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V11-05 LAPAROENDOSCOPIC SINGLE-SITE (LESS) VARICOCELECTOMY USING INDOCYANINE GREEN FLUORESCENCE (ICG) ANGIOGRAPHY
THE JOURNAL OF UROLOGYâ
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adrenal tissue can be spared by selective tumor devascularisation. Excessive bleeding can be avoided by verifying sufficient ischemia in the resection zone, using the NIRF system. CONCLUSIONS: RAPAd in selective ischemia is feasible and safe in the treatment of small adrenal tumors. Standardizing the operation improves reproducibility of the procedure. Source of Funding: none
V11-04 BILATERAL LAPAROSCOPIC ADRENAL TUMOR RESECTION Daniel Salas, Joan Palou*, Oscar Rodríguez, Alberto Breda, ~a, Andre s Kanashiro, Nicola s Nervo, Juan Antonio Pen Humberto Villavicencio, Barcelona, Spain INTRODUCTION AND OBJECTIVES: Since the first laparoscopic adrenalectomy described by Gagner et al in 1992, it has become the approach of election, been safe and effective. Castillo et al presented by first time in the Spanish literature a serial cases of primary aldosteronism caused by adenomas where he performed partial laparoscopic resections with favorable conclusions. METHODS: This is a case of a 44 years old male with secondary hypertension caused by primary aldosteronism by bilateral adrenal masses (Conn Syndrome) 19 mm right y 23 mm left side. Without achieving medical control of hypertension, the resection of both adrenal masses was decided, after laterality functional studies went no conclusive, to be performed in a single procedure. RESULTS: A transperitoneal approach is performed. We started with the right side: the patient is positioned in the left lateral flank position. Pneumoperitoneum using open technique, opening of the retroperitoneal space, identification and dissection of the adrenal gland, identification, dissection and resection of right adrenal tumor. Hemostasis with the bipolar grasper. The patient is re-positioned in the right lateral flank position. Pneumoperitoneum using open technique. The line of Toldt is incised and the colon retracted medially, the spleen and tail of pancreas are also mobilized cephalad and medially, identification of the adrenal tumor in the anterior inner edge of the gland and the enucleation of adrenal adenoma is performed The Operative time was 190 minutes with minimal bleeding. The patient was discharge in the 3rd postoperative day without any incidents. Less requirement of anti-hypertensive drugs since the postoperative time was reported. The pathology reported bilateral adrenal adenomas 3.5cm left and right 2.5cm side. The tests one month after surgery showed normal potassium. The hypertension was controlled with fewer drugs, without requirement of corticosteroid therapy. In our center we have performed in the last 10 years 38 laparoscopic adrenalectomy, 27 with benign results, been our most frequently found pheochromocytoma. CONCLUSIONS: The laparoscopic adrenal tumor resection (partial adrenalectomy or enucleation) could be considered the procedure of choice in cases of accessible tumors with bilateral tumors or single gland. This is our first case of laparoscopic bilateral adrenal tumor resection in one surgical time. The procedure coursed without complications and favorable clinic results. Source of Funding: None
V11-05 LAPAROENDOSCOPIC SINGLE-SITE (LESS) VARICOCELECTOMY USING INDOCYANINE GREEN FLUORESCENCE (ICG) ANGIOGRAPHY Keiji Tomita*, Eiki Hanada, Susumu Kageyama, Kazuyoshi Johnin, Mitsuhiro Narita, Akihiro Kawauchi, Otsu-city, Japan INTRODUCTION AND OBJECTIVES: Varicocelectomy is the most commonly performed operation for the treatment of male infertility.
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
Today, for this condition, the current standard surgical procedures are microscopic inguinal or subinguinal operations, laparoscopic retroperitoneal repair and sclerotherapy with the microsurgical technique is most popular approach of them. The treatment should be safe, minimally invasive and have a low rate of recurrence. Laparoscopic repair has higher recurrence rate than the microscopic technique with recurrences due to collaterals. On the other hand, Laparoscopic varicocelectomy should allow preservation of the testicular artery in a majority of cases, as well as preservation of lymphatics. We think that the persistent tiny vessels near the preserved arteries and lymphatics also cause recurrences. Therefore, to facilitate the identification of veins and to ensure the ligation, we performed Laparoendoscopic single-site (LESS) varicocelectomy using indocyanine green (ICG) fluorescence angiography. METHODS: A 2.5cm skin incision was made on the umbilicus with an approximately 3.5cm fascia incision. We used the OCTO PORT?, which had one 12mm port and two 5mm ports. After the exposure of the spermatic cord blood vessels, 1 ml of ICG (2.5mg/ml) was injected intravenously. The spermatic veins were sealed by ENSEAL? and cut. The spermatic artery and lymphatics were preserved. ICG was injected intravenously again in order to confirm that the arterial blood flow was preserved and that there was no remaining vein. RESULTS: About 20seconds after injection of ICG, one spermatic artery could be clearly identified. And further about 20seconds after, 3 spermatic veins were identified. The artery could be preserved and the veins were sealed and cut. At this time, we performed ICG angiography again. The flow of the artery was adequately preserved and 1minute after the injection, venous flow was not observed. 3months after this operation, the varicocele had completely disappeared as was confirmed by color Doppler ultrasonography. CONCLUSIONS: LESS varicocelectomy using ICG angiography facilitates identification of blood vessels and lymphatics by enabling the visualization of the spermatic cord blood arteries and vessels. We will continue to investigate whether this procedure will be considered a beneficial method. Source of Funding: none
V11-06 POSTERIOR RETROPERITONEOSCOPIC BILATERAL ADRENALECTOMY IN ECTOPIC CUSHIN’S SYNDROME ~ena*, Alberto Jurado Navarro, Patricio Garcia Marchin Ignacio Costabel, Jorge Jaunarena, Oscar Damia, Jose noma de Buenos Aires, Argentina Guillermo Gueglio, Ciudad Auto INTRODUCTION AND OBJECTIVES: Over the years, a number of different surgical approaches to the adrenal glands have been described. Minimally invasive adrenalectomy has become the procedure of choice for benign adrenal pathology. Although the adrenal glands are located in the retroperitoneum, most surgeons prefer the transperitoneal laparoscopic approach. The purpose of this video is to show the feasibility of performing a posterior retroperitoneoscopic bilateral adrenalectomy in a woman with ectopic Cushin’s syndrome. METHODS: A 23-year-old woman presented with past medical history of metastatic Pancreatic Neuroendocrine Tumor with ectopic production of Gastrin and ACTH treated with Lanreotide since 2004. The patient was referred to the department of urology with Cushin’s disease, refractory to medical treatment. The CT scan showed an enlarged liver due to multiple metastases, that collapsed the right adrenal space. For this reasons, we decided a posterior retroperitoneoscopic bilateral adrenalectomy. RESULTS: The patient was placed in prone position. Three trocars were placed 2 centimeters under the 12th rib, between sacroespinalis muscle and posterior axillary line. A small cavity in the retroperitoneum was made with blunt finger dissection. Once the right adrenal space was created, we could identify the anatomic landmarks (psoas, diaphragm, liver). Dissection of the gland was begun with lower margin detachment from the upper kidney pole in a lateral to medial direction using 5?mm ultrasonic dissector. After exposing adrenal gland
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adrenal tissue can be spared by selective tumor devascularisation. Excessive bleeding can be avoided by verifying sufficient ischemia in the resection zone, using the NIRF system. CONCLUSIONS: RAPAd in selective ischemia is feasible and safe in the treatment of small adrenal tumors. Standardizing the operation improves reproducibility of the procedure. Source of Funding: none
V11-04 BILATERAL LAPAROSCOPIC ADRENAL TUMOR RESECTION Daniel Salas, Joan Palou*, Oscar Rodríguez, Alberto Breda, ~a, Andre s Kanashiro, Nicola s Nervo, Juan Antonio Pen Humberto Villavicencio, Barcelona, Spain INTRODUCTION AND OBJECTIVES: Since the first laparoscopic adrenalectomy described by Gagner et al in 1992, it has become the approach of election, been safe and effective. Castillo et al presented by first time in the Spanish literature a serial cases of primary aldosteronism caused by adenomas where he performed partial laparoscopic resections with favorable conclusions. METHODS: This is a case of a 44 years old male with secondary hypertension caused by primary aldosteronism by bilateral adrenal masses (Conn Syndrome) 19 mm right y 23 mm left side. Without achieving medical control of hypertension, the resection of both adrenal masses was decided, after laterality functional studies went no conclusive, to be performed in a single procedure. RESULTS: A transperitoneal approach is performed. We started with the right side: the patient is positioned in the left lateral flank position. Pneumoperitoneum using open technique, opening of the retroperitoneal space, identification and dissection of the adrenal gland, identification, dissection and resection of right adrenal tumor. Hemostasis with the bipolar grasper. The patient is re-positioned in the right lateral flank position. Pneumoperitoneum using open technique. The line of Toldt is incised and the colon retracted medially, the spleen and tail of pancreas are also mobilized cephalad and medially, identification of the adrenal tumor in the anterior inner edge of the gland and the enucleation of adrenal adenoma is performed The Operative time was 190 minutes with minimal bleeding. The patient was discharge in the 3rd postoperative day without any incidents. Less requirement of anti-hypertensive drugs since the postoperative time was reported. The pathology reported bilateral adrenal adenomas 3.5cm left and right 2.5cm side. The tests one month after surgery showed normal potassium. The hypertension was controlled with fewer drugs, without requirement of corticosteroid therapy. In our center we have performed in the last 10 years 38 laparoscopic adrenalectomy, 27 with benign results, been our most frequently found pheochromocytoma. CONCLUSIONS: The laparoscopic adrenal tumor resection (partial adrenalectomy or enucleation) could be considered the procedure of choice in cases of accessible tumors with bilateral tumors or single gland. This is our first case of laparoscopic bilateral adrenal tumor resection in one surgical time. The procedure coursed without complications and favorable clinic results. Source of Funding: None
V11-05 LAPAROENDOSCOPIC SINGLE-SITE (LESS) VARICOCELECTOMY USING INDOCYANINE GREEN FLUORESCENCE (ICG) ANGIOGRAPHY Keiji Tomita*, Eiki Hanada, Susumu Kageyama, Kazuyoshi Johnin, Mitsuhiro Narita, Akihiro Kawauchi, Otsu-city, Japan INTRODUCTION AND OBJECTIVES: Varicocelectomy is the most commonly performed operation for the treatment of male infertility.
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
Today, for this condition, the current standard surgical procedures are microscopic inguinal or subinguinal operations, laparoscopic retroperitoneal repair and sclerotherapy with the microsurgical technique is most popular approach of them. The treatment should be safe, minimally invasive and have a low rate of recurrence. Laparoscopic repair has higher recurrence rate than the microscopic technique with recurrences due to collaterals. On the other hand, Laparoscopic varicocelectomy should allow preservation of the testicular artery in a majority of cases, as well as preservation of lymphatics. We think that the persistent tiny vessels near the preserved arteries and lymphatics also cause recurrences. Therefore, to facilitate the identification of veins and to ensure the ligation, we performed Laparoendoscopic single-site (LESS) varicocelectomy using indocyanine green (ICG) fluorescence angiography. METHODS: A 2.5cm skin incision was made on the umbilicus with an approximately 3.5cm fascia incision. We used the OCTO PORT?, which had one 12mm port and two 5mm ports. After the exposure of the spermatic cord blood vessels, 1 ml of ICG (2.5mg/ml) was injected intravenously. The spermatic veins were sealed by ENSEAL? and cut. The spermatic artery and lymphatics were preserved. ICG was injected intravenously again in order to confirm that the arterial blood flow was preserved and that there was no remaining vein. RESULTS: About 20seconds after injection of ICG, one spermatic artery could be clearly identified. And further about 20seconds after, 3 spermatic veins were identified. The artery could be preserved and the veins were sealed and cut. At this time, we performed ICG angiography again. The flow of the artery was adequately preserved and 1minute after the injection, venous flow was not observed. 3months after this operation, the varicocele had completely disappeared as was confirmed by color Doppler ultrasonography. CONCLUSIONS: LESS varicocelectomy using ICG angiography facilitates identification of blood vessels and lymphatics by enabling the visualization of the spermatic cord blood arteries and vessels. We will continue to investigate whether this procedure will be considered a beneficial method. Source of Funding: none
V11-06 POSTERIOR RETROPERITONEOSCOPIC BILATERAL ADRENALECTOMY IN ECTOPIC CUSHIN’S SYNDROME ~ena*, Alberto Jurado Navarro, Patricio Garcia Marchin Ignacio Costabel, Jorge Jaunarena, Oscar Damia, Jose noma de Buenos Aires, Argentina Guillermo Gueglio, Ciudad Auto INTRODUCTION AND OBJECTIVES: Over the years, a number of different surgical approaches to the adrenal glands have been described. Minimally invasive adrenalectomy has become the procedure of choice for benign adrenal pathology. Although the adrenal glands are located in the retroperitoneum, most surgeons prefer the transperitoneal laparoscopic approach. The purpose of this video is to show the feasibility of performing a posterior retroperitoneoscopic bilateral adrenalectomy in a woman with ectopic Cushin’s syndrome. METHODS: A 23-year-old woman presented with past medical history of metastatic Pancreatic Neuroendocrine Tumor with ectopic production of Gastrin and ACTH treated with Lanreotide since 2004. The patient was referred to the department of urology with Cushin’s disease, refractory to medical treatment. The CT scan showed an enlarged liver due to multiple metastases, that collapsed the right adrenal space. For this reasons, we decided a posterior retroperitoneoscopic bilateral adrenalectomy. RESULTS: The patient was placed in prone position. Three trocars were placed 2 centimeters under the 12th rib, between sacroespinalis muscle and posterior axillary line. A small cavity in the retroperitoneum was made with blunt finger dissection. Once the right adrenal space was created, we could identify the anatomic landmarks (psoas, diaphragm, liver). Dissection of the gland was begun with lower margin detachment from the upper kidney pole in a lateral to medial direction using 5?mm ultrasonic dissector. After exposing adrenal gland