Although radical prostatectomy is a curative therapy that has proven effective in many of our patients with prostate cancer, it is still associated with significant morbidity, which includes postoperative erectile dysfunction among its leading exponents. Potency after the intervention may be influenced by many factors, among which, presence of adequate erectile function before surgery, patient’s age, stage of disease at the time of treatment, surgeon’s experience and, of course, interpersonal anatomical variations may be pointed out.In recent decades, the exact knowledge of the neuroanatomy of the male pelvis has become very important, for both the student of human anatomy and the pelvic surgeon. Therefore, the anatomical nerve sparing techniques have led to fewer complications related to the injury of these structures. This article presents a brief description of the neuroanatomical substrate of the neurovascular bundles along with a detailed compilation of the different surgical techniques for their preservation during radical retropubic prostatectomy.
The most important current concept in therapeutic management of female genital prolapse is the use of non absorbable prosthesis through a vaginal approach. The application of these surgical techniques to repair prolapse aims to restore the anatomic position of the pelvis, while preserving urinary, bowel and sexual functions. Since 2005, we use the Apogee® prosthesis for the treatment of both the vault prolapse and associated posterior colpocele.The purpose of this paper is the detailed description of the technique of placement of Apogee® prosthetic sys-tem, so that it can be useful to clarify the key points of this surgical reconstructive surgical technique and different gestures associated with the placement of this type of prosthesis.
Historically, the surgical treatment of benign prostatic hyperplasia (BPH) in glands with volumes over 75-80 grams was performed using the conventional surgical approaches described by Terence Millin and Peter Freyer.Due to technological advancement over the past three decades, at present, minimally invasive techniques are being used with good results in the treatment of BPH. The incorporation of the laparoscopic approach to urologic surgery has allowed the technical development of adenomectomy using the same guidelines followed by conventional approaches.The aim of this paper is to describe in detail, step by step, the surgical technique of laparoscopic prostatectomy to treat BPH in glands larger than 60 cc., and to perform a re-trospective analysis of preliminary results obtained in the immediate postoperative period of our initial series.
Since the initial report in 1992, lapa-roscopic adrenalectomy has proved substantial advan-tages over the conventional procedure in terms of de-creased postoperative pain and hospital stay, allowing earlier return to normal activity. The technical details are in permanent evolution and the most widely accepted laparoscopic surgery for the adrenal gland is the transabdominal lateral approach. We hereby describe step by step the way we perform the lateral approach after 41 consecutive cases.
Radical cystectomy with extended pelvic lymphadenectomy remains the treatment of choice for muscle invasive bladder cancer and non-metastatic cho-rion-invasive high grade tumors resistant to treatment with intravesical chemotherapy. During the last decade the procedure has been refined and we have acquired the skills necessary to perform it using the laparoscopic approach. In this way, the oncologic and functional outcomes obtained can be compared to those of its open counterpart. This article descri-bes in detail the technique of radical cystoprostatectomy and urinary diversion in the male patient conducted by our group in an attempt to improve the knowledge and spread of this always difficult procedure.
Currently, we have different technical options for treating clinically complex scenarios such as neurogenic bladder, difficult to manage lower urinary tract obstruction and many disasters sometimes seen after prostate cancer treatment.During the seventies, clean intermittent bladder catheterization was established as the best treatment option for these patients. As a method, suprapubic urinary diversion has undergone a major evolution over the past fifty years trying to solve the most refractory and poor prognosis cases. Continent ileovesicostomy is an easy emptying and low-pressure non-catheterizable urinary conduit that enables safe and durable urine elimination. In this article a detailed and updated knowledge of this technique is provided.
Approximately 4-14% pelvic fractures cause a posterior urethral injury. Pelvic fractures associa-ted with straddle injuries or large trauma accidents are more frequently involved with this kind of lesions. Primary open repair of the urethral injury is discouraged in the acute setting. 3-6 months after urinary diversion a formal open reconstruction can be safely attempted. This gives time for scar maturation, reabsorption of pelvic hematomas, and relative restoration of anatomical fascial layers. The complexity of such interventions can be mini-mized following proper diagnostic and surgical protocols. Anastomotic urethroplasty under the precepts of the progressive perineal approach provides an excellent treatment option for these patients.The aim of this paper is the detailed description of the procedure for the treatment of such injuries.
Renal artery aneurysm is an infrequently seen disease. The most feared symptom is ruptu-re, which is often rapidly fatal. Indications for interven-tion include size, intractable symptoms and pregnancy. Many cases are managed by endovascular techniques; however, very complex cases often are referred to the urologist. We report our experience with the rarely used technique of renal artery aneurysms repair comprised of nephrectomy, extracorporeal vascular reconstruction with aneurysmectomy, and autotransplant.
During the past 15 years, orthotopic uri-nary diversion surgery has evolved from “experimental” to become the standard treatment in higher volume and experience world centers as the preferred method of uri-nary diversion in both sexes.The overall complication rate of the intussuscepted affe-rent segment required for the construction of a continent Koch reservoir, led to the late 90’s development and des-cription by Skinner et al. of the continence and anti-reflux “T- mechanism”. Based on the sub-serosal appendix-tun-neling described by Mitrofanoff and the extra-serosal ureteric-tunnelling by Ghoneim, this new mechanism has been used successfully incorporated into an orthotopic diversion system (“T-neobladder or T-pouch”). Apparent-ly, this “T-mechanism” has eliminated the problems asso-ciated with the intussuscepted intestinal segment, while maintaining an effective anti-reflux and continence sys-tem. This article describes in detail the surgical steps for the construction of an ileal T-neobladder.
Holmium laser enucleation of the prostatic adenoma (HoLEP) represents an innovative surgical option for the treatment of bladder outlet obstruction caused by benign prostatic hypertrophy. The results of numerous randomized prospective studies and clinical case series have confirmed that HoLEP is a procedure that attains immediate bladder outlet obstruction release, that improvement of symptomatic and uroflowmetry parameters is maintained in the midterm and, it is associated with less morbidity than conventional surgery. On the other hand, the shortage of urologists with experience in this procedure, and its technical difficulty have limited its spread in our environment. In this article we describe in detail the technique we use in our center for the performance of HoLEP, emphasizing the modifications we have introduced with time to make the operation easier and to avoid complications.
The excision of large retroperitoneal mas-ses poses a challenge for every surgeon. Sometimes the urologist must face situations that do not fit to any con-ventional approach or technique previously described. Obtaining adequate exposure for safe and oncologi-cally correct management of these masses is based, on many cases, in the mobilization of anatomical adjacent structures to generate a sufficient field in abdominal areas of difficult access.Complex visceral mobilization maneuvers derived from multivisceral transplantation organ procurement surgery provides ancillary techniques that used properly facilita-te their successful resolution.The main purpose of this paper is the description of the-se surgical maneuvers essential to increase both exposu-re and vascular control in addressing the ever-dreaded high-volume retroperitoneal masses.
IIdiopathic retroperitoneal fibrosis is an un-common disorder of unclear etiology characterized by a chronic and non-specific inflammatory process of the retroperitoneal fibro-fatty tissue. During the last decade, major advances have been made in the understanding and management of this entity and it is nowadays pro-posed to be the result of an autoimmune reaction that involves other surrounding structures, notably the ureters, leading the development of obstructive uropathy and secondary renal failure as the disease advances.To date, it has not been reported a widely accepted therapeutic schedule, although surgical approach has become the best treatment option in case of conservati-ve strategies failure. Surgical treatment main goals are obtaining biopsies of the fibrous plaque during the release of both ureters and their transposition inside the peritoneal cavity. This procedure is completed with a ureteral comwrapping with omentum to prevent a new entrapment. The purpose of this paper is the de-tailed description of the ureterolysis and omentoplasty technique, since, although recently some authors have reported small series of similar laparoscopic procedu-res, it is time consuming, complex and there is a possibility of potential serious complications, which still keep alive the con-ventional technique.
The propensity of upper tract transitional cell carcinoma towards recurrence and the limitations of upper tract endoscopy have led to nephroureterec-tomy being the gold standard treatment, even though major open surgery risks outweigh the risks of cancer. Thus, removal of the entire unit may not be warranted when the tumor can be safely controlled endoscopica-lly. Recent advances in technology and techniques have permitted the effective endourologic management of up-per transitional cell carcinoma.
Since the introduction of extracorporeal shock wave lithotripsy and the various modalities of endoscopic surgery, the number of open procedures for the treatment of urolithiasis has decreased dramatically. The use of these techniques in the management of easier cases leaves no doubt, but there is still some controversy about what should be the best treatment option for the largest and most complex staghorn calculi. Anatrophic nephrolithotomy is still considered the gold standard for the treatment of such lithiasis. This paper presents in detail the key technical points to consider during its performance.
Renal cell cancer with tumor thrombus is present in 4-15% of cases. The prognostic significance of this entity has been object of intense debate. Nowadays, it is considered, that the presence of thrombus itself does not have a negative prognostic impact on survival rates if the thrombus could be excised satisfactorily. Complete removal of renal malignant tissue is the only curative strategy for the treatment of this kind of tumors.During the last three decades, there has been steady im-provements in surgical technique and preoperative care fields that have favorably modified the surgeons’ ability to safely excise these tumors. In this sense, the experien-ce provided by multiorgan, kidney-pancreas and liver procurement and transplantation techniques led the uro-logists re-examine their approaches to the inferior vena cava and retroperitoneum, thus they could result useful in the always challenging resection of these complex tumors with neoplasic extension into the vena cava.
Moderate-severe urinary incontinence and refractory-to-treatment erectile dysfunction after radical prostatectomy are two entities causing an important loss of quality of life to patients.The double implant of penile prosthesis and artificial urinary sphincter is a safe and effective option in these cases. This article describes preoperative considerations and the most important technical steps to do it satisfactorily.