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VID-06.09: Transperitoneal approach for laparoscopic retro peritoneal lymph node dissection (RPLND) for large residual mass
VIDEO POSTER SESSIONS
Disease. (D.E.). All treatments were carried out on a Day-Hospital basis, by using a Dornier machine equipped with an aiming scan device, by using between 20002500 strokes per treatment, with no less than 10-12 treatments for an average of at least three treatment cycles. Follow-up consisted in a check-up visit every three months in which, in addition to evaluation of plaque characteristics and post-FIC curvature with picture taking, a dynamic scan was carried out with PGE1, in order to check on results obtained. “Sexual performance” was constantly monitored with I.E.F.F.-5. Results: The results obtained after treatment show a significant reduction both of the pain during flaccidity phase (55/ 56%, 98,2%) and tumescence (38/56,69,7%), as well as of penile curvature (28/56,50%). After the first therapy cycle 60,7% of the patients experienced the presence of calcifications intra-plaque, with a slight reduction in the dimensions of the plaque/s (45mm x 420 mm pre vs 41mm x 380 mm post), whereas 36,7% showed a significant reduction of the same. 66,1% of the patients experienced the persistence of a venous escape around the plaque. An overall significant improvement of “sexual performance” was observed, with 21 patients (55,3%) presenting a I.E.F.F.5 ⬎ 21. The side effects were limited, with four patients (7,0%) developing urethrorrhagia which required using a catheter in three of them (5,3%), and with another 6 patients (10,7%) developing haematoma, which rapidly disappeared in all of them following treatment with Escine, without consequences. On three patients (5,3%) analgesics had to be used in order to bring treatment to conclusion. The assessment carried out after 3 treatment cycles showed an overlap with previous data as far as pain in flaccidity conditions (98,7%), tumescence (73,4%) and penile curvature (57%) were concerned, but a significant reduction in the dimensions of the plaque/s (49,2%). Side effects overlapped with previous ones. Conclusions: The use of ESWT in the treatment of Peyronie disease proved to be highly effective in improving the painful-inflammatory symptoms related to the presence of the plaque, showing encouraging results also on other typical aspects of this disease, especially if repeated treatments protocols are applied, with no less than 10 treatments each time, for prolonged periods of treatment.
VID-06.07 Introduction of the 2M CW laser for several applications in urology De Boorder T1, Grimbergen M1, Bosch R2, Klaessens J1, Verdaasdonk R1, Lock T2 1 Department of Clinical Physics; 2Dept. of Urology, University Medical Center Utrecht, Utrecht, Netherlands Introduction: Recently 2 m continuous wave (CW) lasers were introduced for endoscopic and open surgery. The 2 m wavelength is predominantly absorbed by water and enables effective cutting and ablation of tissue with tissue effect comparable to the CO2 laser. A major advantage over the CO2 laser is the possibility of endoscopic application by fiber delivery of this wavelength. Methods: The 15W Revolix junior (LISA laser, Germany), a 2 m CW laser was used for various urological applications. The clinical treatment strategies were studied in an experimental setup to find the optimal laser settings in regard to thermal and mechanical effects with respect to the clinical application. In 18 patients with penile tumors, resection was performed with haemostatic effects and good aesthetic healing. In 6 patients suffering from a urethral stricture, endoscopic ablation at 3W minimized deep thermal trauma. Some of these patients (n⫽4) also developed hair growth after urethraplasty which was treated superficial coagulation of the hair follicle. Five patients who developed an obstruction in a previously placed urethral wall-stent in 2-3 years after surgery, desobstruction was performed with the 2m CW laser at 7.0W. At 6 months follow-up all wallstents were open and an inspection of the bladder could be performed. Other urological applications of the 2m CW laser involved removal of penile condylomata accuminata (n⫽9) and subsequent superficial coagulation improving the aesthetic wound healing. One patient with atheromata-cysts on the scrotum was treated by cutting the posterior wall after manual evacuation of the cysts. Results: In a non contact mode the 2m CW laser enables controlled ablation with sufficient superficial coagulation to ensure haemostasis during surgery. In contact mode the 2m CW laser is very efficient in tissue ablation compared to the Nd: YAG laser. Endoscopically, strictures in the urethra were incised and stents could effectively be desobstructed at low power, reducing thermal damage to surrounding structures. Conclusion: The 2 m CW laser has shown to be a versatile instrument for effective treat-
UROLOGY 70 (Supplment 3A), September 2007
ment at several urological indications. More patients and long term follow up are needed to prove the clinical significance compared to other treatment modalities. VID-06.08 Laparoscopic extra peritoneal post chemo retroperitoneal lymph node dissection (RPLND) Massoud W, Rebai N, Saheb N, Dumonceau O, Baumert H Paris Saint Joseph Hospital Trust, Paris, France Introduction: Retro-peritoneal lymph node dissection (RPLND) can be performed laparoscopically. When the postchemotherapy residual masses are smaller than 3 cm, the extraperitoneal approach is recommended. Here we present our technique. Methods: Fifteen RPLNDs were performed by an extraperitoneal approach between October 2002 and March 2007. The first port was inserted in the flank. Two or three 5mm ports were subsequently placed in the flank and iliac fossa. The retroperitoneal space was created and the RPLND was performed retrogradely from the common iliac artery up to the renal pedicle. The lymph nodes were placed into an endo bag and removed. At the end of the procedure a window was created in the peritoneum to avoid lymphocele formation. Results: No conversion to open operation was required. The mean blood loss was 100 cc and the mean operative time 121 minutes. No major peri-operative complication occurred. The mean post operative hospitalization stay was 3.2 days. Conclusion: The extraperitoneal approach fascilitates laparoscopic RPLND for small residual masses. The morbidity of this approach can be low for experienced teams. VID-06.09 Transperitoneal approach for laparoscopic retro peritoneal lymph node dissection (RPLND) for large residual mass Baumert H1, Massoud W1, Rebai N1, Schlosser J1, Dumonceau O1, Fizazi K2 1 Department of Urology. Paris Saint Joseph Hospital Trust, Paris, France; 2 Department of Oncology, Institut Gustave Roussy, Villejuif, France Introduction: Some teams have realized laparoscopic RPLND for post-chemotherapy residual lymph node masses. These masses are generally smaller than 4 or 5 cm. This film shows the feasibility of laparoscopic RPLND for a 9⫻4 cm mass.
187
VIDEO POSTER SESSIONS
Methods: It was a 27-year-old man to whom a first chemotherapy had been realized (4 BEP) prior to orchidectomy. (Exam of the testis normal and important increasing of markers). The post chemotherapy CT scan found residual masses. The patient was placed in a supine position, with spread legs and in trendelenbourg position. The surgeon was between these legs and the assistant to his left. The different steps of the operation were : 1Insertion of one 10 mm port and four 5 mm ports, 2-Dissection of the right colon and the root of the mesentery. This dissection allowed to expose the retroperitoneal space, 3-Realization of the peri aortic RPLND by sparing the lower mesenteric artery. This dissection was prolonged up to the left renal pedicle, 4-Realization of the RPLND in the inter aortico cave space up to the right renal pedicle. 5- Dissection of the left spermatic vein which was removed, 6-Drainage and extraction of the masses put in a bag. Results: The operative time was of 6 hours and the blood losses of 200 cc. The post operative period was uncomplicated. The patient discharged on day 5. The residual masses were 9⫻4 cm and 5⫻2 cm. Histology showed fibrosis only. Conclusion: Some voluminous residual masses can be extracted by laparoscopy, with the benefit from all the advantages of a minimally invasive approach. Advanced laparoscopic technique is necessary to perform such procedures.
188
VID-06.10 Bipolar endoscopic procedures in complicated urethral strictures Geavlete P, Georgescu D, Cauni V, Mirciulescu V, Geavlete B Department of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania Objective: Urethral strictures (US) that are impassable in retrograde fashion impose a special problem to the urologist because they cannot be managed by direct-vision internal urethrotomy. Open urethroplasty is usually required. Our goal was to evaluate in a retrospective study, the results of bipolar endoscopic procedures in such cases. Methods: Between November 1999 and January 2007 we evaluated 33 patients with complicated urethral stricture treated by bipolar endoscopic procedures. Etiological we found: perineal urethral trauma (22 cases), inflammatory stenosis in 9 cases and previous prostatic surgery in 2 cases. The stricture location was penian (3 cases), bulbous (19 cases) and membranous (11 cases). Retrograde urethrography, urethral ultrasonography and urethoscopy have been the main investigations. All cases underwent previous minimal suprapubic cystostomy. In 28 cases we performed retrograde urethrotomy guided by the light of the flexible cystoscope introduced antegradely, and in 5 cases the incision
was retrograde over the guidewire placed antegrade. The incision was made by cold knife (23 cases) or Nd: YAG laser (10 cases). The median follow-up period was 49 months. Results: In 30 patients an endoscopic incision of fibrotic tissue was carried out thus the entering the bladder cavity was successful. Two patients developed penian edema imposing stopping the procedure and cystostomy. In one patient the failure of the endoscopic approach imposed open surgery. The global recurrence rate in the follow-up period was 67% (20 cases), imposing further endoscopic management in order to maintain urethral patency. Regarding the location of the stricture, the recurrence rate was: 66% for penile, 70.5% for bulbous and 63.6% for membranous urethra. The recurrence rate was higher for the patients treated with cold knife incision (75%) compared to Nd:YAG laser (50%). The median time to recurrence was 8 months. The recurrent stricture was treated by urethroplasty (14 cases) or internal urethrotomy (6 cases). Conclusions: Bipolar endoscopic urethrotomy, or the cut-to-light procedure, represents an alternative for complete urethral stenosis. This method could represent the first-choice treatment for severe strictures of the bulbar and membranous urethra.
UROLOGY 70 (Supplment 3A), September 2007
Disease. (D.E.). All treatments were carried out on a Day-Hospital basis, by using a Dornier machine equipped with an aiming scan device, by using between 20002500 strokes per treatment, with no less than 10-12 treatments for an average of at least three treatment cycles. Follow-up consisted in a check-up visit every three months in which, in addition to evaluation of plaque characteristics and post-FIC curvature with picture taking, a dynamic scan was carried out with PGE1, in order to check on results obtained. “Sexual performance” was constantly monitored with I.E.F.F.-5. Results: The results obtained after treatment show a significant reduction both of the pain during flaccidity phase (55/ 56%, 98,2%) and tumescence (38/56,69,7%), as well as of penile curvature (28/56,50%). After the first therapy cycle 60,7% of the patients experienced the presence of calcifications intra-plaque, with a slight reduction in the dimensions of the plaque/s (45mm x 420 mm pre vs 41mm x 380 mm post), whereas 36,7% showed a significant reduction of the same. 66,1% of the patients experienced the persistence of a venous escape around the plaque. An overall significant improvement of “sexual performance” was observed, with 21 patients (55,3%) presenting a I.E.F.F.5 ⬎ 21. The side effects were limited, with four patients (7,0%) developing urethrorrhagia which required using a catheter in three of them (5,3%), and with another 6 patients (10,7%) developing haematoma, which rapidly disappeared in all of them following treatment with Escine, without consequences. On three patients (5,3%) analgesics had to be used in order to bring treatment to conclusion. The assessment carried out after 3 treatment cycles showed an overlap with previous data as far as pain in flaccidity conditions (98,7%), tumescence (73,4%) and penile curvature (57%) were concerned, but a significant reduction in the dimensions of the plaque/s (49,2%). Side effects overlapped with previous ones. Conclusions: The use of ESWT in the treatment of Peyronie disease proved to be highly effective in improving the painful-inflammatory symptoms related to the presence of the plaque, showing encouraging results also on other typical aspects of this disease, especially if repeated treatments protocols are applied, with no less than 10 treatments each time, for prolonged periods of treatment.
VID-06.07 Introduction of the 2M CW laser for several applications in urology De Boorder T1, Grimbergen M1, Bosch R2, Klaessens J1, Verdaasdonk R1, Lock T2 1 Department of Clinical Physics; 2Dept. of Urology, University Medical Center Utrecht, Utrecht, Netherlands Introduction: Recently 2 m continuous wave (CW) lasers were introduced for endoscopic and open surgery. The 2 m wavelength is predominantly absorbed by water and enables effective cutting and ablation of tissue with tissue effect comparable to the CO2 laser. A major advantage over the CO2 laser is the possibility of endoscopic application by fiber delivery of this wavelength. Methods: The 15W Revolix junior (LISA laser, Germany), a 2 m CW laser was used for various urological applications. The clinical treatment strategies were studied in an experimental setup to find the optimal laser settings in regard to thermal and mechanical effects with respect to the clinical application. In 18 patients with penile tumors, resection was performed with haemostatic effects and good aesthetic healing. In 6 patients suffering from a urethral stricture, endoscopic ablation at 3W minimized deep thermal trauma. Some of these patients (n⫽4) also developed hair growth after urethraplasty which was treated superficial coagulation of the hair follicle. Five patients who developed an obstruction in a previously placed urethral wall-stent in 2-3 years after surgery, desobstruction was performed with the 2m CW laser at 7.0W. At 6 months follow-up all wallstents were open and an inspection of the bladder could be performed. Other urological applications of the 2m CW laser involved removal of penile condylomata accuminata (n⫽9) and subsequent superficial coagulation improving the aesthetic wound healing. One patient with atheromata-cysts on the scrotum was treated by cutting the posterior wall after manual evacuation of the cysts. Results: In a non contact mode the 2m CW laser enables controlled ablation with sufficient superficial coagulation to ensure haemostasis during surgery. In contact mode the 2m CW laser is very efficient in tissue ablation compared to the Nd: YAG laser. Endoscopically, strictures in the urethra were incised and stents could effectively be desobstructed at low power, reducing thermal damage to surrounding structures. Conclusion: The 2 m CW laser has shown to be a versatile instrument for effective treat-
UROLOGY 70 (Supplment 3A), September 2007
ment at several urological indications. More patients and long term follow up are needed to prove the clinical significance compared to other treatment modalities. VID-06.08 Laparoscopic extra peritoneal post chemo retroperitoneal lymph node dissection (RPLND) Massoud W, Rebai N, Saheb N, Dumonceau O, Baumert H Paris Saint Joseph Hospital Trust, Paris, France Introduction: Retro-peritoneal lymph node dissection (RPLND) can be performed laparoscopically. When the postchemotherapy residual masses are smaller than 3 cm, the extraperitoneal approach is recommended. Here we present our technique. Methods: Fifteen RPLNDs were performed by an extraperitoneal approach between October 2002 and March 2007. The first port was inserted in the flank. Two or three 5mm ports were subsequently placed in the flank and iliac fossa. The retroperitoneal space was created and the RPLND was performed retrogradely from the common iliac artery up to the renal pedicle. The lymph nodes were placed into an endo bag and removed. At the end of the procedure a window was created in the peritoneum to avoid lymphocele formation. Results: No conversion to open operation was required. The mean blood loss was 100 cc and the mean operative time 121 minutes. No major peri-operative complication occurred. The mean post operative hospitalization stay was 3.2 days. Conclusion: The extraperitoneal approach fascilitates laparoscopic RPLND for small residual masses. The morbidity of this approach can be low for experienced teams. VID-06.09 Transperitoneal approach for laparoscopic retro peritoneal lymph node dissection (RPLND) for large residual mass Baumert H1, Massoud W1, Rebai N1, Schlosser J1, Dumonceau O1, Fizazi K2 1 Department of Urology. Paris Saint Joseph Hospital Trust, Paris, France; 2 Department of Oncology, Institut Gustave Roussy, Villejuif, France Introduction: Some teams have realized laparoscopic RPLND for post-chemotherapy residual lymph node masses. These masses are generally smaller than 4 or 5 cm. This film shows the feasibility of laparoscopic RPLND for a 9⫻4 cm mass.
187
VIDEO POSTER SESSIONS
Methods: It was a 27-year-old man to whom a first chemotherapy had been realized (4 BEP) prior to orchidectomy. (Exam of the testis normal and important increasing of markers). The post chemotherapy CT scan found residual masses. The patient was placed in a supine position, with spread legs and in trendelenbourg position. The surgeon was between these legs and the assistant to his left. The different steps of the operation were : 1Insertion of one 10 mm port and four 5 mm ports, 2-Dissection of the right colon and the root of the mesentery. This dissection allowed to expose the retroperitoneal space, 3-Realization of the peri aortic RPLND by sparing the lower mesenteric artery. This dissection was prolonged up to the left renal pedicle, 4-Realization of the RPLND in the inter aortico cave space up to the right renal pedicle. 5- Dissection of the left spermatic vein which was removed, 6-Drainage and extraction of the masses put in a bag. Results: The operative time was of 6 hours and the blood losses of 200 cc. The post operative period was uncomplicated. The patient discharged on day 5. The residual masses were 9⫻4 cm and 5⫻2 cm. Histology showed fibrosis only. Conclusion: Some voluminous residual masses can be extracted by laparoscopy, with the benefit from all the advantages of a minimally invasive approach. Advanced laparoscopic technique is necessary to perform such procedures.
188
VID-06.10 Bipolar endoscopic procedures in complicated urethral strictures Geavlete P, Georgescu D, Cauni V, Mirciulescu V, Geavlete B Department of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania Objective: Urethral strictures (US) that are impassable in retrograde fashion impose a special problem to the urologist because they cannot be managed by direct-vision internal urethrotomy. Open urethroplasty is usually required. Our goal was to evaluate in a retrospective study, the results of bipolar endoscopic procedures in such cases. Methods: Between November 1999 and January 2007 we evaluated 33 patients with complicated urethral stricture treated by bipolar endoscopic procedures. Etiological we found: perineal urethral trauma (22 cases), inflammatory stenosis in 9 cases and previous prostatic surgery in 2 cases. The stricture location was penian (3 cases), bulbous (19 cases) and membranous (11 cases). Retrograde urethrography, urethral ultrasonography and urethoscopy have been the main investigations. All cases underwent previous minimal suprapubic cystostomy. In 28 cases we performed retrograde urethrotomy guided by the light of the flexible cystoscope introduced antegradely, and in 5 cases the incision
was retrograde over the guidewire placed antegrade. The incision was made by cold knife (23 cases) or Nd: YAG laser (10 cases). The median follow-up period was 49 months. Results: In 30 patients an endoscopic incision of fibrotic tissue was carried out thus the entering the bladder cavity was successful. Two patients developed penian edema imposing stopping the procedure and cystostomy. In one patient the failure of the endoscopic approach imposed open surgery. The global recurrence rate in the follow-up period was 67% (20 cases), imposing further endoscopic management in order to maintain urethral patency. Regarding the location of the stricture, the recurrence rate was: 66% for penile, 70.5% for bulbous and 63.6% for membranous urethra. The recurrence rate was higher for the patients treated with cold knife incision (75%) compared to Nd:YAG laser (50%). The median time to recurrence was 8 months. The recurrent stricture was treated by urethroplasty (14 cases) or internal urethrotomy (6 cases). Conclusions: Bipolar endoscopic urethrotomy, or the cut-to-light procedure, represents an alternative for complete urethral stenosis. This method could represent the first-choice treatment for severe strictures of the bulbar and membranous urethra.
UROLOGY 70 (Supplment 3A), September 2007