (38.38%) (P = .31). The mean (SD) number of units of packed red blood cells transfused was 0.67 (1.18) in the tranexamic acid group and 1.01 (1.54) in the aprotinin group (P = .07). The mean preoperative hemoglobin concentration in the tranexamic acid group (11.79 [1.71]  mg/ dL) was significantly lower than in the aprotinin group (12.35 [1.70]  mg/ dL) (P < .01). Incipient postoperative renal failure tended to occur more frequently in the aprotinin group (19.6% compared to 16%; P = .47). Mortality at 1 year was 9.02% in the tranexamic acid group (compared to 14.14% in the aprotinin group; P = .21); the trend for mortality related to postoperative renal failure was similar (7.6% in the tranexamic acid group compared to 12.4% in the aprotinin group; P = .22). No significant differences were observed in postoperative complications or length of hospital stay. However, the lack of randomization and the small sample size do not allow for definitive conclusions.ConclusionsThis study, subject to the aforementioned limitations, shows that tranexamic acid is as effective as aprotinin for reducing transfusion requirements in cardiac surgery in Spain     

经腹、经后腹腔途径腹腔镜肾上腺肿瘤切除术(附56例报告)

目的 总结经腹腔、经后腹腔途径腹腔镜肾上腺肿瘤切除术的临床经验. 方法 2001年12月～2004年12月,我院施行腹腔镜肾上腺切除术56例.采用经腹腔途径肾上腺肿瘤切除术10例,腹部取3个trocar 穿刺入路,切开侧腹膜和肾周筋膜,在肾上极内上方分离肾上腺或瘤体,结扎速结合超声刀将肿瘤切除.经后腹腔途径切除肾上腺肿瘤46例,腰部取3个trocar 穿刺入路,用自制的气囊扩张后腹腔,切开肾周筋膜,在肾上极内上方分离肾上腺或瘤体,结扎速结合超声刀将肿瘤切除. 结果 10例经腹腔途径中3例因腹腔广泛粘连中转开放手术,46例经后腹腔途径中1例因下腔静脉损伤大出血中转开放手术.余52例术中出血量20～200 ml,平均70 ml,均未输血.手术时间40～200 min,平均110 min.术后住院3～8 d,平均5.4 d.52例随访6～36个月,平均8个月,未见肿瘤复发和转移. 结论 腹腔镜肾上腺切除术效果确切,损伤小,术后恢复快,住院时间短,是肾上腺手术的首选术式.     

Suprarrenalectomía retroperitoneoscópica por puerto único: experiencia inicial y estandarización de la técnica

Introduction and objectiveThe minimally invasive surgical approach to adrenal gland pathology is the most widely used nowadays, and retroperitoneoscopy occupies a relevant place. However, the evolution of these techniques towards even less invasive surgery through single-port access is anecdotal. The aim of this work is to describe our initial experience in single-port retroperitoneoscopic surgery (SPORS) of the adrenal gland focusing on perioperative data and postoperative pain.Material and methodsWe collected and analyzed the demographic and operative data of a series of patients undergoing adrenalectomy through SPORS. All procedures were performed through a single 3-4 cm subcostal incision with a multichannel port. Surgical data such as operative time, bleeding, length of stay and presence of complications were collected. We used the visual analog scale (VAS) for postoperative pain assessment.ResultsFrom December 2018 to August 2020, 6 patients with different types of adrenal pathology underwent consecutive surgeries in our Department by the same surgeon using SPORS. All surgeries were performed without requiring accessory trocar placement or reconversion to open surgery. The mean operative time was 91.6 ± 16.3 minutes, with < 150 mL bleeding, mean length of stay of 35.8 ± 13.3 hours and postoperative pain of VAS ≤3 (median 0.5). The mean size of specimens was 57.8 ± 18 mm. No complications were reported according to the Clavien-Dindo scale.ConclusionsEven in initially adverse cases, SPORS adrenalectomy is a feasible and safe technique with good cosmetic and perioperative results.     

Control de la hemostasia durante la nefrectomía parcial laparoscópica sin renorrafia parenquimatosa: la experiencia Vivostat®

ObjectiveTo present our experience using an autologous fibrin sealant prepared with the Vivostat system^® to control haemostasis without any renal parenchymal reconstruction.Material and methodsWe performed 45 laparoscopic partial nephrectomies using this haemostatic agent. The surgical steps were: colon mobilization, identification of ureter, renal vessels and renal tumor, renal artery control with Rummel tourniquet, tumor excision with harmonic scalpel, application of fibrin glue to the resection bed twice (before and after kidney reperfusion). Patients were evaluated for acute or delayed bleeding.ResultsMean age was 63.9 years (33-80); mean tumor size was 2.5 cm (1.5-4); mean operative time was 136.1 min (90-180). Mean warm ischemia time was 19.2 min (10-30). Mean blood loss was 97 ml (50-300). Individual haemostatic stitches were performed before application of the sealant if acute bleeding was observed (14 cases). We did not achieve any case of postoperative bleeding from resection bed or renal failure. 1 patient required transfusion due to an abdominal wall haematoma. 65% were clear cell carcinoma, 10% were papillary carcinoma, 20% were oncocitoma. Free margin rate was 100%. Mean hospital stay was 4 days (2-6). Mean follow-up was 14 months (5-45).ConclusionsExcluding renorrhaphy during laparoscopic partial nephrectomy is feasible and safe. Our initial experience with the vivostat system in laparoscopic partial nephrectomy has been encouraging, but longer follow-up is needed to determine the real benefit of this surgical technique in laparoscopic partial nephrectomy     

Comparative study between laparoscopic extraperitoneal and open adenomectomy

ObjectivesIn spite of the development of endoscopic techniques, open adenomectomy continues to be the treatment of choice for large adenomas. Laparoscopic and robotic adenomectomy provides good results in specialized centers. The experience acquired with laparoscopic extraperitoneal adenomectomy (LEA) in a regional center is presented to evaluate its results and compare them prospectively with the results of open surgery.Patients and methods46 patients with benign prostatic hyperplasia (BPH) (prostate >80 g) and an indication for surgery were evaluated. The first 11 patients underwent LEA and were not included in the comparison. Thereafter, the cases were compared; 17 patients underwent LEA and 18, open surgery. In the extraperitoneal technique with 4 trocars, enucleation was performed with an ultrasonic scalpel.ResultsThere were no significant differences between groups in age, prostate volume, uroflow (Qmax), International Prostate Symptom Score (IPSS), Quality of Life scale (QoLs). The operation time was significantly greater in the LEA group (135.2 vs. 101.2 minutes, p=0.022). Intraoperative bleeding (250 vs. 493.3 ml, p = 0.004), irrigation time (22.2 vs. 39.1 hours, p = 0.038), catheter indwelling time (5.5 vs. 7.5 days, p = 0.030), hospital stay (3.7 vs. 6.6 days, p = 0.006) and transfusion rate (0 vs. 22.2%) were significantly less in the laparoscopy group. There was a greater incidence of hemorrhagic and surgical wound complications in the open surgery group.ConclusionsLEA is a relatively complex technique that requires laparoscopic skills, but it is a feasible and safe alternative to open surgery and has several advantages.     

Laparoscopic adrenalectomy for pheochromocytoma: morbidity compared with adrenalectomy for tumors of other pathology

PURPOSE: We report our experience with laparoscopic adrenalectomy in nine patients with pheochromocytoma and compare the morbidity with that of laparoscopic adrenalectomy for tumors of other pathology. PATIENTS AND METHODS: Between January 1997 and November 1999, nine patients underwent laparoscopic surgery for pheochromocytoma via a transperitoneal approach. Of the patients, eight had solitary tumors, and one presented with bilateral pheochromocytomas. The mean size of the tumors was 5.4 cm. The surgical outcomes of the 9 patients were compared with those of 28 patients with adrenal tumors of other pathology (primary aldosteronism in 15 patients, Cushing syndrome in 6, and nonfunctioning adenoma in 7) who underwent transperitoneal laparoscopic adrenalectomy during the same period. The mean size of the adrenal tumors of other pathology was 2.4 cm. RESULTS: In eight of the nine patients with pheochromocytoma, laparoscopic adrenalectomy was successful. The procedure was converted to open surgery in the patient with bilateral tumors because of uncontrollable hemorrhage. A hypertensive crisis with the systolic blood pressure >200 mm Hg occurred in 6 patients (67%), but the episode could be controlled by temporary discontinuation of tumor manipulation, administration of drugs, or both. In adrenalectomy for pheochromocytoma, the mean operative time was longer (199 v 177 minutes) and the mean estimated blood loss was greater (360 v 54 mL) than for tumors of other pathology. Blood transfusion was given to two patients with pheochromocytoma but to no patient with tumors of other pathology. The patients with adrenal tumors of other pathology could resume normal activity earlier (mean 18 v 26 days) than those with pheochromocytoma. CONCLUSION: The operation is more difficult and the morbidity is higher in laparoscopic adrenalectomy for pheochromocytoma than that for tumors of other pathology. An experienced team of surgeons with advanced laparoscopic skills and anesthesiologists is mandatory. In large tumors, great caution should be taken for intraoperative complications. Nevertheless, laparoscopic adrenalectomy is not contraindicated for pheochromocytoma and can be performed safely.