RO performed via an inguinal approach should be described as the gold standard for oncological control in the majority of patients (6,7). It not only establishes diagnosis and facilitates clinical staging, but is also curative for >80% of men with clinical stage one testicular seminoma and 70% of clinical stage one NSGCT (8). Testis sparing surgery (TSS) and surveillance should be described as alternative approaches only in specific scenarios and risk of disease progression or recurrence should be discussed (6,7).
Scrotal violation tends to occur with the unexpected intra-operative finding of a testis tumour during elective scrotal surgery. In this scenario where scrotal orchidectomy is performed, patients should be counselled that the risk of local recurrence is 2.5% which is higher than those having inguinal RO, and that rarely they may be considered for adjunctive therapy with scrotal scar excision and/or radiotherapy but that this is not mandated (7).
A cornerstone of Northwell Health, Long Island Jewish Medical Center provides the full spectrum of clinical health care for patients of all ages. Our world-class services include minimally invasive robotic surgery, thoracic surgery, orthopedics, urology, gynecology and vascular programs. Our relentless dedication to quality care has earned us national recognition in various clinical specialties, as well as Magnet® designation by the American Nurses Credentialing Center for the second consecutive time in 2020.
Discover our extensive selection of the best urology books. These books are ideal for medical and nursing students, studying urology. They cover an array of relevant topics, including paediatric urology, urology surgery, and clinical urology.
The thoracoabdominal incision was first described in 1946 as an approach to concomitant abdominal, retroperitoneal, and thoracic injuries. In urology, this technique was popularized in 1949 for the resection of large renal tumours. Today, it is reserved for complex cases where optimal exposure of the renal hilum and adrenal and superior pole of the kidney is necessary. We present four consecutive cases in which this approach was taken by a single surgeon at our tertiary surgical centre. The outcomes, postoperative course, and pathology are described. We provide a comprehensive literature review and outline the indications, advantages, and disadvantages of this approach. Objectives. To present a case series outlining the efficacy and safety of the thoracoabdominal incision in complex oncologic procedures in urology. Methods. Four cases utilizing the thoracoabdominal incision, performed by a single surgeon at our tertiary care center, were reviewed. Case history, preoperative imaging, intraoperative experience, postoperative course, final pathology, and complications were examined. A thorough literature review was performed and comparison made with historical cohorts for estimated blood loss, length of stay, and complications encountered versus other common surgical approaches. The indications, advantages, and disadvantages of the thoracoabdominal approach were outlined. Results. All patients had large retroperitoneal masses of varying complexity, requiring maximal surgical exposure. Surgery was straightforward in all cases, without any significant perioperative or postoperative complications. Postoperative pain, length of hospital stay, estimated blood loss, and analgesia requirements were all similar to open and mini-flank approaches in review of historical case series cohorts. Laparoscopic approaches had lower estimated blood loss and length of stay. Conclusions. The thoracoabdominal approach is rarely utilized in urological surgery, due to the perceived morbidity in violating the thoracic cavity. These cases outline the benefit of the thoracoabdominal approach in select cases requiring maximal surgical exposure, and the generally benign postoperative course that appropriately selected patients may hope to endure. Postoperative pain, length of hospital stay, estimated blood loss, and analgesia requirements can be expected to be similar open and mini-flank approaches. As expected, laparoscopic approaches had lower estimated blood loss and length of stay.
After a thorough discussion with medical oncology and a full assessment of her functional status, the patient was enrolled in a tumour vaccine trial, which required cytoreductive nephrectomy. With the assistance of the general surgery team, she underwent a left radical nephrectomy, splenectomy, distal pancreatectomy, and retroperitoneal lymph node dissection (RPLND). A 28 Fr chest tube was placed prior to the closure of the thoracic cavity and connected to low suction. Due to the size and location of the tumour, and the suspected local invasion, a thoracoabdominal approach was pursued. No complications were encountered intraoperatively and EBL was 400cc.
A recent study by Yang et al.  compared the morbidity of various surgical incisions. In this retrospective study, the thoracoabdominal approach was compared to the flank incision for radical nephrectomy and found no significant difference in operative time, removal of surgical drains, postoperative pain scores, amount of analgesia use, length of hospital stay, and time from surgery to return to work. The only significant difference was estimated blood loss, with volumes of 150.2 cc and 209.9 cc for flank and thoracoabdominal approaches, respectively. Of note, there was a significant difference in the size of the tumours, with maximum diameters of 21.8 cm and 13.8 cm for the thoracoabdominal and flank approaches, respectively.
These case reports represent clinical scenarios where the thoracoabdominal surgical approach was indicated. All patients had large retroperitoneal masses of varying complexity, requiring maximal surgical exposure. The thoracoabdominal approach is rarely utilized in urological surgery, due to the perceived morbidity in violating the thoracic cavity. However, comparison with several retrospective series examining open and mini-flank approaches suggests no difference between thoracoabdominal and the open flank approaches in terms of postoperative pain, length of hospital stay, EBL, analgesia requirements, return to work, and complication rates. As expected, laparoscopic approaches had lower EBL and LOS. Although a small series, our cases outline the benefit of the thoracoabdominal approach in select cases, and the generally benign postoperative course that appropriately selected patients may hope to endure. In the era of robotic assisted and minimally invasive surgery, urologists should be reminded of this effective and safe approach to address challenging retroperitoneal masses.
Covers hot topics such as minimally invasive and robotic surgery; advancements in urologic oncology, including innovative therapeutics for personalized medicine; new approaches to male infertility; technological advances for the treatment of stones; and advances in imaging modalities.
The optimal management of vesicoureteral reflux (VUR) is quite controversial. For many years, only antibiotic prophylaxis and open surgery were considered possible options. Since the first descriptions in the early 1980s, endoscopic treatment (ET) has gained popularity and is now considered a valid alternative both to open surgery and antibiotic prophylaxis. Many surgical antireflux techniques have been described in the past 50 years. The general principle of reflux surgery, usually defined as ureteric reimplantation, is elongation of the submucosal ureteral tunnel with creation of a flap-valve mechanism. The antireflux operation can also be carried out laparoscopically, either extravesically or intravesically (pneumovesicum). Open surgery is associated with a high success rate (>95%) regardless of the technique adopted. However, because it is invasive, it is limited to selected cases. Laparoscopic technique is less invasive, but the mean operative time is much longer and results depend significantly on the learning curve. ET involves injecting material endoscopically into the submucosal space under the ureteric orifice. It is associated with a good success rate (about 80% after one injection). Advantages of this minimally invasive treatment include repeatability and the fact that postoperative complications are rare. With a second injection, after few months if needed, the success rate of ET approaches that of open surgery. Our 20-year experience in ET is described in detail in this paper, as this technique has changed the management algorithm for VUR dramatically.
Technical adjustments are necessary in some instances, particularly in cases of ET for VUR after failed surgery . In 2005, Kirsch and Scherz presented a modification of the technique as an evolution of the STING procedure, named the hydrodistention implantation technique (HIT). This technique is based on two concepts: hydrodistention of the ureteral orifice and submucosal intraureteral implantation of the material. With this technique, the needle is placed within the ureteral tunnel, and the injection is performed into the submucosal intraureteral space along the entire length of the detrusor tunnel . In our experience, this technique has proved useful in high-grade reflux with a short tunnel when an intraureteral injection is feasible even without hydrodistention. In low-grade VUR, we give preference to the standard technique, which avoids hydrodistention and the consequent risk of seeding the kidney with bacteria. The amount of injectable material varies from 0.1 to 1.5 ml, depending on the experience of the operators. With greater experience, less material can be used to achieve a satisfactory implant configuration. 2b1af7f3a8