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İ. Yalç ınkaya and M. T. Doğruyol
bullectomy [3]. These high risks of recurrence
have prompted thoracic surgeons to investigate
which factors are decisive for the development of
recurrence in pneumothorax. The presence of
bullae on high-resolution computed tomography
(HRCT) for pediatric patients presenting with
pneumothorax has been reported as a risk factor
for ipsilateral recurrence. Studies show that prophylactic surgery can be performed in these
patients [4, 5]. Contralateral bullae visible on
HRCT and a low body mass index have been
reported as the indications for prophylactic surgery in adult patients with pneumothorax
(Fig.31.1) [6, 7].
Sihoe etal. [8] emphasized the importance of
preoperatively performed computed tomography
(CT) imaging of patients with primary spontaneous pneumothorax. They reported contralateral
bullae or blebs in 53.6% of patients; contralateral
pneumothorax developed in 26.7% of them during the follow-up period. Besides, none of the
patients with contralateral bullae or blebs developed contralateral pneumothorax during the follow- up. For this reason, it was stated that
prophylactic treatment could be performed in the
presence of contralateral bullae or blebs on CT in
patients with primary spontaneous pneumothorax [8]. Liu et al. [9] reported that 70 of 335
patients with primary spontaneous pneumothorax, who showed contralateral bullae or blebs,
underwent bilateral video-assisted thoracoscopic
surgery (VATS) in a single session. The recurrence rate in the VATS group was low, and hence
the necessity of prophylactic treatment in these
patients was emphasized. This surgery would
reduce hospital stays and relieve patients of
b
a
d
c
Fig. 31.1 (a, b) Bilateral bullae are seen in chest X-ray
and axial computed tomography images of a young,
smoker, asthenic, male patient scheduled for prophylactic
surgery, (c) video-assisted thoracoscopic surgery with
wedge resection and pleural abrasion was performed in
two separate sessions, rst on the right and then on the
left, in one and a half months intervals, (d) postoperative
control axial computed tomography
31 Prophylactic Chest Surgery Procedures
Fig. 31.2 (a) A giant bulla is seen in the preoperative chest X-ray of a young female patient, (b) postoperative chest
X-ray of the same patient shows re-expansion of the lung
373
potential socioeconomic and psychological
burdens [9].
However, Li et al. [10] performed preventive
surgery in both hemithoraces with a single incision in 18 patients with primary spontaneous
pneumothorax diagnosed with contralateral
blebs. Patients who were not intubated and had
received mask and epidural anesthesia underwent
ipsilateral surgery via an incision through the
fth or sixth intercostal space on one side while
lying in a semi-supine position. Contralateral
prophylactic surgery was performed in the same
session, passing from the anterior mediastinum
to the hemithorax. This method was found to be
safe and feasible [10].
31.2.2 Giant Bulla
The presence of a giant bulla, the development of
pneumothorax, or the patient showing symptoms
are general indications for surgery. However,
asymptomatic patients should only be considered
for prophylactic surgery when the bulla lls onethird of the thoracic cavity because severe and
irreversible complications may develop in such
patients (Fig.31.2) [1, 11]. It is better to operate
these patients using minimally invasive surgical
options to reduce postoperative pain and improve
cosmetic outcome if possible (Fig.31.3).
Also, as the compression time of a giant bulla
on the intact lung parenchyma increases, parenchyma’s function is less likely to return to normal
even if the lung is fully expanded. The possible
reasons for this are the loss of surfactant in the
parenchyma without function and the development of varying degrees of interstitial brosis [11].
31.2.3 Tuberculosis Sequelae
Tuberculosis sequelae develop due to either the
damage caused by the disease in the lung parenchyma or collapse treatment. Lung lesions appear
as bronchiectasis, brostenosis, and cavitation,
while lymph nodes are characterized by bronchiolitis. Aspergilloma can develop in these lesions
in the parenchymal cavity, or chronic suppurative
disease can lead to damaged lungs, making the
situation more complicated [12].
374
ab
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İ. Yalç ınkaya and M. T. Doğruyol
Fig. 31.3 (a) Video thoracoscopic incisions of the patient mentioned in Fig.31.2, (b) pathological specimen image of
the same patient
Surgical indications can only be mentioned if
symptoms develop in the tuberculosis sequelae. In
asymptomatic patients, prophylactic surgery
should be considered only in the presence of aspergilloma. Planned prophylactic surgery in asymptomatic patients with aspergilloma signicantly
reduces morbidity and mortality. In contrast,
emergency surgery of patients with symptoms of
acute hemoptysis increases these. Careful hilar
dissection for maintaining bronchial blood ow
when performing anatomical resection and careful
hemostasis to prevent postoperative bleeding is
essential. Covering the bronchial stump with supporting tissue is vital to avoid stula development
if pneumonectomy is performed [13].
lies are diagnosed early in life as cardiac malformations and severe cardiorespiratory symptoms
accompany them. However, a small group of
patients is not diagnosed until adulthood or may
be asymptomatic [
14].
Pulmonary arteriovenous malformations
(PAVMs) are characterized by abnormal junctions between the pulmonary artery and the vein;
their most common cause is Osler–Weber–
Rendu disease (hereditary hemorrhagic telangiectasia). Most of these patients are diagnosed as
they show symptoms. Only a tiny patient population may be asymptomatic, or the patient may
have been diagnosed and is being followed up.
Spontaneous arteriovenous stula-induced
bleeding may occur in these patients. Iwabuchi
etal. reported a case in which emergency thora-
31.2.4 Pulmonary Arteriovenous
Malformations
cotomy was performed due to the spontaneous
development of intrathoracic hemorrhage in an
asymptomatic patient with PAVM followed up
Congenital vascular pathologies may originate
from the pulmonary artery, pulmonary vein, or
lymphatic vascular system. Most of these anoma-
for 5years and recommended prophylactic sur-
gery, especially in peripheral lesions under the
visceral pleura [
15]. In recent years, arterial
31 Prophylactic Chest Surgery Procedures
375
embolization has also been frequently used to
treat these patients [14].
31.2.5 Sequestration
These intrathoracic lesions, which feed from the
systemic circulation and have no contribution to
breathing, are divided into two groups: intrapulmonary and extrapulmonary. Prophylactic surgery is recommended for both types because of
the risk of infection, whereas the risk is higher in
intrapulmonary lesions [16]. A prophylactic surgical indication is also mentioned due to the risk
of malignant degeneration in both intrapulmonary and extrapulmonary sequestrations [17].
31.2.6 Diaphragmatic Paralysis
A prophylactic plication of the diaphragm can be
performed when phrenic nerve injury develops in
patients undergoing thoracic surgery, or to reduce
future respiratory complications due to a tumor
invading the phrenic nerve during the same session. The results of the prophylactic plication of
the phrenic nerve were investigated in the best
evidence topic article that examined a total of 4
studies with 37 patients plus 2 animal studies. It
is reported that plication with phrenic nerve
injury reduced the postoperative radiological diaphragmatic paralysis image, the shortness of
breath, and the need for a ventilator. The predicted values of the respiratory function of
patients who underwent lung resection and diaphragmatic plication in the same session were
consistent with the measured postoperative values. The authors concluded that a diaphragmatic
plication could be performed during surgery if
the phrenic nerve was injured or sacriced [18].
In the extended resection study of Tokunaga etal.
[19] conducted with 13 patients, one of the studies examined in the aforementioned best evidence
topic article, postoperative complications did not
develop in 77% of patients. Further, it was
emphasized that no diaphragmatic paralysis
occurred clinically or radiologically in any
patient during the postoperative period [19].
Takahashi etal. (2018) reported a case in which
the patient underwent left upper lobectomy and
plication with VATS because the left upper lobe
lung cancer invaded the phrenic nerve [20].
The situation is similar in cases with pneumonectomy. Another best evidence topic article that
examined four studies reported that the plication
of the hemidiaphragm due to the development of
paralysis after pneumonectomy reduced respiratory failure. This result was because a preserved
phrenic nerve after pneumonectomy can function
for up to 11years, and plication mimics such a
function [21].
31.3 Precancerous Pathologies
One of the main topics related to thoracic surgery in terms of malignancy is lung cancer.
Although genetic predisposition is involved in
lung cancer development, tobacco use is the
most common etiological cause of lung cancer
[22]. Other etiological factors, such as passive
smoking, air pollution, workplace exposure, and
genetic sensitivity, should not be ignored. In
recent years, an individual who has never smoked
in his life is thought to have an increased tendency to have lung cancer. Adenocarcinomas
mostly occur in these individuals. These tumors
contain mutations more prone to targeted therapy compared with lung cancer in smokers [23].
We can easily make an inference with today’s
knowledge that no hereditay tumor in thoracic
surgery is suitable for prophylactic surgery for
reasons, such as the lung being a vital organ, very
small genetic predisposition in the tumor’s etiology, and not knowing in which part of the lung
the tumor may develop, even if it is predicted.
However, prophylactic surgical indications can
be counted in benign or premalignant lesions of
almost all thoracic structures, including lung
parenchyma.
31.3.1 Benign Chest Wall Tumors
The only prophylactic surgical indications for
benign chest wall tumors are for osteochondroma
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İ. Yalç ınkaya and M. T. Doğruyol
and chondroma. Unlike other benign ribcage
tumors, these tumors have a risk of malignant
degeneration. Osteochondroma is a small, slowgrowing tumor. The risk of malignant degeneration after surgery is eliminated, and recurrence has
not been reported [24]. It may be challenging to
distinguish chondromas from early-grade chondrosarcoma, even under a microscope. Therefore,
resection with a minimum of a 2cm surgical margin is recommended at the time of diagnosis [25].
31.3.2 Benign Pleural Tumors
Although solitary brous tumors are benign, they
should be treated surgically after diagnosis
because of the risk of developing Doege–Potter
syndrome (which may be fatal), the possibility of
malignant transformation, and the potential of
rapid growth after many years of follow-up [26–
28]. Surgical margins should be observed during
resection, and patients should be followed up by
CT for many years to prevent recurrence [29, 30].
A condition called reactive mesothelial hyperplasia with recurrent pleural effusion has been
described in the literature [31]. In people with
asbestos exposure, in situ mesothelial lesions,
which are considered as the precursor of mesothelioma, have also been shown. Malignant pleural and peritoneal mesotheliomas have been
reported in a patient diagnosed with atypical
mesothelial hyperplasia 8 years later [32].
Histologically important characteristics, degree
of mesothelial proliferation, supercial invasion,
uniform mild cytological atypia, and mesothelial
proliferation reasons other than asbestos have
been put forward for patients with atypical mesothelial hyperplasia. However, no information is
available on whether to perform preventive
decortication in patients with these characteristics and how it affects the process.
Also, pleura-induced thymomas, welldifferentiated papillary mesotheliomas, and desmoid tumors with low malignancy potential can be
treated with prophylactic surgery after diagnosis
[33].
31.3.3 Congenital Lung
Malformations
Severe respiratory distress develops in most
patients with congenital pulmonary airway malformation (CPAM). However, a small portion of
patients may remain asymptomatic. Although
surgery is undeniable for symptomatic patients,
no consensus exists on whether to perform prophylactic surgery in asymptomatic ones [34].
Hsu etal. (2019) examined the development
of cancer gene mutation in patients with CPAM
and reported that these patients carried a higher
risk than the healthy population, and prophylactic surgery might be an option [35].
Malignant transformation is not uncommon in
asymptomatic patients, and malignancy may
develop even after many follow-ups [36]. Thus,
it was emphasized that aggressive prophylactic
surgery is acceptable, and low morbidity prevails over the risk of malignancy [37]. In a
study in which parenchymal prophylactic surgery (segmentectomy or atypical resection) was
performed in 50 patients, prophylactic sublobar
resection was suggested to be performed within
the rst 6 months, if possible, with VATS, in
asymptomatic patients [38]. Similarly, Moyer
etal. (2017) reported that prophylactic surgery
might be performed with VATS within the rst
6months of life or later due to the risk of malignancy and infection development [39]. Another
study reported that prophylactic surgery for
congenital lung cysts did not prevent the development of pleuropulmonary blastoma.
However, resection was still suggested in all
pediatric patients with lung cysts due to the
presence of risk [40].
Opposing views exist for prophylactic surgery
in patients with CPAM.Two patients with right
lung agenesis, aged 44days and 3months, were
approached with the conservative treatment
method; aggressive surgical intervention was
avoided. Both patients responded very well to the
conservative treatment method. These studies
emphasized that prophylactic surgery should not
be performed in asymptomatic patients [41, 42].
31 Prophylactic Chest Surgery Procedures
377
31.3.4 Miscellaneous Conditions
Thymic carcinoid is rarely seen and mostly associated with multiple endocrine neoplasia type-1
(MEN-1) disease. Of all thymic carcinoids
reported in the literature, 25% are related to
MEN-1. Thus, a prophylactic thymectomy is
suggested for patients undergoing subtotal or
total parathyroidectomy [43].
Another condition that requires a thymectomy
related to the parathyroid gland is parathyroid
hyperplasia. In this disease, some of the recurrences after parathyroidectomy have been
reported to occur from the parathyroid glands in
the thymus gland. Therefore, a prophylactic thymectomy has been suggested, especially during
parathyroidectomy in kidney-induced parathyroid hyperplasia [44].
Upper mediastinal lymph node metastasis is
often observed in papillary thyroid carcinoma.
Therefore, prophylactic upper mediastinal lymph
node dissection with a sternotomy suggestion has
been brought up for these patients. In a study
investigating the necessity of prophylactic upper
mediastinal lymph node dissection with a sternotomy, no difference in survival and diseasefree survival was observed between groups with
and without prophylactic dissection. Thus, this
method was not recommended [45].
31.4 Conclusions
The development of anesthesia and surgical techniques paved the way for surgeries to be performed in less time and with less morbidity. Even
major surgeries, which were described in recent
case studies and could not be performed earlier
due to high risk, can now be done using minimally invasive techniques. These developments
can increase the examples of prophylactic interventions in thoracic surgery and enhance their
application by thoracic surgeons.
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Prophylactic Surgery forUrologic
Pathologies
YiğitAkın, MariaDelPilarLaguna,
andJeanDe La Rosetta
32
32.1 Introduction
Prophylactic surgery is also known as preventative surgery. It is novel for urologic surgery literature. Herein, we described “prophylactic surgery
for urologic pathologies” according to published
literature. Additionally, to our best knowledge,
this is the rst chapter for this issue in the literature. However, organ-preserving surgical modalities are very important urologic surgical
procedures, and there is a separate place of prophylactic surgery.
We divided the genitourinary system anatomically and dened prophylactic surgery for urologic pathologies. We hope that this pioneer
section would be a useful guide for clinicians.
Y. Akın (*)
Department of Urology, School of Medicine, Izmir
Katip Celebi University, Izmir, Turkey
e-mail: yigit.akin@ikcu.edu.tr
M. D. P. Laguna · J. De La Rosetta
Department of Urology, School of Medicine,
Istanbul Medipol University, Istanbul, Turkey
e-mail: plaguna@medipol.edu.tr;
jdelarosette@medipol.edu.tr
32.2 Upper Urinary Tract
32.2.1 Kidney Surgery
32.2.1.1 Preventive Nephrectomy
Both kidneys are valuable for homeostasis in the
human body. However, one of them can be
enough to survive without dialysis, and occasionally, bilateral nephrectomies should be performed
for prophylaxis. This is sometimes indicated in
association with end-stage renal disease (ESRD)
managed with kidney transplantation [1].
However, ESRD is the part above the water,
chronic kidney disease (CKD) is the part of an
iceberg under the water. ESRD due to vesicoureteral reux (VUR) is a prevalent notably in the
paediatric population [2]. In this section, we
described ESRD due to VUR.The importance of
xing VUR is described in another section below.
However, it can be managed by medication, and
when ESRD occurs, bilateral nephrectomies
come into question. Of course, the suitable indications for the prophylaxis word are presented in
the literature. This surgical procedure is performed as a prophylaxis for avoiding complications after kidney transplantation. The VUR
process mostly begins from the prenatal period.
Sargent revealed that 1/3 of patients who had a
urinary tract infection (UTI) have VUR, and
9–20% of patients with prenatal hydronephrosis
have VUR when tested in the postnatal period
[3]. The VUR mentioned herein is primary VUR
or secondary VUR, which is the cause of poste-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_32
379
380
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Y. Ak ın et al.
rior urethral valve disease and/or lower urinary
tract obstruction from the neurogenic origin, such
as spina bida. As a result, ESRD can be occurred
due to VUR. Sometimes, VUR causes reux
nephropathy (RN), and indirectly, RN brings
CKD, and a small number of patients progress to
ESRD [4]. However, ESRD is rare in the paediatric population when it could not be managed with
both medical and surgical treatments; as the most
serious consequence, ESRD might be developed.
Radiological examinations can easily show the
degree of VUR (Fig. 32.1). Additionally, the
VUR has been announced as one of the common
causes of ESRD in children, in 2007, in USA [5].
The necessity of performing bilateral nephrectomy is for the prevention of complications after
transplantation. Grade 5 VUR can cause voiding
problems and UTI. Therefore, impaired urodynamic status can easily damage transplant kidney
[6]. This can be performed before transplantation, meanwhile with transplantation. Papalois
etal. (2000) reported that there was not any signicant difference between preoperative or
simultaneous patients who underwent bilateral
native nephrectomy [7]. Fuller etal. found similar ndings with them [8]. In addition, Ismail
etal. noted that patients with simultaneous native
nephrectomies and transplantation would need
additional surgeries in short-term follow-up [9].
On the other hand, Glassman et al. (2000)
reported higher patient satisfaction for concomitant native bilateral nephrectomy and renal transplant [10]. Kim et al. (2016) reported a higher
risk of vascular diseases after concomitant surgery [11]. Elrggal etal. (2018) analysed all these
in a review and found out that there are more
advantages of concomitant surgery [12]. Over
and above, when the laparoscopic nephrectomy
is performed, the advantages could increase in
the favour of the patients without and complications of graft kidneys [13].
One more point, when bilateral native nephrectomy is performed, bilateral ureters can be used
for bladder augmentation [14]. Bellinger
described the surgical technique [15]. Vascular
source of the augmented ureters is always concerned. However, Kajbafzadeh et al. (2010)
reported preserving vascularity of the ureter for
augmentation [16].
Finally, simultaneous laparoscopic bilateral
native nephrectomy and kidney transplantation
seem safe in ESRD patients with grade 5 VUR
[17]. Native ureters can also be used for bladder
augmentation, especially in children. Bilateral
native nephrectomy can be assumed as prophylactic urological surgery for upper urinary tract.
32.2.1.2 Genetic Diseases
Autosomal dominant polycystic kidney disease
(ADPKD) is a hereditary disorder, in which the
ADPKD-1 or ADPKD-2 gene is mutated. Thus,
synthesis of polycystin 1 or polycystin 2 proteins
are changed [
18]. Briey, renal parenchyma is
destructed by a renal cyst, which may become a
huge size in the progress of the disease. ESRD
occurs and half of the patients need dialysis or
renal transplantation at the age of 60years [19].
Sometimes, even the patient does not need renal
replacement; it can take up a lot of space in the
abdomen and make it difcult for the patient to
breathe by pressing the diaphragm. Additionally,
potential complications that may arise from
Fig. 32.1 A voiding cystourethrography of a patient with
end-stage kidney disease. Grade 5 vesicoureteral reux
according to International Reux grading system
pressure on other intra-abdominal organs are not
the subject of this chapter.
32 Prophylactic Surgery forUrologic Pathologies
381
Prophylactic nephrectomies come into question for patients with ADPKD notably, and they
are listed in renal transplant. Sulikowski et al.
(2009) evaluated ADPKD patients and making
nephrectomies before, during and after renal
transplant [20]. Moreover, Rozanski etal. (2005)
agreed with them, as in the case of whom just
ipsilateral nephrectomy is required; it should be
performed before kidney transplant [21].
Laparoscopic nephrectomy is preferable; however, the size of the kidney might not be suitable
for these surgical approaches. If the kidney size is
over 15cm, surgeons should consider this situation, as technical difculties may occur [22].
Evaluation of all, we can easily suggest that
bilateral, preferably laparoscopic, nephrectomy
can be performed simultaneously with kidney
transplantation in ADPKD patients.
32.2.2 Ureter Surgery
The VUR is dened as reux of urine from the
bladder to the ureter and/or renal pelvis [23].
VUR may lead to different clinical reections,
especially in children. VUR affects 1% of children, and it mostly causes UTI.If it is not been
treated, it may lead to pyelonephritis, renal scarring and chronic renal insufciency [24].
Recently, VUR is often questioned in children
who have had a UTI. Contemporary surgical
treatment is performed by endoscopic injection
of non-animal dextranomer–hyaluronic acid
[25]. Peters etal. described the endoscopic technique [26]. The success of treatment was dened
as complete resolution of reux when no VUR
was demonstrated in voiding cystourethrography. Follow-up visits were stopped in the outpatient clinic for successfully treated children.
Children who had persistent VUR were recommended reinjections [27]. Yu et al. (2006)
reported the very successful rate of endoscopic
treatment of VUR [28]. The endoscopic treatment can avoid complications of VUR, such as
UTI.This is not meant to provide prophylactic
endoscopic VUR treatment to every child with
UTI. However, detailed clinical evaluation
should be performed for this patient population.
Indications of surgical intervention for VUR are
listed by European Urology Guidelines on
Paediatrics [29]. Our aim is just to consider urologists to diagnose and to treat VUR in its
indications.
32.3 Lower Urinary Tract
32.3.1 Bladder Surgery
32.3.1.1 Bladder Diverticula
Bladder diverticula are typically classied as
either congenital or acquired [30]. Acquired one
can occur due to bladder outlet obstruction or
neurogenic bladder. Most of the bladder diverticula are asymptomatic and are commonly discovered during the investigation for haematuria,
lower urinary tract symptoms or infection.
However, some can also be found incidentally
during radiographic examinations [31].
Bladder diverticula can be managed in different ways, including conservative non-operative
management, surgical excision and endoscopic
management. Indications for treating bladder
diverticula include urinary infection, stones or
malignancy. Of course, malignancy needs to be
managed according to tumour types and levels.
Endoscopic management includes fulguration
[32]. Surgical management includes, basically,
excision of the diverticula [33]. In the case of
some clinical ndings that are listed above, surgical/endoscopic treatment of bladder diverticula
can provide clinical improvement in patients.
Additionally, bladder diverticula do not have a
muscular wall beyond the mucosal layer. This
potentially can be resulted in increased risk for
extension of possible malignancy outside the
bladder. Thus, prophylactic diverticulectomy can
avoid this. However, laparoscopic and/roboticassisted laparoscopic operative techniques have
been announced as safe and effective for surgical
treatment of bladder diverticula [34]. Endoscopic
or surgical intervention should be preferred
according to diverticula and the patient’s clinical
situation [35].
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