Chirurgie des calculs rénaux :

Urétéroscopie, néphrolithotomie percutanée (RIRS), lithotritie extracorporelle

L'urétéroscopie est un instrument permettant d'extraire les calculs rénaux. Elle est utilisée lorsque le calcul est trop volumineux pour être évacué dans l'urine et nécessite donc une intervention chirurgicale. Il s'agit d'une technique mini-invasive, car elle consiste à insérer un petit endoscope dans la vessie par l'urètre, sans pratiquer d'incisions pour extraire le calcul. Le taux de réussite de cette technique est très élevé et le risque de complications, très faible.

Les traitements des calculs rénaux ont trois objectifs : prévenir leur développement, résoudre le calcul existant et éviter ses effets indésirables potentiels, et prévenir sa récidive.

Cas dans lesquels une urétéroscopie est appropriée :

• S’il y a des calculs dans l’uretère qui sont difficiles à évacuer spontanément ou qui causent une gêne importante.
• S’il y a des calculs rénaux qui ne peuvent pas être traités avec une autre technique comme les ondes de choc.
• Pour déterminer pourquoi il y a du sang dans l’urine du patient.

There are two types of ureteroscopy depending on the type of instrument used. It can be rigid or flexible. Rigid ureteroscopy is literally performed with a rigid telescopic tube that only allows vision in a straight line, while the tube used in flexible ureteroscopy can rotate up to 180° and provides a retrospective view. Flexible ureteroscopy is typically used when stones are in or near the kidney, while rigid ureteroscopy is generally used when stones are in the lower or middle part of the ureter, near the bladder. In most cases, it allows direct visualization of the stone and therefore the introduction of special instruments or a laser to break it up. The ureteroscopy passes through natural channels in the body and does not require skin incisions. If the stone can be seen, it can most likely be broken up in a single session. If the stone cannot be accessed with the ureteroscope on the first attempt due to inflammation, a double-J stent may be placed. This allows urine to flow from the kidney to the bladder while widening the ureter, making it easier to push the ureteroscope upward to reach the stone and remove it. Sometimes, if the stone is very large, it may not be possible to remove it in a single session, requiring a second procedure. In other cases, small fragments or even the entire stone may reach the kidney. If a flexible ureteroscope is available, it can be used to reach the kidney to remove the fragments or break them up with a laser. La néphrolithotomie percutanée has very specific indications, replacing traditional open surgery in the case of upper urinary tract stones. This procedure aims to completely or partially remove stones from the diseased kidney, as well as to eliminate symptoms and prevent potential complications caused by the stones. It involves the extraction of kidney stones using a nephroscope (metal tube) inserted into the kidney through a small hole in the skin of the lumbar region. There are two techniques for disintegrating stones: one is the lithotripter (ultrasonic or pneumatic) and the other is laser (holmium or thullium). Lasers pulverize the stone, making it much easier to remove the powder. The lithotripter fragments the stone into several pieces, so these fragments must be removed with metal forceps.  

Cette technique est réservée uniquement aux gros calculs rénaux, tels que :

• Calculs en corne de cerf qui occupent la totalité ou la quasi-totalité des calices et du bassinet du rein.
• Calculs de plus de 2 cm situés dans le bassinet du rein.
• Plusieurs calculs dans les calices et le bassinet du rein.
• Calcification du stent double J qui empêche son retrait.
• Lorsque d’autres traitements ont échoué.

La chirurgie intrarénale rétrograde (CISR) is a minimally invasive endoscopic surgical procedure that allows the removal of stones, also known as renal lithiasis, using an instrument called a flexible ureteroscope with a high-definition camera at its tip. A laser fiber can be inserted through it to fragment and pulverize the stone, extracting small fragments, if necessary, for chemical analysis. The procedure is performed under anesthesia, and the patient can usually go home within the first 24 hours, the next day, or even the same day. It leaves no incisions or external wounds, as it is performed through the urethra and ascends the urinary tract. This procedure can also be used diagnostically or therapeutically for the conservative treatment of urothelial tumors of the upper urinary tract. La lithotritie is a medical procedure that uses shock waves to break up stones that form in the kidney, bladder, or ureter (the tube that carries urine from the kidneys to the bladder). After the procedure, the tiny stone pieces pass out of the body through the urine. Ninety-five percent of stones located in the ureter are spontaneously passed within 3 to 4 weeks, depending on their size and position. Any stones not passed within 2 months require therapeutic intervention. Currently, between 90 and 95% of stones can be removed through noninvasive procedures, such as extracorporeal shock wave lithotripsy, which breaks the stones into small fragments that can be more easily passed. The most common side effect is urinating blood after treatment. This will disappear with regular water intake and within a few hours or days. Most people can go home the same day of the procedure.  

CANCER DE LA PROSTATE : PROSTATECTOMIE ROBOTIQUE

Robotic prostatectomy in the treatment of prostate cancer overcomes the limitations of conventional laparoscopic surgery with more precise surgical interventions, especially in more complex and difficult-to-access prostates. With this robotic surgery, we achieve a urinary continence rate close to 100% and preservation of sexual potency of around 90% in patients under 65 years of age. Due to the characteristics of the tumor, it allows us to preserve the nerves and vessels that determine male erection. Blood loss during the procedure, and therefore the need for transfusions, is 85% lower than with open surgery.

HYPERTROPHIE DE LA PROSTATE : CHIRURGIE AU LASER

Prostatic photovaporization (greenlight laser) is considered a minimally invasive endoscopic treatment for lower urinary tract symptoms caused by obstruction due to prostatic hyperplasia. It consists of the selective application of laser energy to prostate tissue for immediate elimination, thereby reducing prostatic obstruction and symptoms. It is performed through the urethra without incisions and aims to increase the diameter of the prostatic urethra, allowing the patient to experience symptom relief and quickly return to daily activities. Minimally invasive surgical treatment with minimal impact on normal activity and minimal hospital stay. The greenlight laser is best indicated for small and medium-sized prostates, although, depending on the surgeon’s experience, it can be used for large prostates. Although it can be performed on an outpatient basis, we recommend a 48-hour hospital stay so the urinary catheter can be removed the same day, and you can return to your normal activities as soon as possible.  

CHIRURGIE DES TUMEURS DU REIN : NÉPHRECTOMIE PARTIELLE LAPAROSCOPIQUE OU ROBOTIQUE

This is a minimally invasive surgery that allows for the removal of a portion of the kidney affected by cancer, along with the surrounding adipose tissue (fat), which is important for proper staging and prognosis. Laparoscopic partial nephrectomy is the treatment of choice for kidney cancer measuring less than 7 cm in size; however, it must meet certain technical requirements to make the surgery feasible and requires adequate experience in laparoscopy. It is usually performed under general anesthesia. The patient will be hospitalized for 2-3 days, with an abdominal drain that will be removed before discharge and a urinary catheter, which is usually placed only for the first 24 hours. Since the surgical procedure is not as aggressive (since the surgical incision is minimal), postoperative pain is much less, and after the procedure, the patient is able to walk and perform their usual activities independently. Full recovery usually takes two weeks; however, it is important to be cautious and avoid excessive physical activity, as the body still needs time to reduce the inflammatory process from the surgery and heal.  

AVANTAGES DE LA NÉPHRECTOMIE ROBOTIQUE

Robotic surgery is playing an increasingly important role in urological surgery. Rather than robotic surgery, the term “robotic-assisted surgery” would be more appropriate, given that the robot is a tool in the hands of the surgeon, who remains the operator of the surgery. The robot consists of three parts: a patient cart consisting of four robotic arms placed close to the patient; a console with a high-definition 3D display from which the seated surgeon directs the movements of the robotic arms; and a screen for the assistant who assists in the procedure. One of the advantages of the robot is that it performs surgery with very small incisions, generally less than one centimeter: this reduces the patient’s postoperative pain and speeds recovery. Through these small incisions, the robot’s arms allow the surgeon to operate without tremors and with greater freedom of rotation and joint movement than the human wrist. This allows for extremely precise dissection movements, reducing bleeding, helping to remove pathological tissue, and preserving healthy tissue. This feature can contribute to excellent functional results. The surgeon, seated at the console, can operate, reducing physical and therefore mental fatigue. Nous pourrions donc résumer les avantages apportés par le robot comme suit :

• Précision extrême dans les mouvements
• Vision agrandie, tridimensionnelle et haute définition pour le chirurgien
• Réduction des saignements et de la douleur postopératoires
• Récupération fonctionnelle rapide après chirurgie
• Ergonomie améliorée pour le chirurgien

La chirurgie assistée par robot permet de traiter des pathologies oncologiques et non oncologiques.  

CHIRURGIE DU CANCER DE LA VESSIE : TUR, CYSTECTOMIE ROBOTIQUE OU LAPAROSCOPIQUE

When it comes to bladder cancer, early diagnosis and detailed pathological analysis are vital to determine the prognosis and treatment. For this purpose, TUR, or transurethral resection, is one of the most advanced techniques. Bladder cancer is the 7th most common cancer in men and the 10th when both sexes are included. Bladder tumors are caused by the uncontrolled proliferation of groups of mucosal cells (transitional cells). These groups of cells may remain confined to the mucosa or may infiltrate the next layer, the muscle. Depending on the location of the tumor and its degree of aggressiveness, the patient will require different treatment. This is why early diagnosis and detailed pathological analysis are vital in bladder cancer. Transurethral resection of bladder tumors (TURB) is a minimally invasive surgical procedure with a dual purpose. It is used both for definitive diagnosis and as the first step in bladder cancer treatment, removing the tumor tissue. TURB involves the endoscopic removal of cancer cells from the bladder wall through the penis, without incisions or scarring. During this treatment, a visual examination of the entire bladder is performed to identify tumor lesions, followed by complete removal of the tumor tissue. Once the tumor is removed, it is sent for analysis to determine the stage of the cancer and to adjust further treatment, if necessary. There is less than a 10% risk of infection or injury with this technique. The patient will be discharged from the hospital in 2-3 days. The postoperative period is quite bearable, with some mild pain and stinging in the area, which is effectively controlled with painkillers. A urinary catheter is not necessary beyond the first 48 hours after surgery. After surgery, you can resume your normal life but avoid sudden movements or exertion for about 4 weeks. There are no sexual problems, including erection, libido, or ejaculation.  

CYSTECTOMIE RADICALE LAPAROSCOPIQUE

This is a minimally invasive and highly complex surgical procedure that completely removes the urinary bladder affected by severe pathology (metastatic invasive bladder cancer), along with the surrounding lymph nodes and tissue. In men, this involves the seminal vesicles and prostate, and in women, the uterus and vaginal vault, without the need to open the abdomen. The urinary tract is then reconstructed to allow urine to pass from the kidneys to the outside. Plusieurs types de chirurgie reconstructive peuvent être pratiqués, selon le degré d'atteinte, la pathologie et la décision de l'équipe chirurgicale au moment de l'intervention. Les plus couramment utilisés sont :

• La création d'un réservoir (nouvelle vessie) avec des fragments du gros intestin, en essayant d'obtenir la dérivation urinaire la plus naturelle possible.
• Si la reconstruction de la vessie n’est pas possible, les uretères sont reliés à la paroi abdominale (stomie), ce qui nécessite l’utilisation d’une poche de collecte d’urine externe.

Profil statistique des patients atteints d’un cancer de la vessie :

• Les hommes sont plus touchés que les femmes.
• L'âge moyen est d'environ 60-65 ans.
• Patients ayant une forte consommation de tabac.
• Patients exposés à des produits chimiques.

Certains des avantages de la chirurgie laparoscopique par rapport à la chirurgie conventionnelle (chirurgie ouverte) sont les suivants :

• Moins de saignements pendant la chirurgie.
• Moins de douleurs postopératoires.
• Moins de complications postopératoires.
• Moins d’impact esthétique (cicatrices plus petites).
• Récupération plus rapide.

 

CYSTECTOMIE RADICALE ROBOTIQUE

Da Vinci robotic radical cystectomy is the most advanced, sophisticated, and precise minimally invasive surgical procedure currently used for the treatment of muscle-invasive bladder cancer. This technique involves the removal of the urinary bladder along with surrounding lymph nodes, tissues, and organs that are also affected, with the goal of eradicating all tumor tissue. Radical cystectomy is considered a highly complex surgery, and the fact that it can be performed using state-of-the-art robotic technology (Da Vinci robot) provides numerous advantages to the surgical process, both during the execution phase, facilitating and enhancing the surgeon’s skill and precision, and during the patient’s recovery phase compared to more conventional non-robotic techniques such as open or laparoscopic surgery. Avantages de la chirurgie robotique pour le chirurgien:

• Meilleure visualisation, précision et contrôle.
• Élimination du tremblement physiologique.
• Identification et dissection précises des uretères et de la vessie.
• Meilleure accessibilité aux plans anatomiques profonds.
• Plus grande radicalité dans l'élimination des tumeurs.
• Risque d'erreur réduit.

Avantages pour le patient :

• Période postopératoire moins douloureuse.
• Risque moindre de complications.
• Risque d’infection réduit.
• Très petites cicatrices (amélioration esthétique).
• Diminution des effets secondaires (incontinence – impuissance).
• Séjour hospitalier plus court.
• Risque de saignement moindre (moins de transfusions).
• Processus de récupération plus court.
• Retour rapide aux activités quotidiennes normales.

La chirurgie robotique permet au chirurgien de retirer le tissu tumoral avec une précision maximale et facilite la reconstruction des voies urinaires (néo-vessie) pour maximiser la continence urinaire.  

VASECTOMIE

A vasectomy involves the sectioning and ligation of the vas deferens through two small incisions made on either side of the scrotum. As a result, after some time, the ejaculated semen contains no sperm. It is indicated in cases where the couple decides not to have more children. It is also indicated when the woman is contraindicated in contraceptives, regardless of the type.  

PHIMOSE

Phimosis is defined as the difficulty or impossibility of retracting the preputial skin, that is, the skin that covers the tip of the penis or glans. It should not be confused with the presence of balanopreputial adhesions (between the skin of the foreskin and the glans of the penis), which are very common in boys and are independent of the presence or absence of phimosis. In some children, these adhesions are accompanied by a tightness in the skin of the foreskin, which causes intense pain when attempting to retract it. This sometimes causes the foreskin to swell before urination occurs. In milder cases, the only pain experienced is when attempting to retract the foreskin to clean the glans penis. At birth, difficulty retracting the foreskin is common in boys. In the first 3-4 years of life, the epithelial debris that forms between the glans penis and the foreskin (smegma) gradually separates the two structures. By age 3, 90% of foreskins descend completely. Less than 1% of 17-year-old boys have phimosis. Phimosis only occurs if the foreskin presses too hard against the shaft of the penis as it descends; if it prevents the glans penis from being uncovered; or if it is difficult to re-cover the penis after the foreskin descends. If the foreskin falls freely and there is no pressure during erection, there is no phimosis. Excess skin is not phimosis. Only boys who have difficulty retracting the foreskin and who have not responded to less aggressive treatments should undergo surgery. Circumcision can be performed starting at age 11 or 12 with local anesthesia.

CIRCONCISION, POSTECTOMIE OU CHIRURGIE DU PHIMOSE

La circoncision consiste à retirer l’anneau étroit du prépuce et à suturer ensuite la peau avec un matériau résorbable.  

CHIRURGIE DE L'INCONTINENCE URINAIRE POUR HOMMES ET FEMMES

Urinary incontinence is the involuntary loss of urine without control over the filling and emptying of the bladder, sometimes accompanied by a strong urge to urinate. It is caused by age, pregnancy and childbirth, menopause, functional and cognitive decline, and other factors, such as surgery, obesity, certain types of physical exercise, etc. Due to its association with modesty and social shame, consultations for these problems are often delayed or, sometimes, avoided. For this reason, its true incidence is unknown, although it is estimated that around two million people in Spain suffer from it. Of these, only 10% seek medical attention. The paradox is that involuntary incontinence, which so greatly affects the quality of life of those who suffer from it, is susceptible to significant improvements and even complete recovery. Surgery is reserved for patients who have failed conservative treatments. There are around 200 different surgical procedures. The most common treatments for this problem are banding surgery, mini-strip surgery, and botulinum toxin.  

Chirurgie de bandage

Due to its effectiveness, in 90% of cases, the procedure involves placing a synthetic mesh under the urethra, inserted through a small vaginal incision. The operation takes about 25 minutes and is usually performed under epidural anesthesia, although it can also be performed under local anesthesia. It involves a strip, usually made of polypropylene, a material well tolerated by the body, which is placed under the urethra without tension. Because it is porous, it stays in place and eventually integrates with the body. It is a simple and minimally invasive procedure, which facilitates a rapid recovery for the patient at home. Incontinence ceases as soon as the mesh is placed, although it is recommended to avoid excessive straining for the first month after surgery.  

Chirurgie par mini-bandelette

Through a single incision under the urethra, a small strip is placed and secured internally, without any holes in the skin. It has greater advantages than the synthetic mesh technique, including greater comfort for the patient and the advantage of being adjustable. Toxine botulique Dans certains cas, l’injection de toxine botulique dans la vessie réduit le nombre d’épisodes d’incontinence par impériosité.