Management of superficial transitional cell carcinoma in the intramural ureter: what to do?

PURPOSE: We analyze the evolution of superficial transitional cell carcinoma in the intramural distal ureter treated with transurethral resection. MATERIALS AND METHODS: A total of 19 patients underwent transurethral resection of the intramural distal ureter with a mean followup of 57 months. All cases were diagnosed as superficial transitional cell carcinoma and all but 2 had a history of bladder tumor. Upper urinary tract followup consisted of excretory urography every 6 months and ureterorenoscopy in cases with a doubtful diagnosis or positive cytology. RESULTS: Pathological examination revealed stage Ta disease in 42%, T1 in 31.5% and Tx in 26.3% of intramural tumors. Upper urinary tract recurrence was noted in 8 patients (42.1%), including 5 (62.5%) with involvement of the distal ureter. Nontumoral stenosis of the distal ureter in 3 cases was treated endoscopically. An endoscopic procedure resolved 75% of recurrences. A high surgical risk patient who did not undergo open surgery died of recurrence. CONCLUSIONS: Superficial transitional cell carcinoma of the intramural ureter is uncommon in the setting of multiple bladder tumors and recurrent bladder carcinoma. There was a 42.1% rate of ipsilateral recurrence and endoscopic treatment allowed us to preserve 89.5% of the involved renal units. Closer followup of the urinary tract must be performed since these tumors have a higher incidence of upper urinary tract recurrence.     

Does laparoscopic surgery have a role in the treatment of gallbladder cancer?

Background/Purpose: This study was conducted to evaluate the role of laparoscopic surgery in the treatment of gallbladder cancer. Methods: A retrospective study was performed on 31 patients with a postoperative diagnosis of gallbladder cancer. The laparoscopic approach was initially applied to all of them. Results: Ten patients had a pT1a cancer, and all underwent laparoscopic cholecystectomy without recurrence. Nine patients had pT1b lesions, and three had to be converted to an open operation. There were two recurrences. In one of the converted patients the cystic node was invaded. Seven patients had a pT2 lesion, and in four of them the operation was converted to an open procedure. Recurrences were noted in three patients. In two patients with pT3 cancer, the opera-tions were converted; both cancers recurred. Only diagnostic laparoscopy or a palliative laparoscopic procedure was performed for pT4 cancers. The median follow-up time was 17.0 months. The 5-years survival rate was 100% for patients with stage pT1a, 100% for pT1b, and 68% for pT2 lesions. Conclusions: We suggest that when a polypoid lesion of the gallbladder is found on preoperative evaluation, laparoscopic surgery may be attempted initially. During the procedure it is important to open all specimens when a polypoid lesion is present and perform a frozen section biopsy. When a pT1a lesion is found, laparoscopic cholecystectomy is sufficient; however, when a pT1b or more advanced lesion is found, the operation might be converted to a radical cholecystectomy. Received: July 2, 2002 / Accepted: July 2, 2002 Offprint requests to: E.K. Kim     

Aggressive surgery for stage IV gallbladder carcinoma; what are the contraindications?

Background/Purpose Advanced gallbladder carcinoma with paraaortic lymph node metastasis or distant metastasis is normally considered a contraindication for surgery. Our latest analyses suggest otherwise. Methods Records of 166 patients who underwent surgery for stage IV gallbladder carcinoma were reviewed retrospectively. Predictors of hospital mortality and long-term survival were analyzed. Long-term survival in patients with paraaortic lymph node metastasis and/or distant metastasis was also determined. Results Fifteen patients were 5-year survivors, with a 5-year survival rate of 12% among the 166 patients investigated. Overall hospital mortality was 14%. Male sex and portal vein resection were independent predictors of hospital mortality. Multivariate analysis of long-term survival failed to identify independent predictors. Patients with distant metastasis were divided into two groups based on whether or not the metastases were distant from the liver. Patients with paraaortic lymph node metastasis who underwent curative resection or who had isolated liver metastasis survived longer than those with other distant metastasis or those with unresectable advanced cancer. Conclusions Patients with advanced gallbladder carcinoma can benefit from surgical resection even when paraaortic lymph node metastasis and/or liver metastasis are present. However, surgical indications in advanced disease should be determined on an individual basis, based on clinical status.     

The unhappy patient following facial plastic surgery: what to do?

Some patients are unhappy with the results of facial plastic surgery, even if the surgeon is pleased with the outcome. Dealing with this potential problem begins with the preoperative assessment as to how the patient might handle a result that is less than perfect. "When in doubt, don't" is a good rule but needs refinement. This article, based on some 40 years of experience, attempts to provide that refinement.     

How to maintain the quality of laparoscopic surgery in the era of lack of hands?

Lack of personnel in the operating rooms is not a future problem, it is today's reality in many hospitals throughout the OECD countries. As studies anticipate that this situation will not change overnight (1), the issue of the quality of surgery within this new environment needs to be addressed on short notice. The problem is even more critical for laparoscopic surgeons, who have enjoyed proportionally more assistance since the emergence of minimally invasive surgery. After analyzing the tasks performed by OR assistants and nurses, we have looked at available techniques and tools (2) that could help laparoscopic surgeons, using the following criteria to assess their benefits : capability to address the shortage of assistance, impact on quality of surgery, economic affordability within the existing Belgian healthcare system.     

Indications of coronary angioplasty and stenting in 2003: what is left to surgery?

For many years, coronary artery by-pass graft (CABG) remained the only effective treatment of multivessel disease compared to medical treatment. The first technical revolution was in 1977 when Gruentzig introduced balloon percutaneous transluminal coronary angioplasty (PTCA), the 2nd in the 90's with the developments of stents and antiaggregant protocols. The equipment for PTCA became more and more sophisticated, and the skill of cardiologists greater. In the 90's, interventional cardiology played a predominant role in revascularization as the number of CABG decreased at the same time, and emergency CABG for bail out almost disappeared (0% to 0.5%). Systematic stenting decreased the need for repeat revascularization to about 18-20% nowadays in the majority of centers, except in diabetic patients. Despite this fact restenosis remains the pitfall of angioplasty, mostly in diabetic patients presenting multivessel disease in which surgery with "all arterial grafts" gives good long term RESULTS: The first studies comparing PTCA and CABG are favourable to surgery (BARI), then late ones using stents (ARTS, ERACI 2) showed that stenting was at least equivalent to CABG, in terms of mortality or serious complications (major acute coronary events, MACE), despite a higher target vessel revascularisation (TVR) mainly due to restenosis in the angioplasty cohort. The same results are observed by stenting a high risk lesion as the unprotected left main stenosis can be, until then treated surgically. However, high volume centers studies treating by PTCA+stent the unprotected left main artery (LMA) shows that the 1 year survival rate is similar to surgery, but always related to a restenosis rate of 20% at 6 months in the stent group, which represents the only significant difference in terms of MACE; the new drug eluting stents lead us to expect, according to SIRIUS and TAXUS II studies, to reduce the restenosis rate, and by the way, the MACE could be dramatically lowered from 50% to 60%. Randomised studies would be necessary, but the extrapolation of the actual data, more particularly results of subgroups with a high risk of restenosis, diabetic patients and small vessels, lead us to think that stenting could come in first intention before surgery if TVR is significantly reduced. A complex anatomy, failed attempted chronic occlusion, several lesions on tortuous vessels, would remain the last surgical indication if CABG provides a more complete revascularization. The impact of these new drugs seems promising. However, we should await early results of studies in diabetic patients and bifurcations. But in high volume experienced centers, CABG indications would be reduced in the future to the technical pitfalls of stenting (complex or tortuous anatomy, chronic occlusions) or to the adverse additional cost of this device, unless reduction of restenosis or TVR could also cancel this extra cost. We expect randomised studies CABG versus stented angioplasty using drug eluting stents to confirm these preliminary data.     

Periprosthetic femoral fractures: What to do,what to do?

Post-operative periprosthetic fractures have an incidence of 1.1% (Berry, 1999 [1]). The periprosthetic fracture is commonly classified by the location of the fracture. The most frequently utilized fracture classification categorizes patients by the location of the fracture including: peritrochanteric, around the stem, or distal to the femoral implant. Additional considerations incorporated in this classification include femoral implant stability and host bone status. We will review the different treatment modalities for each fracture type with consideration given to stem stability and host bone status.     

Is laparoscopic surgery the technique of choice in nephrectomy?

Laparoscopic is performed in adults for the treatment of benign renal diseases. It is widely accepted that laparoscopic surgery has more advantages than open surgery in many procedures such as nephrectomy, but there is no further experience in this technique. In pediatric urology laparoscopy has become an accepted approach for varicocele, non palpable testis, bladder augmentation, adrenalectomy and urinary diversion. We report our experience with 25 laparoscopic nephrectomies in children.     

Do complications related to laparoscopic cholecystectomy influence the prognosis of gallbladder cancer?

Background: Laparoscopy is thought to worsen the prognosis of gallbladder cancer (GBC) discovered unexpectedly at laparoscopic cholecystectomy (LC). However, laproscopy has never been shown to have an influence on patient survival in clinical series. Methods: We Performed a two-center retrospective analysis of 28 patients with GBC (11 previously known, 17 unexpectedly discovered by LC) to determine whether laparoscopy and complications related to LC had any influence on the prognosis of GBC. Resectability for cure after LC, survival, and recurrence related to both the procedure itself and complications associated with LC were analyzed. Results: Of the 17 patients with unexpected GBC, 16 were considered resectable for cure at the time of LC. Advanced disease was detected in eight patients by re staging (n = 5) or exploration (n = 3). Seven patients (43.8%) underwent reoperation for cure. Mean survival of patients with unexpected GBC was 26.5 months. Mean survival was shorter when complications (bile spillage, injury of common bile duct, or tumor violation) occurred during LC (10.2 vs 33 months, p = 0.016). If bile spillage was the only complication at LC, there was also a trend to shorter survival (12 vs 33 months, p = 0.061). Conclusion: Complications during LC significantly worsen the prognosis of GBC. Therefore, bile spillage and excessive manipulation of the gallbladder should be avoided.     

Do laparoscopic skills transfer to robotic surgery?

Background

Identifying the set of skills that can transfer from laparoscopic to robotic surgery is an important consideration in designing optimal training curricula. We tested the degree to which laparoscopic skills transfer to a robotic platform.

Methods

Fourteen medical students and 14 surgery residents with no previous robotic but varying degrees of laparoscopic experience were studied. Three fundamentals of laparoscopic surgery tasks were used on the laparoscopic box trainer and then the da Vinci robot: peg transfer (PT), circle cutting (CC), and intracorporeal suturing (IS). A questionnaire was administered for assessing subjects' comfort level with each task.

Results

Standard fundamentals of laparoscopic surgery scoring metric were used and higher scores indicate a superior performance. For the group, PT and CC scores were similar between robotic and laparoscopic modalities (90 versus 90 and 52 versus 47; P > 0.05). However, for the advanced IS task, robotic-IS scores were significantly higher than laparoscopic-IS (80 versus 53; P < 0.001). Subgroup analysis of senior residents revealed a lower robotic-PT score when compared with laparoscopic-PT (92 versus 105; P < 0.05). Scores for CC and IS were similar in this subgroup (64 ± 9 versus 69 ± 15 and 95 ± 3 versus 92 ± 10; P > 0.05). The robot was favored over laparoscopy for all drills (PT, 66.7%; CC, 88.9%; IS, 94.4%).

Conclusions

For simple tasks, participants with preexisting skills perform worse with the robot. However, with increasing task difficulty, robotic performance is equal or better than laparoscopy. Laparoscopic skills appear to readily transfer to a robotic platform, and difficult tasks such as IS are actually enhanced, even in subjects naive to the technology.