Laparoscopic Pelvic Lymph Node Dissection for Genitourinary Malignancies: Indications, Techniques, and Results

Applications of laparoscopic surgery in urology: impact on patient care

From its first use as a diagnostic tool, urologic laparoscopy has developed into a complex therapy for both benign and malignant disease. Most procedures are still performed at large centers with experienced laparoscopists but nonacademic urologists are starting to gain the necessary training and skills. With the clear advantage that laparoscopy shows over open procedures in terms of decreased perioperative morbidity and quicker recovery times, patients are increasingly asking for this approach. The urologic community must meet this challenge and train future urologists to meet the expected demand.

Laparoscopic partial nephrectomy and wedge resection for the treatment of renal malignancy

The widespread use of abdominal ultrasonography, CT, and MRI has led to an increase in the number of incidentally detected renal masses, some of which are malignant. Numerous studies suggest that partial nephrectomy or wedge resection of these lesions yield cure rates similar to those obtained with radical surgery. Laparoscopic nephron-sparing surgery is one of the more challenging minimally invasive surgical techniques, and its use is largely restricted to specialized medical centers. The techniques and available results are described.

Videoendoscopically assisted transvaginal radical cystectomy

We describe our experience of anterior pelvic exenteration for bladder cancer in women using a combined transvaginal and laparoscopic approach. The feasibility of videoendoscopically assisted transvaginal cystectomy was demonstrated several years ago, but the indications have been greatly reduced by the spreading use of orthotopic neobladders in women. Moreover, nulliparous patients or patients with vaginal atresia are not suitable for this technique, even if the specimen can also be retrieved through the minilaparotomy used for performing urinary diversion. In the last 3 years, we have performed only four additional cases. Nevetheless, the results are satisfactory. We did not have any major intraoperative complication. Patients were discharged after 7 to 11 days (average 8.6 days) without any postoperative complications. The minimum survival was 13 months, and four patients are still alive. The operation itself is not easy and therefore can be offered only by centers where videoendosurgery has already entered common clinical practice.

Indications, technique, and results of laparoscopic pelvic lymphadenectomy

Despite considerable clinical research, there is still controversy about the optimal management of the pelvic lymph nodes in men with prostate cancer. This article reviews the creation and application of selection criteria for laparoscopic pelvic lymphadenectomy and describes the various techniques.

Laparoscopic partial nephrectomy and wedge resection

Partial nephrectomy is a more challenging operation than radical or simple nephrectomy, primarily because of the risk of complications such as bleeding. This problem is even more troublesome with minimally invasive approaches because of the dearth of effective hemostatic instruments and supplies. The location of the lesion determines whether a transperitoneal or a retroperitoneal route will be employed. Centrally located or anterior renal lesions generally are approached transperitoneally whereas peripheral lateral or posterior lesions are accessed by retroperitoneoscopy. The Harmonic Scalpel with slow cutting and high coagulation settings is useful for incising the renal capsule and parenchyma. The argon beam coagulator is helpful to stop any persistent bleeding. The few reported series of laparoscopic partial nephrectomy indicate considerably longer operative times than are needed for open surgery and hospitalization of upwards of 5 days, largely to monitor drainage and urine leakage. It is hoped that this advanced laparoscopic technique will become more user friendly with further developments in techniques and instrumentation to provide patients with the expected benefits of minimally invasive surgery.

Laparoscopy in urology

Mention of all of the procedures in urology that have been attempted, or are being done, laparoscopically is beyond the scope of this article. The laparoscopic procedures outlined in this article are gaining increasing support as surgeons attempt to redefine gold standard minimally invasive therapies in the new millennium. Additional procedures, such as laparoscopic retroperitoneal lymph node dissections for low-stage, nonseminomatous germ cell testicular cancers and laparoscopic renal cryoablation of small renal cancers, are soon to be added to this list. As laparoscopic instrumentation and equipment continue to improve, it will become possible to explore even more procedures laparoscopically. Advances in imaging techniques, lasers, miniaturized robotics, and other areas may further define what is meant by the term minimal access surgery in the decades to follow.

Comparison of clinical outcomes of laparoscopic and conventional open adrenalectomy

From September 1992 to November 1996, 28 patients underwent laparoscopic adrenalectomy at Osaka University Medical Hospital. They were compared with 25 instances of conventional open surgery performed between May 1990 and April 1996 at the same institution. Laparoscopic adrenalectomy was performed via either a transperitoneal or a retroperitoneal approach. The mean operative time of 375 minutes for laparoscopic adrenalectomy was significantly longer than that of 133 minutes for open surgery. The average hospital stay for laparoscopic surgery was significantly shorter than that of conventional open adrenalectomy. The convalescent period was also significantly shorter in the patients who had laparoscopic adrenalectomy. There was no statistical difference in blood loss during the operation or the number of doses of analgesics administered after operation in the two groups. We conclude that laparoscopic adrenalectomy is one of the options to be selected in surgically managing adrenal tumors. Laparoscopic adrenalectomy could become a standard operative procedure as instruments and techniques of laparoscopy improve significantly.

Laparoscopic adrenalectomy: the preferred choice? A comparison to open adrenalectomy

PURPOSE

We compare the effectiveness and efficiency of laparoscopic adrenalectomy to open surgical management of adrenal disorders.

MATERIALS AND METHODS

A retrospective comparison was undertaken of 21 patients who underwent transperitoneal laparoscopic adrenalectomy between April 1996 and May 1997 with 17 patients who underwent open adrenalectomy between October 1994 and January 1996. Any patient suspected of having primary adrenal carcinoma and/or an adrenal lesion larger than 6 cm. was excluded from the study.

RESULTS

Patient demographics were matched well. Mean laparoscopic surgical time was 79 minutes longer than for open surgery. After overcoming the learning curve, the surgical time decreased by 59 minutes in the last 10 laparoscopic adrenalectomies. All laparoscopic intraoperative complications were managed without the need for open surgical conversion. Postoperative characteristics demonstrated significant benefits in the laparoscopic group (p=0.001) with respect to days to return to full diet (1.7 versus 4.6), analgesic pain requirements and days of hospitalization (2.7 versus 6.2).

CONCLUSIONS

Laparoscopic adrenalectomy offers significant postoperative benefits to patients with benign adrenal disease requiring surgical intervention. The surgical time is longer than that for open adrenalectomy but there was an encouraging reduction in time after overcoming the laparoscopic learning curve. Laparoscopic adrenalectomy is an excellent choice for tumors smaller than 6 cm. Its role for larger lesions and/or primary adrenal carcinoma is currently under investigation.

Lymphoceles after laparoscopic pelvic node dissection

OBJECTIVE

Lymphocele formation has been infrequently reported as a complication of laparoscopic pelvic lymph node dissection (LPLND). We determined the incidence of clinical and subclinical lymphocele formation in patients undergoing transperitoneal LPLND.

METHODS

Charts and radiological records of 111 patients undergoing transperitoneal LPLND at this institution between January 1991 and December 1995 were reviewed to determine the incidence of lymphocele formation.

RESULTS

Of 111 patients undergoing LPLND, 12.6% had positive lymph nodes and received hormonal therapy. Radical retropubic (12) or perineal (28) prostatectomy was performed either simultaneously or within 2 weeks in 41% of the node-negative patients. Radiation therapy was the treatment modality in the remaining node negative patients (N = 57). Twenty-three patients undergoing radiation therapy had preplanning pelvic computed tomography (CT) scans 2 to 16 weeks (mean 8.2 weeks) after LPLND. These were reviewed by a single radiologist to determine the presence of subclinical lymphoceles. Seven patients (30.4%) had lymphoceles of varying sizes (3 large and 4 small). Although most were identified on CT scans 4 weeks after the procedure, two were identified on scans 12 and 16 weeks after the procedure (mean 6.5 weeks). None of these patients developed symptoms referable to or had treatment for the lymphocele during a 2 to 37 month follow-up (mean 20 months). Only two patients (3.5%) undergoing LPLND as an isolated procedure had clinical evidence of lymphocele formation, both of which were subsequently confirmed with CT scans (1 large, 1 small). One was treated with CT-guided drainage and sclerosis and the other resolved spontaneously.

CONCLUSION

The clinical incidence of lymphocele formation following LPLND remains relatively low. Only a portion of these patients requires intervention. Subclinical lymphoceles, as detected on follow-up CT scans, occur with a much greater frequency. These seldom become symptomatic requiring treatment. Rather, they appear to resolve spontaneously. Nevertheless, clinical suspicion should remain high in order to detect and properly treat symptomatic lymphoceles when they occur.

Laparoscopic staging of bladder tumor: concerns about port site metastases

Since the first laparoscopic pelvic lymph node dissection (LPLND) was performed for prostate cancer, only one case of port site metastasis has been reported, an incidence of 0.1%. On the other hand, three cases of port site metastasis have been reported after laparoscopic staging of transitional-cell carcinoma (TCC) of the bladder, a reported incidence of almost 4%. Herein, we review the circumstances of these three cases and address the potential risk factors and possible preventive measures regarding LPLND and port site metastasis in patients with TCC of the bladder.

Initial experience with extraperitoneal endoscopic radical retropubic prostatectomy

OBJECTIVES

We report our initial experience using laparoscopic instruments and techniques in the performance of radical retropubic prostatectomy (RRP) through an entirely extraperitoneal endoscopic (EE) approach.

METHODS

A 62-year-old man with a Gleason score of 7 and clinical stage T1c adenocarcinoma of the prostate underwent EERRP. The procedure was evaluated for achievement of removal of the prostate and seminal vesicles and for complete vesicourethral anastomosis. Operative time, blood loss, hospital stay, and pathologic findings were also evaluated.

RESULTS

Complete endoscopic removal of the prostate and seminal vesicles was achieved. Endoscopic reconstruction of the bladder neck with a watertight anastomosis was successful. Operative time was 5 hours and 45 minutes, with an estimated blood loss of 600 cc. Hospital stay was 2.5 days. Final pathologic evaluation was a Gleason score of 7 and Stage T2 disease with negative margins.

CONCLUSIONS

The initial experience for EERRP is encouraging. Further evaluation to refine the technique and determine its efficacy and role in treating prostate cancer is in order.

Technique of laparoscopic adrenalectomy

Laparoscopic adrenalectomy by the transperitoneal route has been shown to be a safe and effective approach to select adrenal pathology. Although the specific indications will continue to be refined, it is clear that for adrenal masses of 6 cm or less, laparoscopy provides excellent access with little additional risk to the patient. In addition there appears to be an improved postoperative course when compared with open adrenalectomy. This latter point, however, requires careful prospective studies to confirm this impression objectively. The operative times are longer by the laparoscopic approach, but undoubtedly these times will decrease with increasing experience and improved laparoscopic instrumentation.

Recent advances in laparoscopic partial nephrectomy: comparative study of electrosurgical snare electrode and ultrasound dissection

Although technically feasible, laparoscopic partial nephrectomy (LPN) using conventional instrumentation presents the intraoperative challenge of hemostasis, creating a flush (i.e., precise guillotine) incision, and closure of the collecting system. In an effort to resolve these technical problems, we used a unique electrosurgical snare electrode (ESE) in combination with an ERBE electrosurgical generator and compared its effectiveness with that of two ultrasonic dissectors (Cavitron Ultrasonic Surgical Aspirator [CUSA] and harmonic scalpel [HS]) in performing LPN. Twelve female minipigs underwent right lower-pole LPN using one of the aforementioned modalities. Six weeks later, in the same animals, a left lower-pole LPN was performed using the same device, thereby providing an acute and chronic renal remnant to examine. The animals were harvested, and transverse and perpendicular histologic sections were prepared of the cut surface of each specimen. The weights of the LPN specimens and the remaining kidney were also recorded. The time required for partial nephrectomy, degree of hemostasis (i.e., blood loss), ease of excising the targeted tissue, changes in renal function, tissue reactivity, and depth of damage to the surface of the remaining renal parenchyma were measured for each device. All 12 procedures were successful using the ultrasonic dissection, and 11 procedures were successful using the ESE. The ESE was significantly faster than the two forms of ultrasonic dissection (p < 0.0001) and produced less intraoperative bleeding (P = 0.002). Both forms of ultrasonic energy produced significantly deeper parenchymal injury in the acute surgical specimen (P = 0.03) and more parenchymal fibrosis and chronic inflammation in the chronic surgical specimens (P = 0.007) than the ESE. None of the animals exhibited any extravasation from the incised collecting system when studied by retrograde pyelography 6 weeks postoperatively at the time of left LPN and harvest. The function of the renal remnant was consistent with the size of the partial nephrectomy specimen. No hypertension developed in any of the study animals. Our results using a unique electrosurgical snare probe show it to have potential advantages as a rapid, hemostatic method for performing a partial nephrectomy. We believe that this instrument may represent an important tool for performing nephron-sparing surgery via an open or laparoscopic approach. Clinical trials are in progress.

Laparoscopic pyelolithotomy

Laparoscopic surgery has been applied to virtually every aspect of urinary tract disease. Presented is a case of laparoscopic-extended pyelolithotomy accomplished in a 16-month-old child with a large cystine stone that occupied the child's entire renal pelvis. Although not the first pyelolithotomy accomplished laparoscopically, we believe this to be the first extended laparoscopic pyelolithotomy and also believe this is the youngest patient in whom laparoscopic pyelolithotomy has been done. Extracorporeal shock wave lithotripsy and percutaneous and endoscopic stone techniques have drastically modified the management of urolithiasis. However, select cases in which these techniques may not be applicable (such as this toddler with bulky cystine lithiasis) may require open surgery. The laparoscopic approach represents an excellent, yet less-invasive option.

Anatomical basis for pelvic lymphadenectomy in prostate cancer: results of an autopsy study and implications for the clinic

PURPOSE

Pelvic lymphadenectomy remains the most reliable method to prove lymph node metastases in prostate cancer. However, evaluation of lymphadenectomy to be complete and sufficient as judged by the number of removed lymph nodes in hampered by the fact that, in contrast to other malignancies (for example breast or gastric cancer), anatomical studies investigating the regular and average number of pelvic lymph nodes are missing. We established an anatomically based standard for pelvic lymphadenectomy.

MATERIALS AND METHODS

Standard pelvic lymphadenectomy was performed on 30 human cadavers and 59 consecutive patients with clinically organ confined prostate cancer during radical retropubic prostatectomy. Number, size and topography of the lymph nodes were noted separately for each anatomical region of both iliac fossas.

RESULTS

The mean number of lymph nodes removed in the autopsy series plus or minus standard deviation (22.7 +/- 10.2, range 8 to 56) was nearly identical to that from patients with prostate cancer (20.5 +/- 6.6, range 10 to 37) but striking interindividual differences were observed. Patients with prostate cancer demonstrated enlarged nodes regardless of whether they did or did not contain tumor. Interestingly, pelvic lymph node metastases were more common on the left side regardless of the primary tumor site.

CONCLUSIONS

Approximately 20 pelvic lymph nodes may serve as a guideline for a sufficient standard pelvic lymph node dissection. Lymphadenopathy in prostate cancer patients is not always a result of metastases but, rather, hyperplastic or regressive alterations. A preferential distribution of lymph node metastases along the left iliac vessels regardless of the primary tumor site in the prostate warrants further investigation.

Carbon dioxide homeostasis during transperitoneal or extraperitoneal laparoscopic pelvic lymphadenectomy: a real-time intraoperative comparison

The primary goal of this study was to evaluate differences in carbon dioxide metabolism between patients undergoing transperitoneal or extraperitoneal laparoscopic pelvic lymph node dissection (L-PLND) for staging of adenocarcinoma of the prostate (CaP). Eighteen candidates undergoing L-PLND were divided between the transperitoneal (N = 12) and extraperitoneal (N = 6) approaches. End-tidal partial pressure of CO2 (PeCO2) and minute volume of expired CO2 (VCO2) were considered indicators of CO2 absorption. These two parameters were monitored intraoperatively utilizing a metabolic cart and Ohmeda Rascal-II. The cardiostimulatory effect of increasing serum CO2 and the ventilatory countermeasures used to correct the iatrogenic hypercapnia associated with CO2 insufflation were also measured. With the exception of the region of CO2 insufflation, the operative procedure and perioperative care were identical for the two groups. Preoperative patient characteristics were similar. The mean time of CO2 insufflation was 136 minutes for the transperitoneal group and 120 minutes for the extraperitoneal group. The absorption of CO2 was significantly greater and more rapid during extraperitoneal L-PLND. This may be attributable to more profound CO2 absorption from the parietal peritoneal surface compounded by subcutaneous CO2 emphysema. Disruption of microvascular and lymphatic channels during the development of the extraperitoneal working space facilitates direct CO2 absorption into the intravascular space. A minor increase in heart rate and systolic blood pressure was noted during CO2 insufflation. In all but one patient (extraperitoneal group), hypercarbia and acidemia were prevented by an increased ventilatory rate. The potential dysrhythmogenicity of hypercarbia may contraindicate the extraperitoneal approach in patients with cardiopulmonary disease.

Value of laparoscopy in the management of calculi complicating renal malformations

A minimally invasive approach for urolithiasis patients with complex anatomic abnormalities occasionally necessitates the use of laparoscopic techniques, either alone or in combination with endourologic techniques. The management of these patients is best accomplished in centers with the facilities to provide a spectrum of endourologic and laparoscopic techniques. Two illustrative cases are described.

Ureteral laparoscopic surgery: 5 years experience

The main problem in surgically treating ureteral pathologies is the choice of approach. In this study we describe our experience in 8 cases of laparoscopic surgery. Two of these cases involved vesico-ureteral reflux, two retroperitoneal fibrosis, two ureterocele in a poorly functioning duplicated kidney and the last two cases dealt with ureteral obstruction from locally advanced pelvic neoplasia. The most widely performed ureteral laparoscopic procedures in the world are also reviewed.

Laparoscopic urethral sling for treatment of intrinsic sphincter deficiency

The surgical treatment of intrinsic sphincter deficiency, or Type III genuine stress urinary incontinence, has traditionally been accomplished by sling cystourethropexy, the placement of an artificial urinary sphincter, or periurethral injection. We developed a laparoscopic approach for the performance of a sling cystourethropexy as an alternative to the open approach and herein describe our experience. We have found that a laparoscopic sling cystourethropexy is feasible, but at the present time, we have been unable to demonstrate any significant advantages to the patient in terms of decreased cost or convalescence compared with the open vaginal sling cystourethropexy.

Laparoscopic surgical lymphadenectomies in urological tumours

In the last few years laparoscopie surgery has also been used in urological pathologies. Various types of operations have been performed with this technique, but only recently has there been an attempt to give precise indications. Laparoscopy is being used to carry out pelvic lymphadenectomy for cancer of the prostate, the penis and the female urethra, and retroperitoneal lymphadenectomy for non-seminomatous germinal cancer of the testis. The aim of this work, which reports the authors’ experience with this technique, is to define its advantages and limitations in order to identify correct indications.

Laparoscopic pelvic lymphadenectomy: transperitoneal approach

Laparoscopic pelvic lymph node dissection (PLND) is the most commonly performed laparoscopic procedure in urology today. Indications for laparoscopic PLND are being refined to selectively identify patients who are at high risk for lymphatic metastases. From a technical standpoint, the anatomic detail and number of lymph nodes retrieved by the laparoscopic approach are comparable to open PLND. Laparoscopic PLND is associated with a steep learning curve and increased operative time; however, the decreased postoperative discomfort, shortened hospital stay, rapid resumption of normal activities, and enhanced cosmesis are clear advantages over open PLND.

Laparoscopic adrenalectomy: review of 14 cases and comparison with open adrenalectomy

We reviewed 14 cases of laparoscopic adrenalectomy and compared the results with those of a recent series of 15 consecutive patients undergoing a traditional open adrenalectomy for a benign tumor. The laparoscopic adrenalectomy group included nine patients with primary aldosteronism, three with Cushing's syndrome, one with pheochromocytoma, and one with a nonfunctioning incidentaloma. In the patient with pheochromocytoma, a good operative field was safely obtained by a combination of pneumoperitoneum at less than 6 mm Hg insufflation pressure and the abdominal wall-lift method. In both groups, the tumors were removed successfully in all cases. Laparoscopic adrenalectomy, which required neither a large skin and muscle incision nor any resection of the ribs, offered a lower morbidity and earlier recovery in spite of the longer operation time. The most important complication observed in laparoscopic adrenalectomy was that of pneumothorax secondary to an injury of the diaphragm and pleura during the dissection of the left adrenal gland using electrocautery. However, the injury wound was small, and the pneumothorax was resolved by suturing the tear under laparoscopy. These results suggest that laparoscopic adrenalectomy is a minimally invasive alternative to traditional open adrenalectomy and thus has the potential soon to become a standard procedure for the treatment of benign adrenal tumors.

Efficacy of an ultrasonic surgical system for laparoscopic adrenalectomy

PURPOSE

We determine the value of an ultrasonic surgical system for laparoscopic adrenalectomy.

MATERIALS AND METHODS

We analyzed 16 patients who underwent laparoscopic adrenalectomy using the ultrasonic surgical system and compared the results with those of patients undergoing laparoscopic adrenalectomy without the system.

RESULTS

The system simplified exposure of the renal pedicles and inferior vena cava, and facilitated adrenal separation from the perinephric fat as well as dissection and identification of the adrenal vessels. Operating time was shorter and blood loss was also less with use of the ultrasonic surgical system.

CONCLUSIONS

The ultrasonic surgical system simplified laparoscopic adrenalectomy and made the operation much safer.

Laparoscopic evaluation of indeterminate renal cysts

OBJECTIVES

To determine the efficacy and safety of laparoscopic evaluation of indeterminate renal cysts.

METHODS

Ten patients with indeterminate renal cysts (5 Bosniak type II and 5 Bosniak type III) underwent transperitoneal laparoscopic aspiration of cyst fluid for cytologic analysis with examination, biopsy, and excision of the cyst wall and base.

RESULTS

All procedures were successful and without complications. All the lesions were benign.

CONCLUSIONS

Laparoscopic evaluation of indeterminate renal cysts is safe and effective. The procedure alleviates patient anxiety about the nature of the lesion and obviates years of radiologic surveillance, thus reducing costs.

Laparoscopic partial nephrectomy: initial experience and comparison to the open surgical approach

During an 18-month period, 6 laparoscopic partial nephrectomies were attempted, 4 of which were successful. The surgical technique was modified and improved between cases aided by new laparoscopic instrumentation, such as the argon beam coagulator and the 7.5 MHz. ultrasonic sector scanning system. In a retrospective comparison between laparoscopic and open partial nephrectomy, estimated blood loss was 525 ml. for the former versus 708 ml. for the latter procedure. However, operating time was more than 2 hours longer with the laparoscopic approach. The major advantages of the laparoscopic procedure appear to be a more rapid return to full diet, less postoperative pain and less requirement for parenteral narcotics. Despite the small size of this series and limited followup data, convalescence may be shortened by 4 weeks after laparoscopic partial nephrectomy. Patients with benign diseases of the kidney, especially with a duplicated collecting system, who require partial nephrectomy may be considered candidates for the laparoscopic approach. The advantages to the patient, however, may be offset by the technical demands on the surgeon.

Laparoscopic pelvic lymphadenectomy in the staging of prostatic cancer: Our experience in 37 cases

— This paper reports the result of our experience on 37 patients with prostatic carcinoma who underwent laparoscopic pelvic lymphadenectomy. The technique we practised is very similar to the one described by Schuessler in 1991. The average total number of lymph nodes removed and operative time were comparable to standard open techniques. Nine patients had distant metastasis (24.3%). We had no important complications in our series of patients. The minimally invasive approach and the rapid resumption of everyday activity widely balance the cost of this procedure if we consider its diagnostic use.

Laparoscopic approaches to the treatment of intrinsic urethral weakness (type III stress urinary incontinence)

The treatment of intrinsic urethral weakness (Type III stress urinary incontinence) has traditionally been accomplished by the performance of a sling cystourethropexy or the placement of an artificial urinary sphincter. As experience with operative laparoscopy continues to increase, the possibility of performing these procedures from a laparoscopic approach becomes realistic. We report our experience with the laparoscopic performance of a sling cystourethropexy and placement of an artificial urinary sphincter in the canine model. On the basis of initial results, we believe these techniques are feasible in human subjects.

Role of laparoscopic pelvic lymph node dissection in the management of patients with penile cancer and inguinal adenopathy

Patients with invasive squamous cell carcinoma of the penis and tumor involvement of the inguinal nodes are at risk for pelvic lymph node metastases. When this spread occurs, the chance for patient survival is limited. Because the sensitivity of CT in detecting pelvic lymph node metastases is low, open surgical pelvic lymphadenectomy is frequently performed. We have utilized laparoscopic pelvic lymphadenectomy as a minimally invasive alternative to this open approach in three patients with Stage T3 (UICC staging system) squamous cell carcinoma of the penis who had persistent inguinal adenopathy after a standard course of postpenectomy antiobiotic therapy. There were no intraoperative or postoperative complications, and all patients were discharged within 24 hours after surgery. The mean number of nodes removed was eight, and all specimens were free of tumor. Laparoscopic pelvic lymphadenectomy should be considered in patients with persistent inguinal adenopathy after antibiotic therapy before proceeding with inguinal lymph node dissection.

Laparoscopic excision of urachal cyst

The treatment of choice for persistent urachal anomaly is radical surgical excision intended to prevent complications, notably malignancy in a retained remnant. We report a case of the radical laparoscopic excision of an infected urachal cyst. This effective alternative to an open technique has the advantages inherent in minimally invasive surgery.

Open surgical revision of laparoscopic pelvic lymphadenectomy for staging of prostate cancer: the impact of laparoscopic learning curve

We attempt to clarify the impact of the learning curve on the first 30 laparoscopic pelvic lymphadenectomies performed at our institute. Open surgical revision of the area of laparoscopic dissection was performed at radical retropubic prostatectomy. The mean number of obturator and iliac lymph nodes removed laparoscopically was 8.7 and 8.8 from the right and left sides, respectively. The mean number of residual obturator and iliac lymph nodes removed at open operation was 3.2 and 3 from the right and left sides, respectively. The amount of residual lymph node tissue after laparoscopic lymphadenectomy progressively decreased with time, especially after the first 20 cases. A microscopic pelvic lymph node metastasis was found at open operation in patients 6, 14 and 15, who had false-negative results at laparoscopy. Due to the learning curve effect, the first 30 patients who undergo laparoscopic pelvic lymphadenectomy should be assessed again by an open operation at radical retropubic prostatectomy.