Archivi

Simultaneous Laparoscopic Nephroureterectomy and Cystectomy: our experience

==inizio abstract==

Patients with muscle-invasive bladder cancer and concomitant upper urinary tract tumors may be candidates for simultaneous cystectomy and nephroureterectomy. Other clinical conditions such as dialysis-dependent end-stage renal disease and non-functioning kidney are also indications for simultaneous removal of the bladder and kidney. In the present video, we report our laparoscopic experience with simultaneous laparoscopic radical cystectomy (LRC) and nephroureterectomy.
Our surgical technique was performed as follows through a trans-peritoneal approach. First surgical time was rapresented by nephroureterectomy. After recognizing the ureter, the kidney was completely isolated from the perirenal fat and the ureter followed down to the intersection with the iliac vessels. For subsequent cystectomy and bilateral lymph-node dissection, the patient was re-positioned in a supine position and 2 more accesses (10- and 5-mm trocars) were placed in the iliac fossa. In this position we completed the ureter isolation without dissecting it. Radical cystectomy was performed with a descending approach. . Bilateral iliac-obturator extended lymphadenectomy and separate extraction of lymph-node specimens. The ureter was now identified and ejected from the corresponding side access. Specimens were extracted through a 6-cm skin incision along the linea alba. Monolateral ureterocutaneostomy.

==fine abstract==

Laparoscopic nephroureterectomy and cystectomy

==inizio abstract==

The video shows a case of a 70 years old male affected by muscle invasive bladder cancer with monolateral hydronephrosis. Patient underwent a laparoscopic transperitoneal nephroureterectomy and cystectomy with monolateral ureterocutaneous anastomosis. Isolation of renal vessels that are clamped with HemOlok. Isolation of kidney using Ligasure device. Isolation of ureter until bladder insertion. Isolation of controlterl ureter that are clamped and cut. Pelvic lymphadenectomy using laparoclips. Posterior dissection of bladder and resection of bladder pedicles with Ligasure. Isolation of seminal vessels and deferens that are cut. Haemostatic suture of Santorini. Dissection of prostatic apex and section of distal urethra. Positioning of surgical specimen in endobag. Monolateral ureterocutaneous anastomosis.

==fine abstract==

Ten years experience with intravesical thermo-chemotherapy MMC 40mg for Non Muscle Invasive Bladder Cancer high/intermediate risk

==inizio objective==

Management of non muscle invasive bladder cancer (NMIBC) after transurethral resection of bladder tumor generally consists of surveillance and intravesical therapy (1). Particularly challenging is the treatment of patients who have not responded to first-line intravesical bacillus Calmette-Guerin (BCG) or that have high-risk features. For such patients, radical cystectomy remains a commonly recommended alternative treatment. High risk Non Muscle Invasive Bladder Cancer (HR-NMIBC), as stated by EORTC, is an important challenge for urologist and oncologist to avoid tumor progression and to preserve the bladder. The aim of the study is to evaluate the long-term experience on a treatment combining intravesical hyperthermia with Mytomicin C (HT-MMC) delivered with the Synergo® device.

==fine objective==

==inizio methodsresults==

In a period between August 2004 and November 2015 a group of 146 patients (108 male and 38 female, mean age 68+/- 9 y.o. Range 40 -84y.o.) affected by high risk NMIBC were recruited. All of them were treated with endovesical thermo-chemotherapy MMC C 40mg (HT-MMC) performing more than 1600 treatment sessions using the Synergo® device. After an initial induction of 4 weekly treatments with 2 x 40mg MMC, the efficacy was checked in tumor eradication by TUR B and cytology at week 6. Tumor-free patients continued with the maintenance therapy every 15 days with 3 sessions 2 x 40mg MMC, then every 21 days with 3 sessions 2 x 40mg MMC, and every 45 days with 3 sessions 2 x 40mg MMC and in parallel cystoscopy and urine cytology every 3 months. The follow-up was conducted over an average period of 39.2months (Range 2.4 months – 7.9 years). The majority of patients were at high-risk including G3 (64 – 44%), T1 (79 – 54%) and Cis (22 – 15%), high frequency of recurrences (2,1 +/- 2,7 – Range 0-17 n° of recurrences before the first treatment). First aim of the study was the Recurrence-Free Survival (RFS) and disease progression for stage and grade (PFS), the secondary aim was the tolerability and adherence to the proposed schedule of treatment.

Patients characterisrics N=146
Male 108 (74%)
Female 38 (26%)
Age (at the start of treatment)
mean (SD) 68 (9)
median (min-max) 70 (40-84)
Smoking habit*
Non smoker 47 (32%)
Smoker 98 (68%)
*(1 missing data)
Stage
Ta 45 (31%)
Cis 22 (15%)
T1 79 (54%)
Grade (Without Cis)
G1 13 (9%)
G2 47 (32%)
G3 64 (44%)

==fine methodsresults==

==inizio results==

After the first treatment of 4 weekly sessions of HT-MMC, only 11 patients (7.5%) were stopped for recurrences: 3 progressions and 8 recurrences. At the end of each treatment 37/146 patients reported a recurrence and 14/146 patients presented a progression. The RFS at 1, 2 and 5 years was 89.6%, 79.2 and 68.3 respectively. The PFS at 1, 2 and 5 years was 98%, 96.2 and 83.7 respectively. The number of treatment sessions for each patients were 10.4+/- 4.7 with a median of 11 sessions (Range 4-31). The time of exposure over 42°C was 37.4+/-7.4 mins. and the mean temperature was 42.0+/-0.8°C. The safety profile showed mainly grade 1 and 2 side effects. Ten patients complained grade 3 side-effects, including 1 patient bladder spasms/pain during treatment, 3 patients dysuria and 6 patients urgency after treatment.

Treatment (Synergo) characteristics: N=146
Number of treatments (per patient)
mean (sd) 10.4 (4.7)
median (min-max) 11 (4-31)
Time (minutes) over 42°C
mean (sd) 37.4 (7.4)
median (min-max) 38.6 (6.8-55)
Mean temperature (°C)
mean (sd) 42.0 (0.8)
median (min-max) 42.0 (38.2-45.9)
Power (Watt)
mean (sd) 18.7 (2.8)
median (min-max) 18.3 (10.9-26.8)

==fine results==

==inizio discussions==

We evaluated treatment efficacy and tolerability with intravesical HT-MMC in this retrospective cohort of high-risk NMIBC patients. In the high-risk NMIBC the expected recurrence rate is 49% at 5 years (2, 3). In patients affected by high-risk urotelial bladder tumour intravesical Bacillus Calmette-Guerin (BCG) is indicated (4). Intravesical BCG prevents 31% to 50% of tumour recurrence, compared to TUR alone (5). The side-effect of BCG are remarkable, and treatment discontinuation rate of BCG for toxicity is 7% to 19% (6). In a meta-analysis, 32% reduction in tumour recurrence for BCG maintenance compared to MMC was found (7). MMC is considered a less effective alternative treatment for patients intolerant to BCG. Colombo and coll. found out that HT-MMC is more effective than MMC alone (8). The 10-year disease-free survival rate for HT-MMC and MMC alone was 53% and 15% respectively (8). So HT-MMC has shown to be an effective treatment for intermediate and high-risk NMIBC with a good RFS especially in the first two years (9). In our retrospective HT-MMC treatments study the PFS was high considering the percentage of high-risk patients. Tolerability was good without relevant systemic side-effects and most of the patients demonstrated a complete adherence to the proposed schedule of treatment.

==fine discussions==

==inizio conclusion==

Endovesical thermo-chemotherapy MMC 40mg seems to be an effective treatment for NMI Bladder Cancer. Patients affected by highly recurrent disease before chemo-hyperthermia have a lower recurrence free survival. Although the 5-year survival to NMIBC is more than 90%, the survival period is not disease-free (10, 4). BCG intravesical is considered more effective than chemotherapy for NMIBC, representing the first line approach in high-risk patients (4, 7). Due to side-effects and failure of BCG, new chemotherapy agents and device-assisted instillation have been tested in high-risk patients (1). To enhance the efficacy of MMC, a valid method for intravesical HT-MMC delivering was adopted in our department from 2004. We reported our experience over a period of more than 10 years. The results of RFS and PFS are encouraging to maintain this kind of protocol of treatment, although the high dosage of MMC used with ablative intent is well tolerated by a good percentage of patients.

==fine conclusion==

==inizio references==

1. Lammers RJM, et al. The role of combined regimen with intravesical chemotherapy and hyperthermia in the management of non-muscle-invasive bladder cancer: A systematic review. Eur Urol 2011; 60:81-93
2. Rahmi GE, et al. Intravesical bacillus Calmette-Guerin versus chemohyperthermia for high-risk non-muscle-invasive bladder cancer. Can Urol Assoc J 2015;9 (5-6): E278-83
3. Fernandez-Gomez J, et al. Predicting nonmuscle invasive bladder cancer recurrence and progression in patients treated with bacillus Calmette-Guerin: the CUETO scoring model. J Urol 2009;182:2195-203
4. Babjuk M, et al. EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder: Update 2013. Eur Urol 2013; 64:639-53.
5. Shelley MD, et al. Intravescical therapy for superficial bladder cancer. A systematic review of randomised trials and meta-analyses. Cancer Treat Rev 2010;36:195-205
6. Brausi M, Oddens J, Silvester R et al. Side effects of Bacillus Calmette-Guerin (BCG) in the treatment of intermediate- and high-risk Ta, T1 papillary carcinoma of the bladder: results of the EORTC genito-urinary cancers group randomised phase 3 study comparing one-third dose with full dose and 1 year with 3 years of maintenance BCG. Eur Urol 2014;65:69-76
7. Malmstrom P-U, Sylvester RJ, et al. An individual patient data meta-analysis of the long-term outcome of randomised studies comparing intravesical mitomycin C versus bacillus Calmentte-Guerin for non-muscle-invasive bladder cancer. Eur Urol 2009;56:247-56
8. Colombo R, et al. Long-term outcomes of a randomised controlled trial comparing thermochemotherapy with mitomycin C alone as adjuvant treatment for non-muscle-invasive badder cancer (NMIBC). BJU Int 2011;107:912-8.
9. Moskovitz B, Halachmi S, Moskovitz M, et al. 10-year single-center experience of combined intravesical chemohyperthermia for non-muscle invasive bladder cancer. Future Oncol 2012;8:1041-9
10. Sylvester RJ, et al. Predicting recurrence and progression in individual patients with stage TaT1 bladder cancer using EORTC risk tables: a combined analysis of 2596 patients from seven EORTC trials. EurUrol 2006;49:466-5.

==fine references==

En bloc transurethral resection of bladder tumor with Olimpus button: a novel tecnique

==inizio abstract==

The quality of transurethral resection of bladder tumor is able to determine patients prognosis, main limitation of standard transurethral resection (TUR) of bladder cancer is fragmentation of the specimen, en bloc TURBT overcomes this problem. We describe our “en bloc “ tecnique with button.

Tecnique

The bladder is filled to a medium capacity and the wall is incised using a Bottun loop (with a cutting current), starting from apparently ‘normal’ mucosa surrounding the base and then extending throughout detrusor muscle. The muscular fibres are sectioned cautiously from the periphery to the centre of the lesion base. After the lesion has been detached from the bladder, the tumour is grasped by the loop and taken away from the bladder under direct vision. Each specimen is macroscopically orientated and examined to assess its greatest dimension and the lateral circumferential margins. Staging is done in accordance with TNM classification (2002 International Union Against Cancer/UICC) and grading by the WHO 2004 classification.
Circumferential lateral margins and bottom are resected with a classic loop.

Conclusion
In our preliminary experience en bloc bipolar button TURBT is a feasible and safe tecnique.

==fine abstract==

En bloc transurethral resection of bladder tumor with Collins loop: our experience

==inizio abstract==

The main limitation of standard transurethral resection (TUR) of bladder cancer is fragmentation of the speciment which may impair the pathological analysis. The en bloc TURBT overcomes this problem.

Tecnique
Apart from the standard equipment (ESG 400 scalpels, , optical 0° for uretroscopy and 30° for TURBT), our technique requires a 12° with Collins loop for en bloc TURBT.
The bladder wall is incised around the lesion using a Collins loop (with a cutting current), starting from ‘normal’ mucosa surrounding the base and then extending through the subepithelial connective tissue and muscularis propria strata, inclining the loop to avoid any serious perforation. After the lesion has been detached from the bladder, the tumour is grasped by the loop and taken out under vision. Each specimen is macroscopically orientated and examined to assess its greatest dimension and the lateral circumferential margins. Staging is done in accordance with TNM classification and grading by the WHO 2004 classification.
Margins and bottom are resected with a classic loop and NBI assisted repeat TURBT

Conclusion
In our experience en bloc bipolar TURBT with Collins loop is a feasible and safe tecnique.

==fine abstract==

Chirurgia endourologica estrema per trattamento palliativo di neoplasia dell’alta via escretrice in paziente ad alto rischio anestesiologico

==inizio abstract==

Il video mostra come l’approccio percutaneo è utile nel trattamento di voluminose neoplasie delle alte vie urinarie in pazienti ad altissimo rischio anestesiologico. Paziente di 91 anni, precedentemente sottoposto a nefroureterectomia sinistra per carcinoma ureterale di alto grado e a successive TURBT per NMIBC di basso grado, giungeva alla nostra osservazione nel maggio 2015 per macroematuria e grave anemizzazione. La UroTC evidenziava una neoformazione di 33×14 cm della pelvi renale dx; il paziente veniva sottoposto infruttuosa ureterorenoscopia a scopo emostatico; in relazione all’alto rischio anestesiologico e alla necessità di dialisi post-intervento non si procedeva a nefroureterectomia. Previo posizionamento di catetere ureterale, si eseguiva puntura eco-radioguidata del calice inferiore destro, dilatazione pneumatica e posizionamento di cannula di 30F attraverso la quale si introduceva resettore 26F. Resezione e DTC della neoformazione; introduzione successiva di cistonefroscopio flessibile con esplorazione dei calici superiori e medi e DTC con laser ad olmio di altre neoplasie. Il paziente veniva dimesso con nefrostomia a dimora, normalmente mobilizzato, con risoluzione dell’ematuria, stabilizzazione dell’emoglobina e riduzione della creatininemia.Il trattamento percutaneo è una possibile opzione terapeutica per il trattamento palliativo di voluminose neoplasie della alte vie urinarie in pazienti ad altissimo rischio anestesiologico, con preservazione della loro qualità della vita.

==fine abstract==