Skill and talent
Radical cystectomy, hysterectomy with double adnexectomy and bilateral nephroureterectomy with transvaginal extraction
Cistectomía radical, histerectomía con doble anexectomía y nefroureterectomía bilateral con extracción por vía transvaginal. Descripción y consideraciones específicas de la técnica quirúrgica
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"apellidos" => "Beardo-Villar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:4 [ "nombre" => "M.A." "apellidos" => "Arrabal-Polo" "email" => array:1 [ 0 => "arrabalp@ono.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "UGC Urología, Hospital de Jerez del SAS, Jerez, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "UGC Anestesiología, Hospital de Jerez del SAS, Jerez, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Asesor Científico UGC Urología, Hospital de Jerez del SAS, Universidad de Granada, Jerez, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cistectomía radical, histerectomía con doble anexectomía y nefroureterectomía bilateral con extracción por vía transvaginal. Descripción y consideraciones específicas de la técnica quirúrgica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1050 "Ancho" => 1400 "Tamanyo" => 215620 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Abdominopelvic CT in which there is the presence of a lesion in the bladder (A) compatible with neoplasia, bilateral ureterohydronephrosis (B), and bilateral ureteropelvic filling defects compatible with possibly neoplastic lesions taking up space (C and D).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 58-year-old patient with a history of high blood pressure, hemorrhoids, mild kidney failure, anxiety, and urinary incontinence using absorbents, who was referred to our hospital from another hospital after 30 previous TURs due to high-grade urothelial cancer and bladder instillations with BCG. At present the patient has new bladder tumor recurrence and after performing abdominal-pelvic CT bladder of small capacity is observed with neoplastic lesion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A), bilateral ureteral dilation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B), filling defect in the lumbar ureter and right renal pelvis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C), as well as filling defect in the lumbar ureter and left renal pelvis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). Bladder endoscopy is performed with tumor resection, with histological diagnosis of high-grade urothelial carcinoma, bilateral ureteroscopy, observing a mass in the right pelvic ureter, preventing the passage of the ureteroscope and a mass in the left lumbar ureter. Due to the high tumor burden and multiple location, recurrent disease, and high-grade carcinoma, radical resection surgery laparoscopically is indicated, performing bilateral nephroureterectomy, cystectomy, hysterectomy with double adnexectomy, and bilateral ilio-obturator lymphadenectomy in the same surgery, as well as removal of the parts together transvaginally (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Prior to the surgery, arteriovenous fistula had been performed to start postoperative dialysis. The histological diagnosis was high-grade urothelial carcinoma of the bladder, the right and left ureters extending to both renal pelvis and infiltrating nonkeratinizing squamous cell carcinoma affecting the uterus. There was no neoplastic involvement of the excised lymph node chains.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods and description of the technique</span><p id="par0010" class="elsevierStylePara elsevierViewall">First we positioned the patient in supine position with slight Trendelenburg and 10-mm transumbilical port for the optical equipment that the assistant will carry, another 10-mm port for the use of dissector and Hem-o-lock applicator if necessary and Ligassure<span class="elsevierStyleSup">®</span> which the main surgeon will carry, another 5-mm port for the use of pulling clamp/bipolar clamp for the main surgeon and another 5-mm port for tractor and separation clamps for the assistant (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Surgery begins performing hysterectomy with double adnexectomy, keeping the uterus attached to the vaginal vault to prevent loss of the pneumoperitoneum. Subsequently, bilateral iliopelvic lymphadenectomy along with cystectomy is performed, this time respecting the bladder neck, the urethrovesical junction, and the ureterovesical junction to prevent contamination of the surgical field and allow for kidney function during the following steps of the surgery.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Secondly, we placed the patient in right lateral decubitus, we used the optical equipment introduced through the 10-mm transumbilical trocar and the 5-mm trocar of the main surgeon used in the first section, which on this occasion will be used by the assistant. We placed another two trocars, a 10-mm one for the use of Hem-o-Lock Ligasure<span class="elsevierStyleSup">®</span> and a 5-mm one for the use of traction/bipolar forceps for the main surgeon (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). We performed left nephrectomy and complete dissection of the left ureter to the ureterovesical junction.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Thirdly, we positioned the patient in left lateral decubitus, we used the transumbilical 10-mm trocar for the optical equipment and the 5-mm trocar of the first section of the assistant. We also placed a 10-mm trocar for Ligasure<span class="elsevierStyleSup">®</span> and Hem-o-Lock and another 5-mm one for bipolar/tractor clamps (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). We performed right nephrectomy and complete dissection of the ureter to the ureterovesical junction.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In fourth place, we repositioned the patient supine with slight opening of the lower limbs, and using the same trocars of the first part of the surgery, the surgery is completed with the section of the uterus and the urethrovesical junction and surgical specimen removal through the vagina. After removal, suture of the vagina was made and an 18<span class="elsevierStyleHsp" style=""></span>Ch Foley catheter was left as a drainage through the urethra.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The presence of synchronous or metachronous urothelial carcinoma occurs in a variable percentage depending on the series, from 1.7% to 21%, so this factor must be taken into account in the diagnosis and surgical treatment.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Simultaneous surgical treatment in a single surgical procedure is described, although there are few series and surgical experience. Barros et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> placed eight abdominal trocars, as in our case, to perform cystectomy and bilateral nephroureterectomy. However, in this series, bilateral nephroureterectomy is carried out by means of nephropathy, not urothelial carcinoma. In other published series<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> hand-assisted bilateral nephroureterectomy is performed, either by laparoscopy or by retroperitoneoscopy, but in patients who were previously on dialysis, which does not happen in our patient, who although had renal failure, was not in a dialysis program. Lin et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> perform laparoscopic technique consisting of cystectomy and nephrectomy in dialysis-dependent patients, using only six trocars with transvaginal extraction of the surgical specimen, with surgical results similar to those described in our patient; however, they begin surgery with nephrectomy, the same as the other authors.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> In our case, we prefer to start the surgery with hysterectomy and double adnexectomy along with cystectomy, but with the technical variation that we keep together the cervix to the vaginal vault to prevent loss of the pneumoperitoneum, and more importantly, we keep the ureterovesical junction and the uretrhovesical junction intact to prevent contamination of the abdominal cavity by tumor cells and preserve the kidney function most of the surgery, facilitating excretion of anesthetic drugs used during it, and thus we collaborate with the anesthesiologist in the proper maintenance of the patient during surgery. Berglund et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> set out surgery similarly to the way we perform it; however, although they begin with cystectomy, they make a clamping of the ureters at the level of the crossing of the iliac vessels, and therefore they do not preserve the renal function during it. Furthermore, in the case described by Berglund, following surgical resection, tumor absence was histologically checked in the nephroureterectomy pieces.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> We have not observed in the cases described in the literature that the technique of radical cystectomy was performed in two parts, as we describe it, in order to maintain the renal function as long as possible during surgery. We agree with other authors<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> on the fact that the specimen removal through the vagina is a safe and effective procedure, especially in patients with comorbidities.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although bilateral nephroureterectomy with cystectomy, hysterectomy, and double adnexectomy is a rare surgical treatment, we have shown that it can be performed laparoscopically with specimen removal vaginally without complications for the patient, therefore, we consider it an effective alternative valid in these patients.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres385821" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objectives" 2 => "Material and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec364580" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres385822" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivos" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec364581" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods and description of the technique" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-01-08" "fechaAceptado" => "2014-02-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec364580" "palabras" => array:4 [ 0 => "Laparoscopic surgery" 1 => "Surgical technique" 2 => "Cystectomy" 3 => "Double nephroureterectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec364581" "palabras" => array:4 [ 0 => "Cirugía laparoscópica" 1 => "Técnica quirúrgica" 2 => "Cistectomía" 3 => "Doble nefroureterectomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The onset of synchronous urothelial carcinoma in the upper or lower urinary tract is uncommon. Even more uncommon is the onset the bilateral form. The aim of this article is to describe the surgical technique of complete laparoscopic exeresis of the urinary apparatus and to add several variants of the technique that improve the patient's hemodynamics during surgery.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We present the technique of cystectomy with bilateral nephroureterectomy, hysterectomy with double adnexectomy and bilateral ilio-obturator lymphadenectomy by laparoscopy and transvaginal extraction of specimens from a 58-year-old patient with multiple prior vesical resections of high-grade urothelial carcinoma. The patient currently presents bladder recurrence and bilateral ureteropelvic tumor. The technique consists first of the hysterectomy and double adnexectomy along with the lymphadenectomy and cystectomy, maintaining the urethrovesical, ureterovesical and uterovaginal junctions. After changing the patient's position, both nephroureterectomies were performed. Lastly, we completed the resection of the previously mentioned segments to extract the specimens transvaginally.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The histological result was high-grade urothelial carcinoma that affected the bladder and both ureteropelvic junctions, along with endometrial carcinoma. After reviewing the literature, we found less than 10 cases in which complete exeresis of the urinary apparatus was performed and none with the technical description presented in this article. In most cases described in the literature, surgery was performed at two separate times and without preserving renal function until the end of the complete exeresis.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">This technique helps maintain diuresis for a longer time during surgery and thereby facilitates the work of the anesthesiologist and improves the patient's circulatory dynamics. Additionally, the technique prevents any type of handling of the urinary tract, thereby avoiding the passage of tumor cells to the peritoneal cavity, given that the specimens are extracted whole through the vagina.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La aparición de carcinoma urotelial sincrónico en la vía urinaria superior e inferior es infrecuente, y lo es aún más la aparición de forma bilateral. El objetivo de este artículo es describir la técnica quirúrgica de exéresis completa del aparato urinario por vía laparoscópica y añadir diferentes variantes técnicas que permiten mejorar la hemodinámica del paciente durante la cirugía.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Presentamos la técnica de cistectomía con nefroureterectomía bilateral, histerectomía con doble anexectomía y linfadenectomía ilio-obturatriz bilateral por vía laparoscópica y extracción de piezas vía transvaginal en una paciente de 58 años con múltiples resecciones previas vesicales de carcinoma urotelial de alto grado, que en la actualidad presentaba recidiva vesical y tumoración ureteropiélica bilateral. La técnica consiste en primer lugar en la histerectomía y doble anexectomía junto con linfadenectomía y cistectomía, manteniendo la unión uretrovesical, uniones ureterovesicales y la unión útero-vaginal. Tras cambiar de posición a la paciente se realizan ambas nefroureterectomías y finalmente completamos la resección de los segmentos antes referidos para extraer las piezas por vía transvaginal.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El resultado histológico fue de carcinoma urotelial de alto grado que afecta a la vejiga y a ambas uniones ureteropiélicas, junto con carcinoma endometrial. Tras revisar la literatura hemos encontrado menos de 10 casos en los que se realice una exéresis completa del aparato urinario, y ninguna con la descripción técnica que presentamos en este artículo. En la mayoría de los casos descritos en la bibliografía se hace la cirugía en 2 tiempos y sin preservar la función renal hasta el final de exéresis completa.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Esta técnica permite mantener la diuresis más tiempo durante la cirugía, y de ese modo facilitar la labor del anestesista y mejorar la dinámica circulatoria del paciente. Además, de este modo se previene cualquier tipo de manipulación de la vía urinaria evitando el paso de células tumorales a la cavidad peritoneal, puesto que se extrae de forma íntegra las piezas a través de la vagina.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Juarez-Soto A, Arroyo-Maestre JM, Soto-Delgado M, de Paz-Suarez M, Beardo-Villar P, Arrabal-Polo MA. Cistectomía radical, histerectomía con doble anexectomía y nefroureterectomía bilateral con extracción por vía transvaginal. Descripción y consideraciones específicas de la técnica quirúrgica. Actas Urol Esp. 2014;38:694–697.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1050 "Ancho" => 1400 "Tamanyo" => 215620 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Abdominopelvic CT in which there is the presence of a lesion in the bladder (A) compatible with neoplasia, bilateral ureterohydronephrosis (B), and bilateral ureteropelvic filling defects compatible with possibly neoplastic lesions taking up space (C and D).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1291 "Ancho" => 900 "Tamanyo" => 232870 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Complete surgical specimen of the urinary system extracted transvaginally after laparoscopic excision, along with the uterus and the appendages.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 831 "Ancho" => 900 "Tamanyo" => 45410 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Placement of the trocars used during laparoscopic surgery to perform cystectomy, bilateral nephroureterectomy, lymphadenectomy, and hysterectomy with double adnexectomy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Simultaneous laparoscopic nephroureterectomy and cystectomy: a preliminary report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. 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Chen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1726-4901(09)70371-5" "Revista" => array:6 [ "tituloSerie" => "J Chin Med Assoc" "fecha" => "2007" "volumen" => "70" "paginaInicial" => "260" "paginaFinal" => "261" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17591588" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735786/0000003800000010/v1_201411280052/S2173578614001516/v1_201411280052/en/main.assets" "Apartado" => array:4 [ "identificador" => "6276" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Skill and talent" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735786/0000003800000010/v1_201411280052/S2173578614001516/v1_201411280052/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578614001516?idApp=UINPBA00004N" ]
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