Uro-Oncology Uro-Oncology Uro-Oncology

Prostate Cancer

Introduction

Usually, the words “cancer” or “tumor” are associated with a feeling of panic, due to the possibility of this disease to seriously affect and to threaten the life of our friends and family members. However, tumors are not all the same and prostate cancer has typically a more indolent nature rather than other more aggressive types affecting other organs. It is a condition that develops slowly and it is quite common that an old man lives his entire life with the cancer, dying for other causes.Prostate cancer is rare in younger ages, but30% of men over the age of 50 years can be affected bythe diseaseandit increases progressively with age. So it is very likely that a man around 70 to 80 years may have a prostate cancer, but not ultimately die due to it.

Prostate cancer is the most common malignancy of the urinary system and is the third cause of cancer death in men. The estimated latent risk for prostate cancer during the life of a man in the age of 50 is 40%, but clinically it is found only in 9.5% while only 2.9% of the men will result in death. Therefore, prostate cancer is a slowly progressive condition that probably does not create life-threatening events if diagnosed early and treated appropriately. Moreover, men who have within the immediate family people who had prostate cancer are more likely to have prostate cancer themselves.

The symptoms that bring the patient to a physician are similar to the enlargement of the prostate (benign prostatic hyperplasia-BPH). Nowadays, most cases of prostate cancer are diagnosed at an early stage. Incidental findings after transurethral prostatectomy for BPH may also result in a diagnosis of prostate cancer.

The diagnosis and differentiation from other conditions of the prostateare done by the following means:
• Digital rectal examination of prostate.
• Prostate specific antigen (PSA).
• Prostate Ultrasound.
• Prostate Biopsy.

The urologist performs a digital rectal examination, estimating the prostate by its palpation with the fingertip. It is an old method, but still reliable to initiate an investigation of a prostate gland with possible cancer. A prostate that contains cancer is harder to the touch and loses its normal shape.
PSA test is the next diagnostic step. PSA is a substance produced by the prostate and found in the blood. Its normal range is between 0-4ng/ml but several conditions like (but not only) a prostate tumor may increase the value.This means that a man with an elevated PSA could havethe tumor but not all the men with increased PSA will have it.

Prostate cancer can be addressed in different ways which include active surveillance, radiotherapy, brachytherapy, hormonal therapy and surgery (radical prostatectomy).
Surgery is proposed in the initial stages of the disease. Radical prostatectomy consists in the surgical removal of the whole prostate gland and seminal vesicles. Then, the bladder is sutured again to the urethra in order to re-establish the urinary continuity. Radical prostatectomy has beenperformed for decades with an open surgical approach, including a large incision below the umbilicus.
The laparoscopic radical prostatectomy, proposed in our department is a modern less invasive technique in which five small incisions (5-12mm) are used to insert into the abdomen sophisticated laparoscopic tools to reach the prostate and perform an accurate procedure.

In this way, the laparoscopic approach achieves lower blood loss, less postoperative pain, faster recovery and mobilization of the patient. It is important to underline that, rarely, if during the procedure intraoperative conditions doesn’t allow the surgeon to continue in safety, the conversion into the open approach is possible.
The bladder catheter placed at the end of the surgery is removed the fifth post-operative day. However, since the second day after surgery, the patient may leave the hospital to return after 3 days to remove the catheter.

Radical prostatectomy, in line with any other surgical procedure, may have some postoperative complications but its contribution in the improvement of oncological outcomes for prostate cancer is invaluable.
The main complication is the sexual impotence. This is due to injury to the nerves responsible for sexual function. Impotence is often present immediately after a radical prostatectomy but erectile function is recovered naturally in a percentage of the patients within few weeks or months. The development of new surgical techniques and equipment has significantly reduced the percentage ofpostoperative impotence. During the procedure,the surgeon tries to save as much as possible of the neural pathways that surround the prostate, butthis must always be balanced with the prospect of an optimal cancer survival outcome and the possibility to remove all the tumoral tissue.

Urinary incontinence after radical prostatectomy is the second main complication, due to a damage into the mechanism that holds the urine in the bladder. This mechanism is provided by a valve or sphincter that ensures the so-called continence. The surgeon aims also to preserve this tissue, but as for the impotence, is not always possible for oncological or anatomical limits.This complication is also frequent in the immediate post-operative period and continence can beoften restored over a period of weeks/months.

Anyway, the patient is followed up regularly after the surgery, so that the urologist can adopt solutions suitable for each case.

Bladder Cancer

Introduction

Bladder cancer is one of the 7-th most common occurring malignancy in both genders. The disease affects more frequently men than women and the mean age at diagnosis is 68 years. Cigarette smoking is the most important risk factor predicting the development of bladder cancer. About 75% of cases present in early cases, while advanced disease (cancer invaded into the muscle wall of the bladder) is diagnosed in remaining 25%.

The prognosis of bladder cancer depends on the depth and extent of the tumor in the bladder wall and the degree of differentiation of tumor cells. If the muscular layer of the bladder wall (clinical stage Ta, T1, CIS) is not involved, the 5-year survival ranges from 82-100% with proper treatment. Involvement of the muscular layer without any extension outside the bladder (clinical stage T2) is associated with 63 – 83% 5-year survival rate.

Overall, radical cystectomy offers disease free survival during the first 5 years in 60-70% of patients. Disease free survival up to 77% at 10 years is possible if the tumor was limited to the bladder during surgery. Extravesical extension significantly limits disease-free survival to 44% of the patients while the presence of lymph node involvement further reduces the above rate to 34%.

Therefore, early diagnosis and treatment of bladder cancer is essential for obtaining good surgical and oncological outcomes.

The main symptom of bladder cancer is hematuria. Less common symptoms are pain during urination (dysuria) or frequent urination. As a result, each case of hematuria in older ages should be examined by the urologist with the suspicion of bladder cancer. Imaging examination, such as ultrasound of the bladder and abdominal CT, and the urine cytology are the useful tests for the diagnosis of bladder cancer.

Nevertheless, cystoscopy is the most important examination. The latter is performed by inserting a special instrument through the urethra into the bladder and the urologist evaluates the appearance of the bladder mucosa. The examination is not painful when carried out under local or general anesthesia. Therefore, the diagnosis of bladder cancer most often arises after cystoscopy and visual recognition of the characteristic image of exophytic tumor.

Urine cytology significantly contributes to the diagnosis since cancer cells are detected in the urine.

The final diagnosis is set by the histological examination of biopsy samples taken from the tumor. A biopsy will also determine the aggressiveness of the tumor and the extent of bladder wall involvement. It is worth noting that for small lesions with low aggressiveness, the complete resection of the tumor for biopsy could be also the definitive treatment.

Superficial bladder tumors are treated with transurethral resection (transurethral resection of the bladder tumor (TURBT)). Depending on the stage and aggressiveness recurrence rate could be as high as 80% after initial treatment. The periodically repeating cystoscopy with ablation is often sufficient in low-grade tumors. Alternative means such as repeated injections of chemotherapeutic agents into the bladder are necessary to address intermediate grade tumors. The injections significantly reduce the recurrence rates and the incidence of tumor progression to more aggressive neoplasm.

In case of tumors extending to muscular layer or across the bladder wall, transurethral resection is not sufficient.

These patients are candidates for radical cystectomy (removal of the bladder with simultaneous removal of the regional lymph nodes) if there is no evidence of distant metastasis. Systemic chemotherapy and local radiation therapy adjunct or in combination to radical cystectomy are indicated for more advanced disease or to the patients that are not fit or are not willing to undergo radical cystectomy.

Radical cystectomy is considered to be one of the most demanding urologic procedures. It can be performed by open or laparoscopical approach. Despite the higher technical challenge of laparoscopic cystectomy in comparison to open surgery, the laparoscopic approach is associated with less perioperative morbidity and faster recovery.

The surgery involves the complete removal of the bladder along with fatty tissue around the bladder and lymph nodes. In addition, the prostate and seminal vesicles are removed in male patients while the uterus, fallopian tubes, ovaries as well as the anterior vaginal wall are removed in the female patients. An appropriate procedure to restore the urinary tract is concomitantly performed in order to restore the urinary tract. There are several different techniques to restore the urinary tract. These techniques depend on the stage of the disease and can be categorized into continent and incontinent urinary diversion groups. In continent urinary diversion a bowel segment is used to form a pouch which can be further joined to urethra forming artificial neobladder. This provides the patient the restoration of the normal urinary function in most of the cases. In case of incontinent urinary diversion, the ureters are either joined directly to the skin or to the use of small bowel segment.

In either case urine is drained continuously into the urostomy bag attached on the abdominal wall on one side or on both sides

Complications are limited when the surgery is performed in a specialized center with extensive experience. The most common complications are postoperative ileus, fever, and leakage of urine. These complications are in the majority of cases treated conservatively. However, in limited number of cases, a reoperation could be required. Other complications are disturbed wound healing, thrombosis or embolism, injury of adjacent organs and lymphocele. Mid-term complications include ureteral strictures at sites where the ureter is sutured to bowel, compromised renal function, formation of kidney stones and infection.

Laparoscopic radical cystectomy is associated with significantly faster recovery of the patient in comparison with open cystectomy. The patient is mobilized on the next day of surgery and fed with the return of normal bowel on the fourth postoperative day. Discharge day is scheduled one week after surgery while ureteral catheters (inserted intraoperatively) are removed 2 weeks after surgery.

Kidney Cancer

Introduction

Renal cell carcinoma (RCC) is the most common occurring neoplasm in the kidney. In the early stages of the disease no symptoms are present. However, due to the improvement of modern imaging methods (sonography, CT and MRI), a growing number of such tumors is recognized as an incidental finding while investigating for other diseases. As a result, early intervention is possible before the progression of the disease. Hematuria (blood in urine), flank pain and palpable mass are non-specific symptoms of the disease usually found in more advanced stages.

The prognosis depends on the stage of the disease. Small tumors in early stages can be cured (without any recurrence) in more than 90% of cases. When a total excision of the tumor by partial or radical nephrectomy has been performed and histology demonstrates that the tumor is located exclusively in the kidney, the 5-year survival ranges between 60-70%. In case of tumor extending outside the kidney or the presence of distant metastasis, the prognosis is poor.

Abdominal ultrasound is the initial imaging modality to visualize renal anatomy. I case of any doubts computer tomography (CT) is indicated. The full radiological assessment is done with CT of the chest and abdomen to determine the size of the tumor and exclude distant metastases. If involvement of renal vessels (including tumor thrombus) is suspected, MRI (Magnetic resonance Imaging) angiography may be required to determine the extension of the thrombus in renal and abdominal vessels.

Presence of the renal tumor on CT is usually sufficient for proceeding to surgical treatment. Percutaneous needle biopsy is required only in doubtful cases and in older and ill patients not eligible for the proposed surgery.

The surgical removal of the tumor is the treatment of choice for most of the renal tumors. Depending on the size and localization of the tumor as well as radiological appearance partial nephrectomy (removal of the lesion) or radical nephrectomy (removal of the whole kidney) can be proposed. Radical nephrectomy is the removal of the entire kidney with the surrounding fat and in some cases the ipsilateral adrenal gland (of the same side). In case of small, peripheral tumors, or in cases which require maximum preservation of renal function (eg, contralateral kidney with impaired renal function), the performance of partial nephrectomy is indicated.

In the latter procedure, only the tumor is excised and the remaining kidney remains intact.

In cases with bilateral tumors or patients with significant operative risk who cannot undergo nephrectomy, minimally invasive methods such as cryotherapy, high intensity focused ultrasound, and embolization of the kidney proved useful tools in dealing with the disease.

Laparoscopic radical nephrectomy is performed through small skin incisions on the abdominal wall with the help of laparoscopic instruments. During the procedure the kidney is completely removed. After the nephrectomy, the surgical specimen is placed in a special collection bag and is extracted out of the abdominal cavity. One of the incisions is extended by some centimeters and the kidney is removed.

The significant advantages of laparoscopic nephrectomy in comparison to open nephrectomy are the smaller abdominal wound, lower blood loss and less post-operative pain. As a result, the cosmetic result is superior, the patient recovers faster and returns to pre-surgery physical activity significantly quicker.

Laparoscopic partial nephrectomy is considered one of the most demanding operations in terms of laparoscopic skill. The oncologic principles of laparoscopic partial nephrectomy are the same as radical nephrectomy and require the complete excision of the tumor until the healthy tissue margins. However, the main difference compared to radical nephrectomy is the excision of the tumor only, which requires a transient interruption of blood circulation in the kidney in order to perform the procedure with minimal blood loss. The interruption of renal perfusion is achieved by placing a clamp on the renal artery resulting in ischemia of the kidney. Prolonged ischemia may cause irreparable damage to the kidney. Thus, the procedure should be performed in a time sensitive manner. Only centers of extensive laparoscopic experience are capable into performing laparoscopic partial nephrectomy efficiently.

Developments in laparoscopic surgery are leading to the improvements of the technique while possessing similar outcomes.

In addition, these techniques provide improved cosmetic outcome and less morbidity. The single-port (Laparoendoscopic single site surgery) laparoscopic nephrectomy and transvaginally- assisted laparoendoscopic single-site nephrectomy are the recent laparoscopic urologic procedures. In single-port laparoscopic surgery, all instruments are inserted through the umbilicus and other abdominal incisions are avoided.

At the end of the procedure, the umbilical incision is sutured and concealed in the umbilical fold resulting in “scarless” surgery. Moreover, the performance of only one incision reduces the possibility for related complications (wound infection, hernia formation). In transvaginally- assisted laparoendoscopic single-site nephrectomy, the female vagina is used for the access of laparoscopic instruments into the abdomen in addition to the insertion of instruments through the umbilicus.

The vagina is then used for the removal of the surgical specimen at the end of surgery. The suturing and healing of the vaginal access is excellent and painless. This procedure assures good aesthetic outcomes.

The main complication associated with nephrectomy is the massive bleeding from large vessel injury (renal artery and vein, posterior lumbar arteries, adrenal vessels, aorta, vena) during the performance of the procedure. Although the majority of cases the blood loss during laparoscopic nephrectomy is negligible, massive bleeding can be observed in rare cases and can be life-threatening for the patient. Bleeding is controlled in the majority of the cases laparoscopically. Open surgery is rarely necessary for hemostasis. Injury to adjacent organs is also possible. In the case of partial nephrectomy, blood loss is usually higher than in radical nephrectomy.

The leakage of urine from the kidney to the abdomen and bleeding are rarely seen postoperatively. While most of the complications are managed conservatively, secondary specific intervention can be required in several cases.

The postoperative course after laparoscopic nephrectomy or partial nephrectomy is associated with minimal pain. The patient is mobilized and fed the first day after surgery. A drain tube which is inserted at the end of the procedure is removed on the first postoperative day. The patient leaves the hospital on the 2-3 day after surgery.

Andrenal Tumor

Introduction

An adrenal is an endocrine gland located on the top of the upper pole of each kidney and secretes a range of hormones necessary for humans. The adrenal medulla produces adrenaline and noradrenaline, hormones which are important for regulating the nervous system. The cortical portion of the adrenal produces hormones such as cortisol, aldosterone and androgens. These hormones are necessary for regulating the homeostasis of the human body and immune response. The adrenal glands can be the growth area of adenomas (benign tumors) and malignant tumors. The adrenal adenomas are benign tumors which do not metastasize to other tissues. Nevertheless, most adenomas secrete large amounts of hormones causing hormonal imbalance with significant health effects for the patients. In contrast, malignant tumors of the adrenal gland are still considered rare but extremely aggressive form of cancer. Regardless of the type of the tumor (malignant or benign), increased hormone production remains one of the most threats of adrenal tumors. In all those cases removal of the adrenal gland (adrenalectomy) is indicated.

The prognosis depends on the stage of the disease. Small tumors in early stages can be cured (without any recurrence) in more than 90% of cases. When a total excision of the tumor by partial or radical nephrectomy has been performed and histology demonstrates that the tumor is located exclusively in the kidney, the 5-year survival ranges between 60-70%. In case of tumor extending outside the kidney or the presence of distant metastasis, the prognosis is poor.

The diagnosis of adrenal tumor is usually made due to the developed symptoms of hormone imbalance. The disease can also be incidentally diagnosed when examinations are performed for the investigation of another health problem. Abdominal ultrasound is the initial, safe and cost-effective imaging modality for diagnosis of adrenal tumors.

However, computer tomography of the abdomen represents the most important tool for investigation and proper localization of adrenal tumors.

Surgical removal of the tumor or the affected gland is the main approach to treat the patients. Laparoscopic adrenalectomy (removal of the adrenal gland) is now the procedure of choice for the removal of functional adrenal adenomas such as pheochromocytoma and adrenal non-functioning tumors.

Furthermore, the laparoscopic approach is indicated for the treatment of tumors suspicious for malignancy and secondary adrenal metastases from extra-adrenal tumors. The surgery is performed under general anesthesia with the use of small 5 to 10mm diameter instruments.

Several surgical and endocrine complications are associated with laparoscopic adrenalectomy. Surgical complications are related to intra-operative bleeding, which is, however, when laparoscopic approach is used.

Injury to adjacent organs is a rare complication when the surgery is performed in a specialized center with extensive experience. Hormonal complications are associated with intra-operative release of large amounts of hormones in blood circulation and postoperative adrenal insufficiency following the removal of the gland.

The correct preoperative preparation and postoperative patient assessment by an experienced endocrine team as well as careful surgical manipulations minimize those complications.

The main reason why laparoscopic approach for adrenelectomy is considered the treatment of choice is the significantly reduced morbidity compared to the open surgical approach. Three abdominal or lumbar incisions are necessary for the performance of the procedure. The operative time is approximately two hour and intraoperative blood loss is minimal. The tumor is removed at the end of the procedure by one of the incisions. The patient is mobilized and eats on the first day after surgery and leaves the hospital on the second day. After 10 days the patient is fully capable to return to pre-surgery activity. The aesthetic result is excellent.

Prostate Biopsy

Introduction

Prostate cancer is a rare condition in younger ages, but 30% of men over the age of 50 years can be affected by the disease and it increases progressively with age. Prostate tumour is the third cause of cancer death in men, but fortunately, in most of the cases, it is indolent, developing slowly and remaining confined in the gland. So it is quite common that a man lives his entire life with cancer.
Prostate biopsy is a diagnostic exam and it consists in taking samples of prostatic tissue that are then histologically analyzed in order to find out or exclude the presence of prostate cancer.

The most common indications for the prostate biopsy are:

  • Increased PSA (prostate-specific antigen) in the blood (normal range: 0-4ng/ml)
  • Suspicion finding during the prostate palpation with a digital rectal examination
  • Suspicion finding during a transrectal prostatic ultrasonography

In all these scenarios, prostate biopsy is the only exam that can confirm the diagnosis of tumour definitively. Important to underline that not all the men with increased PSA have a prostate tumour and, for example, only one-fourth of the men undergoing to the biopsy for a mild increase (4-10ng/ml) receive a malignant diagnosis.

In our department, it is performed a transrectal approach in local anesthesia. The patient lies on the side with the knee flexed close to his chest. The urologist starts with a digital rectal examination to palpate the prostate, then he proceeds with a prostate ultrasonography placing a transrectal probe well lubricated and injects a local anesthetic (lidocaine) close to the prostate gland.

After some minutes, through an appropriate device fixed with the probe, a special needle is introduced over the rectum in the prostate where the doctor can take usually 12samples from defined regions of the gland under ultrasound vision. According to the patient, it is possible to take more samples in suspicion areas.

The procedure is safe but invasive, therefore some complications are possible.

  • Bleeding can occur up to 20% of the cases but it is often mild and temporary. The patient complains of the presence of some blood in the urine, sperm or feces. Rarely severe haematuria is possible with clot formation that can obstruct the urethra avoiding the bladder emptying. This condition can be symptomatic and requires sometimes the placement of a bladder catheter. Therefore, in order to reduce these complications, it is important to increase the hydration after the procedure.
  • Inflammatory complications of the gland can occur resulting rarely (<1% of the cases) in an obstructive swelling of the prostate that requires catheterization for some days.
  • Infectious complications (cystitis, prostatitis, epididymo-orchitis) can be associated with difficulty in urination and/or fever. Usually, medical treatment is adopted and only in rare cases hospitalization is needed.

Laparascopic Prostatectomy

<a href=”https://laparoscopy-endourology.com/doctors/”>View more</a>

Forum Search

Recent forum topics

Avatar
test topicby giokou3 years ago

Follow our research activity

Prostate Cancer

Introduction

Usually, the words “cancer” or “tumor” are associated with a feeling of panic, due to the possibility of this disease to seriously affect and to threaten the life of our friends and family members. However, tumors are not all the same and prostate cancer has typically a more indolent nature rather than other more aggressive types affecting other organs. It is a condition that develops slowly and it is quite common that an old man lives his entire life with the cancer, dying for other causes.Prostate cancer is rare in younger ages, but30% of men over the age of 50 years can be affected bythe diseaseandit increases progressively with age. So it is very likely that a man around 70 to 80 years may have a prostate cancer, but not ultimately die due to it.

Prostate cancer is the most common malignancy of the urinary system and is the third cause of cancer death in men. The estimated latent risk for prostate cancer during the life of a man in the age of 50 is 40%, but clinically it is found only in 9.5% while only 2.9% of the men will result in death. Therefore, prostate cancer is a slowly progressive condition that probably does not create life-threatening events if diagnosed early and treated appropriately. Moreover, men who have within the immediate family people who had prostate cancer are more likely to have prostate cancer themselves.

The symptoms that bring the patient to a physician are similar to the enlargement of the prostate (benign prostatic hyperplasia-BPH). Nowadays, most cases of prostate cancer are diagnosed at an early stage. Incidental findings after transurethral prostatectomy for BPH may also result in a diagnosis of prostate cancer.

The diagnosis and differentiation from other conditions of the prostateare done by the following means:
• Digital rectal examination of prostate.
• Prostate specific antigen (PSA).
• Prostate Ultrasound.
• Prostate Biopsy.

The urologist performs a digital rectal examination, estimating the prostate by its palpation with the fingertip. It is an old method, but still reliable to initiate an investigation of a prostate gland with possible cancer. A prostate that contains cancer is harder to the touch and loses its normal shape.
PSA test is the next diagnostic step. PSA is a substance produced by the prostate and found in the blood. Its normal range is between 0-4ng/ml but several conditions like (but not only) a prostate tumor may increase the value.This means that a man with an elevated PSA could havethe tumor but not all the men with increased PSA will have it.

Prostate cancer can be addressed in different ways which include active surveillance, radiotherapy, brachytherapy, hormonal therapy and surgery (radical prostatectomy).
Surgery is proposed in the initial stages of the disease. Radical prostatectomy consists in the surgical removal of the whole prostate gland and seminal vesicles. Then, the bladder is sutured again to the urethra in order to re-establish the urinary continuity. Radical prostatectomy has beenperformed for decades with an open surgical approach, including a large incision below the umbilicus.
The laparoscopic radical prostatectomy, proposed in our department is a modern less invasive technique in which five small incisions (5-12mm) are used to insert into the abdomen sophisticated laparoscopic tools to reach the prostate and perform an accurate procedure.

In this way, the laparoscopic approach achieves lower blood loss, less postoperative pain, faster recovery and mobilization of the patient. It is important to underline that, rarely, if during the procedure intraoperative conditions doesn’t allow the surgeon to continue in safety, the conversion into the open approach is possible.
The bladder catheter placed at the end of the surgery is removed the fifth post-operative day. However, since the second day after surgery, the patient may leave the hospital to return after 3 days to remove the catheter.

Radical prostatectomy, in line with any other surgical procedure, may have some postoperative complications but its contribution in the improvement of oncological outcomes for prostate cancer is invaluable.
The main complication is the sexual impotence. This is due to injury to the nerves responsible for sexual function. Impotence is often present immediately after a radical prostatectomy but erectile function is recovered naturally in a percentage of the patients within few weeks or months. The development of new surgical techniques and equipment has significantly reduced the percentage ofpostoperative impotence. During the procedure,the surgeon tries to save as much as possible of the neural pathways that surround the prostate, butthis must always be balanced with the prospect of an optimal cancer survival outcome and the possibility to remove all the tumoral tissue.

Urinary incontinence after radical prostatectomy is the second main complication, due to a damage into the mechanism that holds the urine in the bladder. This mechanism is provided by a valve or sphincter that ensures the so-called continence. The surgeon aims also to preserve this tissue, but as for the impotence, is not always possible for oncological or anatomical limits.This complication is also frequent in the immediate post-operative period and continence can beoften restored over a period of weeks/months.

Anyway, the patient is followed up regularly after the surgery, so that the urologist can adopt solutions suitable for each case.

Bladder Cancer

Introduction

Bladder cancer is one of the 7-th most common occurring malignancy in both genders. The disease affects more frequently men than women and the mean age at diagnosis is 68 years. Cigarette smoking is the most important risk factor predicting the development of bladder cancer. About 75% of cases present in early cases, while advanced disease (cancer invaded into the muscle wall of the bladder) is diagnosed in remaining 25%.

The prognosis of bladder cancer depends on the depth and extent of the tumor in the bladder wall and the degree of differentiation of tumor cells. If the muscular layer of the bladder wall (clinical stage Ta, T1, CIS) is not involved, the 5-year survival ranges from 82-100% with proper treatment. Involvement of the muscular layer without any extension outside the bladder (clinical stage T2) is associated with 63 – 83% 5-year survival rate.

Overall, radical cystectomy offers disease free survival during the first 5 years in 60-70% of patients. Disease free survival up to 77% at 10 years is possible if the tumor was limited to the bladder during surgery. Extravesical extension significantly limits disease-free survival to 44% of the patients while the presence of lymph node involvement further reduces the above rate to 34%.

Therefore, early diagnosis and treatment of bladder cancer is essential for obtaining good surgical and oncological outcomes.

The main symptom of bladder cancer is hematuria. Less common symptoms are pain during urination (dysuria) or frequent urination. As a result, each case of hematuria in older ages should be examined by the urologist with the suspicion of bladder cancer. Imaging examination, such as ultrasound of the bladder and abdominal CT, and the urine cytology are the useful tests for the diagnosis of bladder cancer.

Nevertheless, cystoscopy is the most important examination. The latter is performed by inserting a special instrument through the urethra into the bladder and the urologist evaluates the appearance of the bladder mucosa. The examination is not painful when carried out under local or general anesthesia. Therefore, the diagnosis of bladder cancer most often arises after cystoscopy and visual recognition of the characteristic image of exophytic tumor.

Urine cytology significantly contributes to the diagnosis since cancer cells are detected in the urine.

The final diagnosis is set by the histological examination of biopsy samples taken from the tumor. A biopsy will also determine the aggressiveness of the tumor and the extent of bladder wall involvement. It is worth noting that for small lesions with low aggressiveness, the complete resection of the tumor for biopsy could be also the definitive treatment.

Complications are limited when the surgery is performed in a specialized center with extensive experience. The most common complications are postoperative ileus, fever, and leakage of urine. These complications are in the majority of cases treated conservatively. However, in limited number of cases, a reoperation could be required. Other complications are disturbed wound healing, thrombosis or embolism, injury of adjacent organs and lymphocele. Mid-term complications include ureteral strictures at sites where the ureter is sutured to bowel, compromised renal function, formation of kidney stones and infection.

Radical cystectomy is considered to be one of the most demanding urologic procedures. It can be performed by open or laparoscopical approach. Despite the higher technical challenge of laparoscopic cystectomy in comparison to open surgery, the laparoscopic approach is associated with less perioperative morbidity and faster recovery.

The surgery involves the complete removal of the bladder along with fatty tissue around the bladder and lymph nodes. In addition, the prostate and seminal vesicles are removed in male patients while the uterus, fallopian tubes, ovaries as well as the anterior vaginal wall are removed in the female patients. An appropriate procedure to restore the urinary tract is concomitantly performed in order to restore the urinary tract. There are several different techniques to restore the urinary tract. These techniques depend on the stage of the disease and can be categorized into continent and incontinent urinary diversion groups. In continent urinary diversion a bowel segment is used to form a pouch which can be further joined to urethra forming artificial neobladder. This provides the patient the restoration of the normal urinary function in most of the cases. In case of incontinent urinary diversion, the ureters are either joined directly to the skin or to the use of small bowel segment.

In either case urine is drained continuously into the urostomy bag attached on the abdominal wall on one side or on both sides

Laparoscopic radical cystectomy is associated with significantly faster recovery of the patient in comparison with open cystectomy. The patient is mobilized on the next day of surgery and fed with the return of normal bowel on the fourth postoperative day. Discharge day is scheduled one week after surgery while ureteral catheters (inserted intraoperatively) are removed 2 weeks after surgery.

Kidney Cancer

Introduction

Renal cell carcinoma (RCC) is the most common occurring neoplasm in the kidney. In the early stages of the disease no symptoms are present. However, due to the improvement of modern imaging methods (sonography, CT and MRI), a growing number of such tumors is recognized as an incidental finding while investigating for other diseases. As a result, early intervention is possible before the progression of the disease. Hematuria (blood in urine), flank pain and palpable mass are non-specific symptoms of the disease usually found in more advanced stages.

The prognosis depends on the stage of the disease. Small tumors in early stages can be cured (without any recurrence) in more than 90% of cases. When a total excision of the tumor by partial or radical nephrectomy has been performed and histology demonstrates that the tumor is located exclusively in the kidney, the 5-year survival ranges between 60-70%. In case of tumor extending outside the kidney or the presence of distant metastasis, the prognosis is poor.

Abdominal ultrasound is the initial imaging modality to visualize renal anatomy. I case of any doubts computer tomography (CT) is indicated. The full radiological assessment is done with CT of the chest and abdomen to determine the size of the tumor and exclude distant metastases. If involvement of renal vessels (including tumor thrombus) is suspected, MRI (Magnetic resonance Imaging) angiography may be required to determine the extension of the thrombus in renal and abdominal vessels.

Presence of the renal tumor on CT is usually sufficient for proceeding to surgical treatment. Percutaneous needle biopsy is required only in doubtful cases and in older and ill patients not eligible for the proposed surgery.

The surgical removal of the tumor is the treatment of choice for most of the renal tumors. Depending on the size and localization of the tumor as well as radiological appearance partial nephrectomy (removal of the lesion) or radical nephrectomy (removal of the whole kidney) can be proposed. Radical nephrectomy is the removal of the entire kidney with the surrounding fat and in some cases the ipsilateral adrenal gland (of the same side). In case of small, peripheral tumors, or in cases which require maximum preservation of renal function (eg, contralateral kidney with impaired renal function), the performance of partial nephrectomy is indicated.

In the latter procedure, only the tumor is excised and the remaining kidney remains intact.

In cases with bilateral tumors or patients with significant operative risk who cannot undergo nephrectomy, minimally invasive methods such as cryotherapy, high intensity focused ultrasound, and embolization of the kidney proved useful tools in dealing with the disease.

The main complication associated with nephrectomy is the massive bleeding from large vessel injury (renal artery and vein, posterior lumbar arteries, adrenal vessels, aorta, vena) during the performance of the procedure. Although the majority of cases the blood loss during laparoscopic nephrectomy is negligible, massive bleeding can be observed in rare cases and can be life-threatening for the patient. Bleeding is controlled in the majority of the cases laparoscopically. Open surgery is rarely necessary for hemostasis. Injury to adjacent organs is also possible. In the case of partial nephrectomy, blood loss is usually higher than in radical nephrectomy.

The leakage of urine from the kidney to the abdomen and bleeding are rarely seen postoperatively. While most of the complications are managed conservatively, secondary specific intervention can be required in several cases.

The postoperative course after laparoscopic nephrectomy or partial nephrectomy is associated with minimal pain. The patient is mobilized and fed the first day after surgery. A drain tube which is inserted at the end of the procedure is removed on the first postoperative day. The patient leaves the hospital on the 2-3 day after surgery.

Laparoscopic radical nephrectomy is performed through small skin incisions on the abdominal wall with the help of laparoscopic instruments. During the procedure the kidney is completely removed. After the nephrectomy, the surgical specimen is placed in a special collection bag and is extracted out of the abdominal cavity. One of the incisions is extended by some centimeters and the kidney is removed.

The significant advantages of laparoscopic nephrectomy in comparison to open nephrectomy are the smaller abdominal wound, lower blood loss and less post-operative pain. As a result, the cosmetic result is superior, the patient recovers faster and returns to pre-surgery physical activity significantly quicker.

Laparoscopic partial nephrectomy is considered one of the most demanding operations in terms of laparoscopic skill. The oncologic principles of laparoscopic partial nephrectomy are the same as radical nephrectomy and require the complete excision of the tumor until the healthy tissue margins. However, the main difference compared to radical nephrectomy is the excision of the tumor only, which requires a transient interruption of blood circulation in the kidney in order to perform the procedure with minimal blood loss. The interruption of renal perfusion is achieved by placing a clamp on the renal artery resulting in ischemia of the kidney. Prolonged ischemia may cause irreparable damage to the kidney. Thus, the procedure should be performed in a time sensitive manner. Only centers of extensive laparoscopic experience are capable into performing laparoscopic partial nephrectomy efficiently.

Developments in laparoscopic surgery are leading to the improvements of the technique while possessing similar outcomes.

In addition, these techniques provide improved cosmetic outcome and less morbidity. The single-port (Laparoendoscopic single site surgery) laparoscopic nephrectomy and transvaginally- assisted laparoendoscopic single-site nephrectomy are the recent laparoscopic urologic procedures. In single-port laparoscopic surgery, all instruments are inserted through the umbilicus and other abdominal incisions are avoided.

At the end of the procedure, the umbilical incision is sutured and concealed in the umbilical fold resulting in “scarless” surgery. Moreover, the performance of only one incision reduces the possibility for related complications (wound infection, hernia formation). In transvaginally- assisted laparoendoscopic single-site nephrectomy, the female vagina is used for the access of laparoscopic instruments into the abdomen in addition to the insertion of instruments through the umbilicus.

The vagina is then used for the removal of the surgical specimen at the end of surgery. The suturing and healing of the vaginal access is excellent and painless. This procedure assures good aesthetic outcomes.

Laparoscopic radical cystectomy is associated with significantly faster recovery of the patient in comparison with open cystectomy. The patient is mobilized on the next day of surgery and fed with the return of normal bowel on the fourth postoperative day. Discharge day is scheduled one week after surgery while ureteral catheters (inserted intraoperatively) are removed 2 weeks after surgery.

Andrenal Tumor

Introduction

An adrenal is an endocrine gland located on the top of the upper pole of each kidney and secretes a range of hormones necessary for humans. The adrenal medulla produces adrenaline and noradrenaline, hormones which are important for regulating the nervous system. The cortical portion of the adrenal produces hormones such as cortisol, aldosterone and androgens. These hormones are necessary for regulating the homeostasis of the human body and immune response. The adrenal glands can be the growth area of adenomas (benign tumors) and malignant tumors. The adrenal adenomas are benign tumors which do not metastasize to other tissues. Nevertheless, most adenomas secrete large amounts of hormones causing hormonal imbalance with significant health effects for the patients. In contrast, malignant tumors of the adrenal gland are still considered rare but extremely aggressive form of cancer. Regardless of the type of the tumor (malignant or benign), increased hormone production remains one of the most threats of adrenal tumors. In all those cases removal of the adrenal gland (adrenalectomy) is indicated

The prognosis depends on the stage of the disease. Small tumors in early stages can be cured (without any recurrence) in more than 90% of cases. When a total excision of the tumor by partial or radical nephrectomy has been performed and histology demonstrates that the tumor is located exclusively in the kidney, the 5-year survival ranges between 60-70%. In case of tumor extending outside the kidney or the presence of distant metastasis, the prognosis is poor.

The diagnosis of adrenal tumor is usually made due to the developed symptoms of hormone imbalance. The disease can also be incidentally diagnosed when examinations are performed for the investigation of another health problem. Abdominal ultrasound is the initial, safe and cost-effective imaging modality for diagnosis of adrenal tumors.

However, computer tomography of the abdomen represents the most important tool for investigation and proper localization of adrenal tumors.

Surgical removal of the tumor or the affected gland is the main approach to treat the patients. Laparoscopic adrenalectomy (removal of the adrenal gland) is now the procedure of choice for the removal of functional adrenal adenomas such as pheochromocytoma and adrenal non-functioning tumors.

Furthermore, the laparoscopic approach is indicated for the treatment of tumors suspicious for malignancy and secondary adrenal metastases from extra-adrenal tumors. The surgery is performed under general anesthesia with the use of small 5 to 10mm diameter instruments.

Several surgical and endocrine complications are associated with laparoscopic adrenalectomy. Surgical complications are related to intra-operative bleeding, which is, however, when laparoscopic approach is used.

Injury to adjacent organs is a rare complication when the surgery is performed in a specialized center with extensive experience. Hormonal complications are associated with intra-operative release of large amounts of hormones in blood circulation and postoperative adrenal insufficiency following the removal of the gland.

The correct preoperative preparation and postoperative patient assessment by an experienced endocrine team as well as careful surgical manipulations minimize those complications.

The main reason why laparoscopic approach for adrenelectomy is considered the treatment of choice is the significantly reduced morbidity compared to the open surgical approach. Three abdominal or lumbar incisions are necessary for the performance of the procedure. The operative time is approximately two hour and intraoperative blood loss is minimal. The tumor is removed at the end of the procedure by one of the incisions. The patient is mobilized and eats on the first day after surgery and leaves the hospital on the second day. After 10 days the patient is fully capable to return to pre-surgery activity. The aesthetic result is excellent.

Copyright © 2017-2020 Laparoscopy-Endourology.com All Rights Reserved

Design and Developed by Best Cybernetics