Laparoscopic staging of bladder tumor: concerns about port site metastases

Port-Site Implantation Diagnosed by Iodine-131 Post-Ablation Single-Photon Emission Tomography-Computed Tomography After Robotic Thyroidectomy: A Case Report

Patient: Female, 37

Final Diagnosis: Port-site implantation after robotic thyroidectomy

Symptoms: None

Medication: —

Clinical Procedure: Iodine-131 post-ablation whole body scan and single photon emission tomography-computed tomography

Specialty: Nuclear Medicine

Impact of Accidental Tumor Incision During Laparoscopic Partial Nephrectomy on the Oncologic and Clinical Outcomes

BACKGROUND

To investigate the impact of accidental tumor incision (ATI) during laparoscopic partial nephrectomy (LPN) on the treatment outcome of LPN and to determine the predictive factors for ATI.

PATIENTS AND METHODS

Consecutive 156 patients with renal tumors suspicious of renal cell carcinoma cT1N0M0 undergoing laparoscopic partial nephrectomy at Yokohama City University between May 2003 and November 2014 were retrospectively evaluated. The analyzed clinical factors included maximum tumor diameter, the R.E.N.A.L. Nephrometry Score, occurrence of ATI during surgery, and the postoperative pathological findings including the presence of a pseudocapsule. Port site metastasis, tumor seeding, and local recurrence were investigated by routine follow-up computed tomography during the postoperative period.

RESULTS

Among enrolled 156 procedures, 12 (7.7%) showed ATI during surgery. Positive surgical margin and local tumor recurrence were observed in 5 and 1 cases in the non-ATI group, respectively, as compared with in no cases in the ATI group. Port site metastasis or tumor seeding was not observed in either group. Multivariate analysis indicated that pseudocapsule formation significantly correlated with ATI (P = .022) and that maximum tumor diameter was a possible predictor of ATI (P = .054).

CONCLUSION

To our knowledge, there are no previous studies to evaluate the impact of ATI, and we here, for the first time, report that the risk of ATI is influenced by the presence of a pseudocapsule, and, to some degree, by the tumor size. Moreover, we also show that ATI during laparoscopic partial nephrectomy is not necessarily associated with poor outcomes such as local tumor recurrence.

Thyroid cancer that developed around the operative bed and subcutaneous tunnel after endoscopic thyroidectomy via a breast approach

Endoscopic thyroidectomy is gaining greater acceptance because of its excellent cosmetic result. As the surgical skill and understanding of the endoscopic cervical anatomy has improved, the surgical indications for endoscopic thyroidectomy have recently expanded to small size thyroid cancer. Despite the many advantages of laparoscopic surgery, there have been incidental reports about recurrences at the site of insertion of the laparoscope or other instruments in other cancers. Herein, we present a case of 25-year-old woman who had recurrent cancers around the operative bed and subcutaneous tunnel after endoscopic thyroidectomy.

Tumor Seeding after Open Nephroureterectomy for Ureteral Transitional Cell Carcinoma

Skeletal muscle metastases following cancer surgery are rare. Few cases of abdominal wall metastasis have been reported in the literature and attributed to tumor seeding after laparoscopic surgery or percutaneous nephrostomy. We report a case of abdominal tumor seeding after open nephroureterectomy managed by means of a surgical and medical approach.

Peritonitis carcinomatosa in a patient with recurrent "superficial" bladder cancer treated with cystectomy and nephroureterectomy

We report on a 45-year-old woman treated with cystectomy after failure of bacille Calmette-Guérin therapy for superficial transitional cell carcinoma. After 9 months, left-sided nephroureterectomy was performed for recurrence in the left ureter. The pathologic examination revealed carcinoma in situ and no tumor-positive lymph nodes (pTisN0Mx). At 2.5 years later, she complained of abdominal distension and pain. She underwent bilateral removal of the ovaries, infracolic omentectomy, and liver biopsy because of suspicious lesions on the liver. Pathologic examination revealed extensive peritoneal spread of transitional cell carcinoma. The seeding potential of high-grade urothelial cancer is well known; however, we found no clear explanation for the peritoneal spread of tumor cells in this patient that occurred years after the surgical procedures.

Is carbon dioxide insufflation safe for laparoscopic surgery? A model to assess the effects of carbon dioxide on transitional-cell carcinoma growth, apoptosis, and necrosis

PURPOSE

To study the effects of carbon dioxide insufflation pressure and concentration on the adhesion, growth, apoptosis, and necrosis of transitional-cell carcinoma (TCC).

MATERIALS AND METHODS

Adhesion and growth of the AY-27 rat TCC cell line was measured after CO2 insufflation in vitro at different pressures ranging from 0 to 15 mm Hg and after incubation in CO2-air mixtures at 5%, 10%, and 15% CO2 by volume.

RESULTS

Tumor adhesion decreased significantly after CO2 insufflation. For all insufflation pressures, there was an increase in cell growth, apoptosis, and necrosis for the first 24 hours followed by a steady decline. High concentrations of CO2 (>5%) inhibited cell growth for only the first 48 hours. The effects of CO2 pneumoperitoneum on tumor-cell adhesion, growth inhibition, apoptosis, and necrosis were more prominent at high CO2 pressure (> or =15 mm Hg) and concentration (>5% CO2). However, insufflation pressure had a greater inhibitory effect on tumor growth than did CO2 concentration. High insufflation pressures and CO2 concentrations significantly decreased extracellular pH.

CONCLUSION

The short-term effect of CO2 on TCC growth and apoptosis is complex. Overall, CO2 has a toxic effect on TCC and inhibits cell adhesion and growth. High CO2 concentrations (>5%) and high insufflation pressures (> or =15 mm Hg) are most effective in decreasing tumor-cell adhesion and growth.

Prevention and management of complications in urological laparoscopic port site placement

OBJECTIVES

To review complications associated with urological laparoscopic port-site placement and outline techniques for their prevention and management.

METHODS

Review of the literature using Medline.

RESULTS

Laparoscopy now plays a key role in urological surgery. Its applications are expanding with experience and evolving data confirming equivalent long-term outcome. Although significant port-site complications are uncommon, their occurrence impacts significantly on perioperative morbidity and rate of recovery. The incidence of such complications is inversely related to surgeon experience. Ports now utilise bladeless tips to reduce the incidence of vascular and visceral injuries, and subsequently port-site herniation. Metastases occurring at the port site are preventable by adhering to certain measures.

CONCLUSIONS

Whether performing standard or robot-assisted laparoscopy, port-site creation and maintenance is critical in ensuring minimal invasiveness in laparoscopic urological surgery. Although patient factors can be optimised perioperatively and port design continues to improve, it is clear that adequate training is central in the prevention, early recognition, and treatment of complications related to laparoscopic access.

Laparoscopic Nephroureterectomy with Bladder-Cuff Resection: Techniques and Outcomes

Advancements in minimally invasive instrumentation and technique have provided the impetus to performing urologic procedures with reduced perioperative morbidity, shorter hospital stays, and, most importantly, efficacious oncologic results. At multiple centers of excellence, laparoscopic nephroureterectomy (LNU) has evolved into a new standard for the management of upper-tract transitional-cell carcinoma (TCC) that is not amenable to endoscopic resection. An LNU may be performed via a transperitoneal or retroperitoneal approach together with excision of the distal ureter and a bladder cuff. Analysis of present-day studies comparing LNU with open techniques demonstrates equivalent oncologic outcomes. In addition, those patients undergoing LNU fare better than their counterparts having open surgery with respect to hospital stay, analgesic requirements, and convalescence. With multiple options for excision of a cuff of bladder, a consensus has not been established. However, LNU has emerged as the new standard of care for the treatment of upper- tract TCC. Review of the techniques and outcomes of LNU from the minimally invasive urology community are described.

Laparoscopic surgery for colon cancer

Acceptance of laparoscopy for the management of oncological disease has been slow due to the increased complexity of the technique, requirement of technological advances, and fears for the oncological safety of the approach. Laparoscopic oncological surgery has a role in the management of oncological patients at all stages of disease. Good evidence exists for the laparoscopic approach being a viable option for colon cancer patients. Current large multicenter trials will report the true outcomes of laparoscopic colon cancer surgery and how it compares with open surgery. This article examines some of the parameters by which laparoscopic colectomy will be judged.

What are the Oncological Risks of Minimal Access Surgery for the Treatment of Urinary Tract Cancer?

OBJECTIVES

A review of the oncological safety of minimal access surgery for the treatment of urinary tract cancers. The particular areas reviewed were port-site metastases, local tumour recurrence and long-term survival.

METHODS

Review of the literature using Medline.

RESULTS

There is a low rate of port-site metastases following laparoscopic surgery for urological malignancies, these are usually related to the stage and grade of the tumour. So far follow-up data shows that laparoscopic surgery for urological malignancy does not result in higher levels of local recurrence or shorter survival than open surgery. Percutaneous (PCN) and ureteroscopic (URS) resection of TCC of the upper urinary tract are acceptable forms of treatment for grade 1 and 2 TCCs even in patients with normal contralateral kidneys. However, for grade 3 TCC nephroureterectomy should be utilised because of increased risk of local recurrence (URS) and track seeding (PCN).

CONCLUSIONS

Provided the principles of cancer surgery, combined with proper case selection are followed, minimal access surgery for urological cancer is safe and is rapidly emerging as the standard of care for many upper tract tumours.

Tumor seeding in urological laparoscopy: an international survey

PURPOSE

During the last 10 years laparoscopy has been applied to treat most urological pathology including malignancies. There has been concern regarding peritoneal dissemination and port site metastases. We undertook a survey to assess the incidence of this occurrence.

MATERIALS AND METHODS

A total of 50 international urology departments with experts in laparoscopic urological surgery were contacted for this study. Each site was asked to complete a 2-page survey regarding the volume of laparoscopic urological procedures and port site recurrences.

RESULTS

Nineteen sites elected to participate. A total of 18750 laparoscopic procedures were performed, of which 10912 were for cancer. These included 2604 radical nephrectomies, 559 nephroureterectomies, 555 partial nephrectomies, 27 segmental ureterectomies, 3665 radical prostatectomies, 1869 pelvic lymph node dissections, 479 retroperitoneal lymph node dissections, 336 adrenalectomies and 108 procedures listed as other. Tumor seeding was reported in 13 cases (0.1%), including 3 nephroureterectomies for transitional cell carcinoma, 4 nephrectomies (incidental transitional cell carcinoma), 4 adrenalectomies for metastases, 1 retroperitoneal lymph node dissection for testicular cancer and 1 pelvic lymph node dissection for cancer of the penis. Port seeding occurred in 10 cases (0.09%) and peritoneal spread in 3 cases (0.03%).

CONCLUSIONS

The incidence of tumor seeding after laparoscopic oncological surgery is rare and does not appear greater than what has been historically reported for open surgery. Tumor seeding seems to be most commonly related to the removal of high grade tumors and deviation from oncological surgical principles.

Critique of laparoscopic lymphadenectomy in genitourinary oncology

Regional lymphadenectomy is prognostic and selectively therapeutic in urologic oncology. The role of lymphadenectomy continues to be defined with the evolving multimodal management of genitourinary malignancies. Laparoscopy is playing a greater role in the management of genitourinary malignancies and thus, it is germane to critique the role of laparoscopic lymphadenectomy in the management of these tumors. Review of the literature suggests that laparoscopic pelvic lymphadenectomy is feasible with nodal yields commensurate to those in open published series. Although laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ cell tumor is feasible, the technique and efficacy of this procedure require further investigation.

Laparoscopic Nerve- and Seminal-Sparing Cystectomy with Orthotopic Ileal Neobladder: The First Three Cases

INTRODUCTION AND OBJECTIVES

Seminal and prostate sparing cystectomy represents an alternative in young patients where preservation of urinary continence and sexual potency are fundamental. We present our preliminary experience with this procedure performed laparoscopically.

METHODS

Three men-53, 58 and 49 years old-suffering from recurrent superficial transitional cell carcinoma of the bladder, resistant to intravesical therapy, underwent laparoscopic nerve, prostate and seminal vesical sparing cystectomy. One week before surgery, TURP was performed to create an adequate prostate capsule. After pneumoperitoneum induction and the positioning of five/six trocars, the ureters were clipped and transected, the vas deferens and seminal vescicles were identified and prepared for the conservative procedure. Cystectomy was performed with vascular pedicles transection by EndoGia. The reconstruction of the bladder was obtained through a 7 cm longitudinal periumbilical incision using 60 cm of ileus and an orthotopic neobladder realized outside the abdomen. The ileocapsular anastomosis was performed laparoscopically after the re-induction of pneumoperitoneum.

RESULTS

No major complications were recorded. The surgical time was respectively 480, 450 and 410 min. Blood loss was 150, 220 and 300 ml respectively. Drains were removed after 4 days (two patients) and 6 days (one patient) and the patients were discharged after 8 days (two patients) and 9 days. The patients were fully continent after catheter removal with normal uroflowmetry. At the three month follow-up they had a normal sexual function, equivalent to the preoperative assessment. The patients reported adequate erections for intercourse.

CONCLUSIONS

Laparoscopic prostate and seminal cystectomy with orthotopic ileal neobladder is a safe, feasible, reproducible surgical technique. In patients who desire to preserve sexual functioning and obtain complete continence it represents a valid alternative to classic radical cystectomy.

Laparoscopic port-site metastases: etiology and prevention

OBJECTIVE

The purpose of this article is to summarize current hypotheses for the possible sources of laparoscopic port-site metastasis, to review the results of experimental models that support such hypotheses, and to discuss the potential options for preventing these metastases.

METHODS

We performed a Medline search to identify in vitro and in vivo studies and clinical trials that analyzed port-site metastases associated with laparoscopic surgery. We report the incidence of port-site metastases and causative factors associated with this condition.

RESULTS

The estimated incidence of port-site metastases in all patients undergoing laparoscopic surgery for malignant disease is approximately 1-2%. Multiple factors are associated with this complication. Among the most common proposed etiologies are the wound implantations caused by the surgical technique and instrumentation; the leakage of insufflation gas through the ports, known as the "chimney effect"; and the impact of pneumoperitoneum on local immune reactions. Several preventive measures, have been suggested, including careful patient selection, lavage of the peritoneal cavity as well as of the port wounds with cytotoxic agents, and modifications of surgical technique.

CONCLUSIONS

Only through the results of well-conducted large multi-institutional prospective randomized trials will we learn not only the true incidence of port-site metastases, but also the potential factors that lead to the occurrence of this complication.

Port site metastases in urological laparoscopic surgery

PURPOSE

Laparoscopic surgery is rapidly gaining widespread acceptance among urologists, including extensive application in malignant conditions. However, untoward occurrences of port site metastases have not eluded to urological applications. This up-to-date review on port site metastases in urology delineates possible contributing factors and describes techniques to prevent it.

MATERIALS AND METHODS

We comprehensively reviewed published experimental and clinical studies with special emphasis on the incidence, pathophysiology and prevention of port site metastases.

RESULTS

Nine cases of port site metastases after urological laparoscopy have been described in clinical and experimental studies. Etiological factors include natural malignant disease behavior, host immune status, local wound factors, laparoscopy related factors such as aerosolization of tumor cells (the use of gas, type of gas, insufflation and desufflation, and pneumoperitoneum) and sufficient technical experience of the surgeons and operating team (adequate laparoscopic equipment, skill, minimal handling of the tumor, surgical manipulation and wound contamination during instruments change, organ morcellation and specimen removal).

CONCLUSIONS

Port site metastases is a multifactorial phenomenon with an as yet undetermined incidence. The problem is influenced to some extent by surgeon and operating team experience and, therefore, it could be partially prevented. The suggested preventive steps are avoiding laparoscopic surgery when there are ascites, trocar fixation to prevent dislodgment, avoiding gas leakage along and around the trocar, sufficient technical readiness of the operating team (adequate laparoscopic equipment and technique, minimal handling and avoiding tumor boundary violation of the tumor), using a bag for specimen removal, placing drainage when needed before desufflation, povidone-iodine irrigation of instruments, trocars and port site wounds, and suturing 10 mm. and larger trocar wounds.

Hand-assisted urological laparoscopy

Hand-assisted laparoscopy has been successfully applied to various applications within the field of urology. Many authors have proved the safety and efficacy of this technique, as well as demonstrating improved patient recovery for such procedures as radical nephrectomy, radical nephroureterectomy and donor nephrectomy. The recent literature regarding this topic is reviewed and evaluated here.

Laparoscopic radical nephrectomy: cancer control for renal cell carcinoma

PURPOSE

We evaluated the clinical efficacy of laparoscopic versus open radical nephrectomy in patients with clinically localized renal cell carcinoma.

MATERIALS AND METHODS

Between 1991 and 1999, 67 laparoscopic radical nephrectomies were performed for clinically localized, stages cT1/2 NXMX, pathologically confirmed renal cell carcinoma. During this period 54 patients who underwent open radical nephrectomy with pathologically confirmed stages pT1/2 NXMX disease were also identified. Medical and operative records were retrospectively reviewed and telephone followup was done to assess patient status.

RESULTS

In the laparoscopic and open groups average tumor size was 5.1 (range 1 to 13) and 5.4 cm. (range 0.2 to 18), respectively, which was not statistically significant. No patient had laparoscopic port site, wound or renal fossa tumor recurrence in either group. All patients were followed at least 12 months. In the laparoscopic group 2 cancer specific deaths occurred at a mean followup of 35.6 months. In the open group there were 2 cancer specific deaths and 3 cases of disease progression at a mean followup of 44 months. Kaplan-Meier disease-free survival and actuarial survival analysis revealed no significant differences in the laparoscopic and open radical nephrectomy groups. Also, no differences were noted in the complication rate.

CONCLUSIONS

Laparoscopic radical nephrectomy is an effective alternative for localized renal cell carcinoma when the principles of surgical oncology are maintained. Initial data show shorter patient hospitalization and effective cancer control with no significant difference in survival compared with open radical nephrectomy.

Laparoscopic nephrectomy for renal cell carcinoma

Since the first reported case of laparoscopic nephrectomy by Clayman et al. in 1991, laparoscopy is gaining acceptance as a viable alternative to open surgery for renal cell carcinoma. The benefits of laparoscopy include improved quality of life and lower incidence of perioperative morbidity. The perceived risks of laparoscopic nephrectomy for renal cell carcinoma include port-site metastasis, increased operative time, and the concern for inadequate surgical resection. The preliminary data concerning laparoscopy in renal cell carcinoma, however, indicate that rates of tumor recurrence are equivalent to open surgery while resulting in better cosmesis, decreased level of perioperative analgesic use, and decreased length of time to full convalescence.

Laparoscopic nephroureterectomy. A new standard for the surgical management of upper tract transitional cell cancer

Laparoscopic nephroureterectomy for upper tract TCC still remains somewhat controversial. Unlike laparoscopic radical nephrectomy, which has become widely accepted, LNU is still in its earliest stages. Although there are obvious benefits for the patient who has LNU--less pulmonary complications, less postoperative discomfort, a shorter hospital stay, a better cosmetic result, and a brief convalescence--there are significant concerns. The longer operative time creates a negative financial and professional inducement to learn this technique. Operative times need to fall into the 4-hour range or less to make the procedure cost-effective. Analysis of the efficacy of laparoscopic nephroureterectomy as a curative treatment modality is important. In the short-run, LNU seems to provide similar results to open nephroureterectomy for upper TCC. Although concerns over port site seeding, bladder recurrence, and intraperitoneal seeding have been voiced, these problems have not occurred. The higher incidence of local recurrence noted in the authors' series, however, is of concern and remains an unsettled issue. Despite these local recurrences, the overall cancer survival for a given grade and stage of upper tract TCC seem to be similar to survivals recorded after open nephroureterectomy. Still, the number of LNU cases remains small, and follow-up is brief. These patients need to be monitored closely, with follow-up CT scans over the next decade. The authors believe that there are still several significant hurdles standing in the path of LNU before it can become a widely accepted procedure. Issues of cost, training, and long-term efficacy must be answered definitively. To obtain these types of data, it will be necessary to create a multi-institutional, cooperative study to obtain sufficient numbers of patients with a more than 5-year follow-up on which to base future recommendations.