Impact of positive surgical margins (PSMs) after robotic prostatectomy on biochemical recurrence (BCR): Multicenter analysis

OBJECTIVE

To study and analyze any correlations between positive surgical margins after RARP and biochemical recurrence.

METHODS

We enrolled 105 patients who underwent robot-assisted radical prostatectomy (RARP) from 2016-2020 with PSMs on final pathology, all performed or supervised by a senior surgeon in two tertiary referral center. Pathology has been described indicating also the area (apical, base, mediolateral, anterior, or multiple) and the extent of PSMs: focal (≤3 mm) or extensive (>3 mm). Cox univariable and multi-variable regression models were used to find the correlation between clinico-pathologic factors: age, local staging, PSA, grading, area, and size of PSMs).

RESULTS

We found a good correlation between PSA and grading and between PSA and local staging (T) (p < 0.001). There was no clear correlation between the PSM area with grading nor with T staging. There is a statistically significant correlation between extensive PSM and the worsening of grading and local staging (p < 0.001). BCR rate also has a strong correlation with the worsening of grading and local staging (T) (p < 0.001). A relevant fact is the difference between the BCR rate in the apical and base PSM (34.88%vs 62.5%; p < 0.001) which are the most frequent locations of PSMs.

DISCUSSION

PSMs remain a predictor of BCR but which may have controversial significance. The likelihood of BCR increases as grading or local staging gets worse. However, apical PSM is a relatively less powerful predictor of postoperative BCR. This can help to better select patients for subsequent RT, which still causes important side effects.

Treatment of 2-4 cm kidney stones: multicentre experience. Comparison of safety, efficacy, and costs of percutaneous nephrolithotomy and retrograde intrarenal surgery

Introduction

The objective of this study is to compare the safety and efficacy, through the stone-free rate (SFR), as well as the costs, between retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL), for 2-4 cm kidney stones.

Material and methods

We analysed the data relating to RIRS and PCNL performed in 3 reference centres for kidney stones, in the period between 1/2019 and 12/2021. The total number of procedures was 130 (63 RIRS and 67 PCNL). We defined SFR as the absence of lithiasic fragments or stones <3 mm. Results were compared between 2 groups depending on the stone size: 2-3 cm stones (group 1) and >3 cm stones (group 2).

Results

The duration of RIRS was 90 minutes for group 1 and 115 minutes for group 2, and for PCNL it was 135 minutes for group 1 and 145 minutes for group 2. RIRS had shorter duration with a significant difference in group 1 (p = 0.000014). SFR for RIRS was 78% for group 1 and 21% for group 2, and for PCNL it was 92% for group 1 and 81% for group 2. Therefore, there is a statistically significant difference, which is more evident for 3 cm and multiple stones (p = 0.0057 for group 1, p = 0.000146 for group 2). The difference in costs was estimated by calculating the expected costs for a single surgical procedure and the estimated cost per day for ordinary hospitalization.

Conclusions

2-4 cm stones can be safely treated with both RIRS and PCNL, but RIRS should not be chosen as an option for stones >3 cm, except in selected cases. PCNL remains the gold standard for the treatment of complex stones, especially for stones >3 cm. Risk of postoperative complications is higher in PCNL, even if this difference is not great. The costs associated with RIRS, even when recalculating with the need for new treatments, remain cheaper.

Idiopathic Retroperitoneal Fibrosis: What Is the Optimal Clinical Approach for Long-Term Preservation of Renal Function?

BACKGROUND

The aim of this study was to investigate the long-term effects of ureteral stenting and the exact timing of stent removal in favor of surgery in patients with idiopathic retroperitoneal fibrosis (IRF).

SUMMARY

Medline research terms of "idiopathic retroperitoneal fibrosis" AND " medical therapy" OR "ureteral stenting" OR "surgical treatment" were done. Systematic reviews and observational and clinical studies were analyzed to obtain indication regarding the objective of the study for a narrative review. Ninety-two papers were analyzed. The treatment of IRF includes the monitoring of retroperitoneal fibrotic process spread and the prevention of abdominal organs entrapment. Treatment of ureteral obstruction includes medical therapy and ureteral stenting (US) or percutaneous nephrostomy (PNS) to overcome the worsening of renal function. Up to now, the timing of US or PNS removal is not yet clear, both for the complexity of evaluating the efficacy of the medical therapy and demonstrating the resolution of obstructive nephropathy. Moreover, it is not yet clear if the long-term ureteral stent placement or PNS is able to maintain an efficient renal function. Ureterolysis with a laparoscopic robot-assisted approach is now considered as an ultimate treatment for ureteral obstruction, limiting the progression of kidney impairment and improving the quality of life of patients, although nephrologists are generally abdicant regarding the potential switch toward the surgical approach.

KEY MESSAGES

Prospective studies regarding the long-term effects of US on the renal function impairment in patients with IRF should be structured to obtain adequate information on the exact timing for the surgical approach.

Improvement prostate cancer detection rate of suspicious lesions through MRI/TRUS fusion guided biopsy by a multiteam of radiologists

Background

The objective of our study was to analyze the data of our biopsies, determine a detection rate (DR), compare it with the data in the literature and draw possible deductions, so as to offer the patient the possibility of not having other biopsies in the future.

Methods

We have enrolled 189 biopsy-naive patients in the period between September 2018 and December 2020. Each patient underwent multiparametric (mp)-MRI which was reviewed by our team of radiologists. In our center, each examination is examined by 4 radiologists separately with an overall final result. Through the t student test, any statistically significant differences between the DRs and the concordance rate between the positive cores and the suspected area on MRI were analyzed for each urologist who performed the procedure.

Results

The absolute (DR) was 69.3% (131/189 patients). The relative DR for each PIRADS score was 41% for PIRADS 3, 70.2% for PIRADS 4, 89.3% for PIRADS 5. We found a high percentage of agreement between the positive biopsy samples and the suspicious area identified on MRI: 90.8% (119/131 patients). There were no statistically significant differences between the DRs of the urologists who performed the procedure (p = 0.89), nor for the percentage of agreement between the positivity of the core and the suspected area on MRI (p = 0.92).

Conclusions

MRI in the future could become the gold standard for performing MRI fusion-guided biopsies to have a better diagnostic result and avoid rebiopsies. A team MRI reading allows greater accuracy in identifying the suspected lesion, which is demonstrated by a high rate of agreement with the positivity of the cores (90.8%). There is a cost problem due to the need to carry out the mpMRI but it could have less impact in the future. In addition, the MRI provides useful information on the extent of the disease (e.g., cT3a/b) which allows you to better plan the surgical strategy or other therapies.

16 years follow-up evaluation of immediate vs delayed vs. combined hormonal therapy on fertility of patients with cryptorchidism: results of a longitudinal cohort study

BACKGROUND

To investigate in a longitudinal cohort study, the best treatment to preserve fertility in cryptorchid subjects. Patients treated with immediate hormonal vs. delayed vs. combined (hormone plus surgery) therapy consecutively enrolled during the period 1987-1997, were evaluated.

METHODS

Two hundred fifty-five subjects were enrolled and 192 patients completed the follow-upt. One hundred fifty-six patients and 36 out 192 had monolateral and bilateral cryptorchidism, respectively. Twenty-nine out of 192 were previously treated by surgery alone (Group A), 93/192 by hormone therapy alone (Group B), 51/192 received sequential combined hormone therapy plus surgery (Group C) whilst 19/192 refused any type of treatment (Group D). The other 63 patients were considered lost to follow-up. All the patients underwent medical consultation, scrotal ultrasound scan, sperm analysis and Inhibin B, Follicular Stimulating Hormone (FSH) and Testosterone (T) serum level determination.

RESULTS

Testicular volume was found decreased in the Group D patients whilst hormone serum levels were comparable in all groups. Statistically significant differences for sperm characteristics were found in patients treated with hormonal therapy alone or combined with surgery (Groups B and C). These two groups reported better semen quality than patients who received surgery alone or no treatment. No differences were observed between monolateral and bilateral cryptorchidism patients.

CONCLUSIONS

Early prolonged hormonal therapy is advisable in all patients with cryptorchidism independently from the surgical option of promoting testicular descent to the scrotum. Hormonal therapy provides in our study better chance to obtain adequate sperm quality in adult life.

Robot-assisted laparoscopic ureteroneocystostomy combined to hysterectomy for intrinsic ureteral and deep pelvic endometriosis: Video presentation

Introduction:

We present a case of posterior deep infiltrating endometriosis with intrinsic ureteral involvement in a 43-year-old patient treated by robot-assisted laparoscopic technique. To our knowledge, this is the second case of robot-assisted ureteroneocystostomy with concomitant hysterectomy reported in the literature1–5, yet the first one to be described with a video presentation.

Case description:

A 43-year-old woman with a past history of endometriosis treated laparoscopically was referred to our clinic for grade II–III left hydronephrosis. Pelvic ultrasound and magnetic resonance imaging demonstrated a 3-cm paracervical endometriotic nodule causing ureteral compression, another 1.6-cm endometriotic nodule at the rectosigmoid junction, an adenomyotic nodule in the anterior uterine wall, and an endometrioma on the right ovary. Given that the patient had an absolute contraindication to hormonal therapy, we opted for robot-assisted laparoscopic complete eradication of endometriosis. The procedure consisted in total hysterectomy with concomitant removal of the rectovaginal nodule, right adnexectomy, left salpingectomy, and left ureteral resection with ureteroneocystostomy. After 8 days, a cystography was accomplished to confirm anastomosis integrity, and the bladder catheter was removed. The patient was discharged on day 8 after a regular postoperative period. One year after the surgery, the patient refers wellbeing.

Conclusion:

The robotic approach in such a complex procedure as surgical treatment of ureteral and deep infiltrating endometriosis is feasible and safe with acceptable postoperative outcome. Further investigations with larger comparative cohorts that include cost analysis are needed to fully assess the benefits achieved by robotic assistance in patients with ureteral and deep infiltrating endometriosis.

Intravesical migration of female urethral dilator: a case report of a new urologic emergency in the era of e-commerce

BACKGROUND

The introduction of foreign bodies in the female urethra for auto-erotic stimulation or in case of psychiatric disorders is not uncommon. The occurrence of intravesical migration of these objects makes it necessary to remove it shortly after insertion, since after long term permanence complications are likely to occurr.

CASE PRESENTATION

A 47-year-old white female was referred at our Urology department for migration inside the bladder of a metallic urethral dilator used for sexual stimulation. An ultrasound study and an X-ray plate of the pelvis clearly visualized the presence of an object shaped like a rifle bullet located in the bladder. Twenty-four hours later, the patient reported its spontaneous emission through the urethra during micturition. This was confirmed by US and X-ray imaging.

CONCLUSIONS

The retrieval of foreign objects introduced through body orifices with purpose of sexual gratification is a known urological expertise. Curiously, in the case reported, the patient was able to manipulate the object thus facilitating its correct orientation and passage outside the bladder during micturition. To the best of our knowledge this is the first case of documented spontaneous emission through the urethra of a sizable intravesical foreign body. Sexual gratification in females though the insertion of urethral dilators is a growing practice, as demonstrated by the broad proposal of such instruments on the web. Therefore, the occurrence of accidental intravesical displacement of such kind of foreign body is increasingly likely, and the Urologists must be aware of this possibility.

Clinical reappraisal and state of the art of nephropexy

The diffusion of minimally invasive techniques for renal surgery has prompted a renewed interest in nephropexy which is indicated to prevent nephroptosis in symptomatic patients and to mobilize the upper ureter downward in order to bridge a ureteral defect. Recent publications have been reviewed to present the state of the art of the diagnosis and management of these two challenging conditions and to try to foresee the next steps. The evaluation of patients with mobile kidney can be made relying on diagnostic criteria such as ultrasound with color Doppler and measurement of resistive index, conventional upright X-ray frames after a supine uro-computerized tomography scan and both static and dynamic nuclear medicine scans, always with evaluation in the sitting or erect position. Laparoscopic nephropexy emerges as the current treatment option combining both objectively controlled repositioning of the kidney and resolution of symptoms with minimal invasiveness, low morbidity, and short hospital stay. The use of robotics is presently limited by its higher cost, but may increase in the future. Downward renal mobilization and nephropexy is a safe and versatile technique which has been adopted as a unique strategy or more often in combination with other surgical maneuvers in order to cope with complex ureteral reconstruction.

Combined bladder neck preservation and posterior musculofascial reconstruction during robotic assisted radical prostatectomy: effects on early and long term urinary continence recovery

Background

To evaluate the effects of combined bladder neck preservation and posterior reconstruction techniques on early and long term urinary continence in patients treated by robotic assisted radical prostatectomy (RARP).

Methods

Two-hundred ninety-two patients who previously underwent radical prostatectomy were retrospectively selected for a case-control study, excluding those with anastomotic strictures and significant perioperative complications and re-called for a medical follow-up visit after their consent to participate the study. They were divided in 3 different groups according to the surgical technique previously received: radical retropubic prostatectomy (RRP) combined with bladder neck preservation (BNP), RARP with bladder neck resection, and RARP combined with BNP and posterior musculofascial reconstruction (PRec).

Functional and oncologic outcomes evaluation were integrated by a questionnaire on urinary continence status, abdominal ultrasound scan, uroflowmetry and post-void urine volume measurement.

Urinary continence definition included the terms “no pad” or “safety pad”.

Results

Two hundred thirty-two patients responded to the phone call interview and were enrolled in the study. They presented comparable age, prostate volume and BMI. Differences in comorbidities, ASA score and medications, did not influence the postoperative functional results, focused on continence outcome.

Early urinary continence was achieved in 49.38% and 24.73% of patients who previously underwent RARP + BNP + PRec and simple RARP respectively (p = 0.000)as well as late 12-months urinary continence was obtained in 92.59% and 79.56% of patients.(p = 0.01). Late urinary continence in the RRP + BNP group was comparable to the result obtained in the simple RARP group. The potential effects of nerve sparing technique on urinary continence have not been evaluated.

Conclusions

The combined technique of RARP + BNP + PRec seems to be effective to determine early and long term significant effects on urinary continence of patients with comparable body mass index, age and prostate volume. No statistically significant differences were found between the simple RARP and the RRP + BNP groups.

Early and late ureteral complications after renal transplant

BACKGROUND

Ureteral strictures occur in approximately 3-8% of kidney transplant (KTx) recipients. They are usually a late event which needs surgical re-intervention with a subsequent increased risk of graft loss. This retrospective study presents a single-centre experience in managing ureteral complications using firstly a minimally invasive approach.

METHODS

Between January 2000 and November 2012, 838 patients underwent KTx with Lich-Gregoire uretero-vesical anastomosis. Ureteral complications consisting in 6 fistulas and 18 strictures were observed in 24 grafts, with an overall incidence of 2.6%. The retrograde placement of a double J stent was attempted first in 16 grafts and succeeded in 12 (75%); the remaining 4 cases underwent open repair with anastomosis to the native ureter. Antegrade/combined ureteral stenting via a percutaneous nephrostomy was attempted in 8 grafts and succeeded in 4 (50%); the remaining 4 (2 fistulas and 2 strictures) underwent open repair with anastomosis to the native ureter.

RESULTS

After an average period of 8.36 months (range 1-36) the double J stents were removed and the ureters were unobstructed in 11 (45.8%), while open surgical treatment was necessary in the remaining 5. Repeated cystoscopic stent changes were successfully performed in 13 patients. Early onset ureteral stenoses were found in 10 out of 19 patients and successfully treated by a mini-invasive approach in 50% of the cases. Three renal grafts were lost, but this was not due to ureteral complications.

CONCLUSIONS

Minimally invasive procedures are recommended in early complications, although open reconstructive surgery maintains a role in late severe obstructions after KTx.

Complete intraperitoneal displacement of a double J stent: a first case

OBJECTIVES

Ureteral double-J stents are known to migrate proximally and distally within the urinary tract, while perforation and stent displacement are uncommon. Possible mechanisms of displacement are either original malpositioning with ureteral perforation or subsequent fistula and erosion of the excretory system, due to infection or long permanence of the device. We present the unique case of complete intraperitoneal stent migration in a 59-year-old caucasian male without evidence of urinary fistula at the moment of diagnosis, so far an unreported complication.

MATERIALS AND METHODS

Eight months after the placement of a double-J stent for lower right ureteral stricture at a district hospital, the patient came at our observation for urosepsis and hydro-uretero-nephrosis. A CT scan demonstrated intraperitoneal migration of the stent outside the urinary tract. Cystoscopy failed to visualize the lower extremity of the stent, a percutaneous nephrostomy was placed to drain the urinary system and the stent was removed through a small abdominal incision on the right lower quadrant.

RESULTS

In our case we presume that during the positioning manoeuvre the guide wire perforated simultaneously the lower ureteral wall and the pelvic peritoneum, and that once the upper end of the stent was coiled, the lower extremity was also attracted intraperitoneally. The lack of pain due to the spinal lesion concurred to this unusual complication.

CONCLUSIONS

We must be aware that ureteral double J stents may be found displaced even inside the peritoneal cavity, and that the use of retrograde pyelography during placement is of paramount importance to exclude misplacement of an apparently normally coiled upper extremity of the stent.

Delayed-onset ureteral lesions due to thermal energy: An emerging condition

Objectives: To describe the risks of ureteral damage occurring during urological and gynecological procedures utilizing energybased surgical devices (ESD) during both laparoscopic and open procedures. Materials and Methods: During the last 20 months we observed five cases of iatrogenic ureteral lesions caused by ESD which required open surgery. There were 3 lesions of the lower ureter occurring during gynecological laparoscopic or robotic procedures, and 2 lesions of the upper ureter occurring during open enucleation of low-stage renal cell carcinomas. Results: In the laparoscopic gynecological lesions the cause was attributable to monopolar cutting and bipolar coagulation: they presented with urine extravasation after 20, 15 and 15 days respectively and required ureteral reimplantation in 2 out of 3 cases. In the upper ureteral lesions the causes were bipolar coagulation and LigaSure Impact TM used for perirenal fat dissection: they presented after 2 and 4 months respectively and required uretero-ureterostomy and inferior nephropexy in one case and nephrectomy in the other. In 3 out of 5 cases there was an unsuccessful attempt at placing an ureteral double J stent, and in the 2 cases where it was placed it did not prevent the formation of subsequent stricture in one. Conclusions: The widespread diffusion of ESD has the potential drawback of inadvertent thermal energy transmission to the ureter. Delayed presentation of ureteral lesions and difficulties in ureteral stent placement were the common features of the cases observed. Inadvertent ureteral damage by different thermal energy sources is an emerging condition, requiring awareness, prompt recognition and adequate treatment with the reconstructive urology principles.

Prulifloxacin versus Levofloxacin in the Treatment of Chronic Bacterial Prostatitis: a Prospective, Randomized, Double-Blind Trial

Ninety-six patients with chronic bacterial prostatitis (CBP) and evidence of infection were randomized to receive a 4-week oral course of either prulifloxacin (a new fluoroquinolone) 600 mg or levofloxacin 500 mg once daily. They were evaluated with the Meares-Stamey test and the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) at baseline and one week after therapy completion. Patients with microbiological eradication were evaluated again with the Meares-Stamey test 6 months after therapy completion. The microbiological eradication rate was 72.73% for prulifloxacin and 71.11% for levofloxacin (p=0.86) and the reduction in the NIH-CPSI was 10.75 and 10.73, respectively (p=0.98). Safety was comparable, with 18.18% adverse events for prulifloxacin and 22.22% for levofloxacin (p=0.79). Thus, a 4-week course of prulifloxacin 600 mg once daily is at least as effective and safe as levofloxacin 500 mg once daily in the treatment of CBP.

Radical prostatectomy, sparing of the seminal vesicles, and painful orgasm

INTRODUCTION

Erectile dysfunction has been widely investigated as the major factor responsible for sexual bother in patients after radical prostatectomy (RP); painful orgasm (PO) is one element of this bother, but little is known about its prevalence and its effects on sexual health.

AIM

This study aims to investigate the prevalence of PO and to identify potential risk factors.

MAIN OUTCOME MEASURES

A total of 1,411 consecutive patients underwent open (radical retropubic prostatectomy) or robot-assisted laparoscopic RP between 2002 and 2006. The patients were asked to complete a study-specific questionnaire.

METHODS

Of a total of 145 questions, 5 dealt with the orgasmic characteristics. The questionnaire was also administered to a comparison group of 442 persons, matched for age and area of residency.

RESULTS

The response rate was 91% (1,288 patients). A total of 143 (11%) patients reported PO. Among the 834 men being able to have an orgasm, the prevalence was 18% vs. 6% in the comparison group (relative risk [RR] 2.8, 95% confidence interval [CI] 1.7-4.5). When analyzed as independent variables, bilateral seminal vesicle (SV)-sparing approach (RR 2.33, 95% CI 1.0-5.3, P = 0.045) and age <60 years were significantly related to the presence of PO (95% CI 0.5-0.9, P = 0.019). After adjustment for age, bilateral SV-sparing still remained a significant predictor for occurrence of PO.

CONCLUSIONS

We found that PO occurs significantly more often in patients undergoing bilateral SV-sparing RP when compared with age-matched comparison population.

Unusual stent after ureteral substitution. A first case

Background

To the best of our knowledge this is the first case where a Silastic drain is used in ureteral surgery instead of a common urological stent. Patients coming from other institutions, especially in peripheral areas, can be treated with non conventional devices and if traditional imaging is inconclusive, computed tomography (CT) can provide valuable information to make the right diagnosis.

Case presentation

We present the unusual case of a 32F Silastic drain found inside the urinary tract in a female patient who had previously undergone ileal loop replacement of the left ureter for post-hysterectomy stricture at another Institution, and had subsequently repeated surgery due to persistent hydronephrosis. Radiological findings on plain abdominal X-ray were quite misleading, while CT allowed a correct assessment of the drain features.

Conclusion

While double J stents of different lengths, sizes and materials are used in ureteral surgery, the use of Silastic drains has not been previously reported. In light of the present experience we don’t suggest its routinely use.

Ureteral reimplantation with psoas bladder hitch in adults: a contemporary series with long-term followup

We retrospectively evaluated our experience with ureteral reimplantation and psoas bladder hitch to restore urinary tract continuity in patients with lower ureteral defects, since long-term data on the outcomes of this procedure have been relatively scarce in the last two decades. The procedure was performed in 24 patients (7 male, 17 female) with a mean age of 54.6 years. The mean ureteral defect length was 4.8 cm (range 3–10), the ureterovesical anastomosis was performed with simplified split-cuff technique in 18 patients, submucosal tunnel in 2, and direct anastomosis without antireflux technique in 2. Mean followup was 53 months (range 12–125), and there were no reinterventions. Postoperative renal imaging was normal in 22 cases (91.6%) and revealed decreased kidney size in 2, 3 patients presented intermittent flank pain, and 5 had sporadic episodes of lower tract UTI but no one pyelonephritis. Psoas hitch ureteral reimplantation can be successfully used for bridging defects of the lower ureter up to 10 cm in length in difficult clinical situations. It is relatively simple to perform, compared to other procedures of ureteral reconstruction, and it provides adequate protection of the upper urinary tract.

Orgasm-associated incontinence (climacturia) after bladder neck-sparing radical prostatectomy: clinical and video-urodynamic evaluation

INTRODUCTION

Orgasm-Associated Incontinence (OAI) or climacturia has been observed in male patients maintaining sexual potency after radical prostatectomy and cystectomy.

AIM

We investigated the incidence and video-urodynamic aspects of this event in continent and potent patients after bladder neck-sparing (BNS) radical prostatectomy (RP).

MAIN OUTCOME MEASURE

Comparing functional and morphological aspects between climacturic and non-climacturic patients to identify a possible explanation of this unusual kind of leakage that could seriously impact the sexual life after surgery.

METHODS

In a pool of 84 men, potent and continent at least 1 year after BNS RP, 24 (28.6%) reported climacturia and 7 agreed to undergo video-urodynamic evaluation (group 1), which was performed also in 5 controls (group 2). Those 12 men were also evaluated with 24-hour pad test, 5-item International Index of Erectile Function and International Prostate Symptom Score questionnaires.

RESULTS

Functional urethral length (FUL) was significantly lower in the climacturia group (P=0.02) and time to continence recovery was significantly longer (P=0.05). No other significant differences were found between the two groups. The radiological appearance of the vesicourethral junction at voiding cystourethrography was similar.

CONCLUSIONS

To the best of our knowledge, this is the first functional and morphological evaluation of climacturia after RP. In our experience, this event is indirectly associated with a reduced FUL in the sphincter area, although both patients and controls were continent during daily activities. BNS technique seems to reduce time to continence recovery, although climacturic patients need longer time than control patients. Since in our series no rigidity of the vesicourethral anastomosis was radiographically evident, we believe that differences in FUL could explain OAI. Anatomical difference in membranous urethra length could explain the occurrence of this symptom in patients treated with the same surgical technique.

Testis-sparing surgery for benign and malignant tumors: A critical analysis of the literature

In order to explore the latest advances in organ-sparing treatment of testicular tumors, a literature search of the Medline/PubMed database was carried out for published data in the English language up to 2007.

In the recent past the management of testicular tumors has evolved in favor of a testis-sparing approach in selected cases, both in the adult and pediatric population. The widespread use of high-frequency testicular ultrasound has led to detecting an increasing number of asymptomatic, non-palpable, small-volume masses. A higher proportion of testicular lesions of benign nature than previously reported has now been documented. The high accuracy of frozen section examination and the increasing interest in the potential functional, psychological and cosmetic advantages related to preserved testicular parenchyma are other arguments currently favoring the adoption of an organ-sparing policy for most testicular masses. Greater experience has been gained in also managing conservatively malignant tumors. Patients with germ-cell cancer in solitary testis or bilateral tumors can be submitted to testis-sparing surgery, provided that the maximum size of the lesion is <2 cm, preoperative testosterone is normal and adjuvant radiotherapy of the residual parenchyma is delivered. Cancer-specific survival is excellent, local recurrence rate very low and androgen supplementation unlikely.

Orthotopic bladder substitute in renal transplant recipients: experience with Studer technique and literature review

Renal transplant recipients with high-risk bladder cancer following cystectomy need a urinary diversion preserving the renal function and possibly maintaining body image, while still offering the best oncological outcome. The aim of this report is to describe our experience of radical cystectomy and orthotopic ileal neobladder with Studer technique in this population, and to review the literature. We performed radical cystectomy and Studer ileal neobladder in four male patients (median age 67 years) after median time of 9.5 years following renal transplantation. Pathology revealed pT1HGN+ transitional cell carcinoma in one case, pT1HGN0 in two and pT3aHGN0 in one. Two patients presenting aggressive disease (N+ and pT3a) died of tumour progression after 20 and 14 months, respectively, while the other two are alive after 56 and 36 months of follow-up with no evidence of disease, stable serum creatinine (2.29 and 1.6 mg/dl) and mild metabolic acidosis. Day and night-time urinary continence were satisfactory in all patients. Good functional outcomes have been reported in the 20 cases of ileal orthotopic neobladder with different techniques published so far and the global experience of 24 cases with a median follow-up of 39 months documents a cancer specific survival of 62.5%.

Candida bezoars with urinary tract obstruction in two women without immunocompromising conditions

More than half of the cases of fungal infections of the urinary tract are caused by Candida sp., but occurrence of obstructive uropathy caused by mycetomas or fungus balls (urobezoars) is extremely rare. The latter are conglomerates of fungal hyphae. Diabetes mellitus, immunosuppression, chronic disease, and malignancies are known predisposing factors. Preoperative imaging is not pathognomonic; blood clots, radiolucent urinary calculi, air bubbles, and inflammatory debris can mimic urobezoars. We report on two otherwise healthy women presenting with urinary tract obstruction caused by candidal mycetomas of the renal pelvis that mimicked matrix lithiasis.

Predictors of morbidity in patients with indwelling ureteric stents: results of a prospective study using the validated Ureteric Stent Symptoms Questionnaire

OBJECTIVE

To assess the predictors of morbidity in patients with indwelling ureteric stents using a validated questionnaire.

PATIENTS AND METHODS

Eighty-six consecutive patients with indwelling double-J ureteric stent of different length and size enrolled at an Italian tertiary academic centre were prospectively evaluated with the Italian-validated Ureteric Stent Symptoms Questionnaire (USSQ), which explores the stent-related symptoms in six domains. Ureteric stents were placed for benign ureteric obstruction or after uncomplicated ureterorenoscopy, and were all removed after 28 days. The questionnaire was administered on days 7 and 28 after stent placement and on day 28 after removal. A plain abdominal X-ray was performed on days 7 and 28 after placement to determine stent location. Univariable and multivariable analyses tested the association of patient age, sex and body mass index (BMI), and stent side, length, calibre and distal loop location, with the index score of the various domains on days 7 and 28.

RESULTS

All patients completed the study. At multivariable analysis, on day 7, sex, BMI and stent calibre were significantly associated with one domain (general health, body pain and work performance, respectively), while location of stent distal loop was significantly associated with five domains (urinary symptoms, body pain, general health, work performanc, and sexual matters). On day 28, body mass index was significantly associated with two domains (body pain and general health), while location of stent distal loop remained significantly associated with the same five domains (urinary symptoms, body pain, general health, work performance and sexual matters).

CONCLUSION

Location of stent distal loop with respect to midline had the strongest association with most domains of the USSQ on both days 7 and 28 after stent placement. The visualization of stent distal loop crossing the midline may therefore identify patients at higher risk of post-procedural morbidity requiring early management.

Renal cell carcinoma with caval involvement: contemporary strategies of surgical treatment

OBJECTIVES

We retrospectively evaluated the outcome of the surgical treatment of patients with renal cell carcinoma (RCC) and extensive inferior vena cava (IVC) involvement. Our aim was to investigate if a particular surgical technique could reduce morbidity and complications associated with this condition.

MATERIALS AND METHODS

From 1996 to 2007, 22 patients with RCC and extensive IVC involvement underwent radical surgical treatment with the intention to avoid, whenever possible, sternotomy and cardiopulmonary bypass. The level of the tumor thrombus was I (<2 cm above the renal vein) in 2 patients, II (below the intrahepatic vena cava) in 9 patients, III (intrahepatic vena cava below the diaphragm) in 7 patients, and IV (atrial) in 4 patients. Extracorporeal vascular bypass was used for 4 patients with level IV and for 2 patients with level III tumor thrombi, with hypothermic circulatory arrest in 2 patients. Extensive liver mobilization techniques were adopted in 16 patients. Overall and cancer-specific survival (CSS) were analyzed based on tumor extent (N0M0, N+M+), pathologic stage (pT3b, pT3c, pT4), thrombus level, and caval wall infiltration.

RESULTS

Two patients died within 1 month of surgery and the remaining 20 patients have a mean follow-up of 32.2 months (range 6-90): 8 are alive (overall survival 40%), but 2 with disease (CSS 30%). A total of 10 severe complications developed in 8 patients (36%). Both overall and CSS were significantly associated with tumor stage (Log-rank P = 0.0237 and 0.0465), presence of nodal or systemic metastases (Log-rank P = 0.0835 and 0.0669; Wilcoxon's test P = 0.0407 and 0.0411), and caval wall infiltration (Log-rank P = 0.0200 and 0.0418).

CONCLUSIONS

Despite the low overall survival, related to the high percentage of nodal and systemic metastases, aggressive surgical management with resection of synchronous metastatic disease for symptom palliation and cytoreduction, followed by immunotherapy is justified in this setting. A transabdominal approach to RCC and IVC involvement, even in patients with level III thrombus, can provide the surgeon with an exposure similar to thoracoabdominal incisions without the complications associated with thoracotomy.

The role and extension of lymphadenectomy in bladder cancer: a review of the current literature

Radical cystectomy (RC) with pelvic lymph node dissection (LND) is the gold standard for high grade and muscle invasive bladder cancer. Although consensus exists on the need for node dissection, its extent and role are still matter of debate. However, an ever-growing body of data supports an extended dissection since it may provide a survival advantage in both node positive and node negative patients without significantly increasing morbidity and mortality. Besides dissection extent, the modality of specimen submission and node retrieval have a key role in the quality of node assessment. Moreover the stage of primary bladder tumor, the total number of lymph nodes removed, the lymph node tumor burden, the extracapsular extension and the lymph node density have been demonstrated to be important prognostic variables in patients undergoing cystectomy with node metastases and could be useful to accurately stratify patient risk in order to identify those who may benefit from adjuvant therapies. Even if evidence from the literature is only based on retrospective studies, an extended dissection at the time of cystectomy appears to provide a more accurate staging and enhance survival; future prospective studies taking into account the new prognostic factors are needed.

Simultaneous penile and signet ring cell bladder carcinoma in renal transplant recipient: a first case

The incidence and prevalence of cancer increase with time after transplantation. Therefore, a risk-adapted screening process is very important in order to identify low-grade malignancies early in their development. This provides the opportunity to initiate appropriate immunosuppressive regimens depending on the tumor type and stage of development. The first case presented is one of a 65-year-old patient with a double genitourinary carcinoma (penis and bladder). The patient received kidney transplantation 7 years prior to this event. After adequate surgical treatment (partial amputation of the penis for squamous cell carcinoma and complete transurethral resection of bladder adenocarcinoma), the patient was noted to be free of tumor recurrence and had functioning renal graft with a 2-year follow-up.

Isolated polyarteritis nodosa of the genitourinary tract presenting with severe erectile dysfunction: a case report with long-term follow-up

INTRODUCTION

Polyarteritis nodosa (PAN) is a rare necrotizing vasculitis affecting small- and medium-sized arteries of multiple organs. Spreading to the genitourinary tract is very common, with invariable involvement of kidneys or testes, but its impact on erectile function remains undetermined.

AIM

We describe a case of isolated PAN of the genitourinary tract diagnosed in a young man presenting with severe erectile dysfunction (ED), debate the critical issues of the differential diagnosis, and provide the long-term follow-up outcome.

METHODS

The case report profiled a 36-year-old man who presented with progressively worsening erectile function and was incidentally found to suffer from genitourinary PAN. Extensive clinical, laboratory, and instrumental investigations, including brachial artery dilation test, suggested an arteriogenic etiology for ED and excluded a systemic involvement by PAN. Management featured use of a long-term, on-demand phosphodiesterase type 5 (PDE5) inhibitor regimen for ED, and close surveillance with no immunosuppressive therapy for PAN.

MAIN OUTCOME MEASURES

Clinical history data, brachial artery dilation test, response to PDE5 inhibitor therapy.

RESULTS

After 12 months of PDE5 inhibitor therapy, the patient recovered a normal erectile function, paralleled by restored endothelial function as assessed with brachial artery dilation test. At a 5-year clinical follow-up, he continued to have full erectile ability with only occasional use of PDE5 inhibitor, and no evidence of progressive PAN was documented.

CONCLUSIONS

We propose PAN as a novel cause of arteriogenic ED, report the effective therapy with PDE5 inhibitor, and confirm the good long-term prognosis of isolated genitourinary PAN without immunosuppressive treatment.

Pseudodiverticula of ureter: radiologic and histologic findings

A 70-year-old man with previous history of TUR-BT presented positive urinary cytology at one year follow-up. Cystoscopy with bladder mapping was negative, and IVP revealed multiple outpouchings of the right upper ureter without hydronephrosis. Ureteroscopy failed because of an underlying stricture. Surgical excision of the strictured segment and of 2.5 cm of cranial ureter was performed. Histopathology demonstrated focal hyperplasia of the urothelium with outpouchings involving only the mucosa, compatible with the diagnosis of pseudodiverticula.

The Italian linguistic validation of the ureteral stent symptoms questionnaire

PURPOSE

We validated the Italian version of the Ureteral Stent Symptoms Questionnaire in male and female patients with an indwelling ureteral stent.

MATERIALS AND METHODS

A double-back translation of the original Ureteral Stent Symptoms Questionnaire was performed by 3 urologists and 4 professional translators. A total of 78 patients (cases) with and 35 healthy subjects without (controls) an indwelling ureteral stent were asked to complete the Italian version of the Ureteral Stent Symptoms Questionnaire and a visual analog scale for pain as well as the International Prostate Symptom Score (men) and Urogenital Distress Inventory-6 plus Incontinence Impact Questionnaire-7 (women). Cases were evaluated at weeks 1 and 4 after stent placement, and at week 4 after removal, while controls were evaluated once. The psychometric properties of the questionnaire were analyzed.

RESULTS

A total of 66 cases and 30 controls were suitable for analysis. The questionnaire showed good internal consistency in all domains except global quality of life compared with that of the International Prostate Symptom Score (Cronbach's alpha >0.75). Test-retest reliability was good except for the sexual matters domain (Pearson's coefficient >0.7). Relatively high correlation coefficients (greater than 0.65) were found for the visual analog scale for pain, the International Prostate Symptom Score, the Urogenital Distress Inventory-6 and the Incontinence Impact Questionnaire-7 with the corresponding Ureteral Stent Symptoms Questionnaire domains, suggesting good convergent validity. Sensitivity to change and discriminant validity were also good (p <0.001).

CONCLUSIONS

The Italian version of the Ureteral Stent Symptoms Questionnaire is a reliable and robust instrument that can be self-administered to male and female Italian patients with an indwelling ureteral stent in the clinical and research settings.

Cold-knife incision of anastomotic strictures after radical retropubic prostatectomy with bladder neck preservation: efficacy and impact on urinary continence status

OBJECTIVES

To evaluate the incidence and characteristics of anastomotic strictures (AS) after radical retropubic prostatectomy (RRP) with bladder-neck preservation (BNP), the efficacy of management with cold-knife incision (CKI), and its impact on urinary continence.

METHODS

Seven hundred five consecutive patients who underwent RRP with BNP were prospectively followed with uroflowmetry at postoperative months 1, 3, 6, 9, 12, and investigated for urinary incontinence with the 1-h pad test at AS diagnosis obtained with urethroscopy. If the instrument could not dilate the stricture, CKI was subsequently performed. Follow-up after treatment was performed with uroflowmetry and 1-h pad test at months 1, 3, 6, 9, 12. Recurrent AS was always treated with repeated CKI.

RESULTS

Six hundred forty-eight patients were assessable. After a median time of 3.8 mo from RRP, 46 (7.1%) patients developed AS. Urinary incontinence was present in 21 (46%) men at AS diagnosis. Three (7%) patients were successfully managed by urethroscopic dilation only, whereas 43 (93%) required CKI. Eleven (26%) of the latter had recurrent AS. After a median follow-up of 48 mo from the last AS treatment, all patients are stricture-free, de novo urinary incontinence was never documented, and of the 21 originally incontinent men, 11 became continent, 8 improved and 2 remained unchanged.

CONCLUSIONS

In our experience, BNP does not decrease the incidence of AS after RRP; however, AS can be effectively managed with repeated CKI with a final 100% success rate. CKI has a possible positive impact on urinary continence in 90% of patients, without causing de novo incontinence.

Low velocity gunshot wound to the penis

A ricocheting 30-06 calibre bullet caused a low velocity penile injury in a 54-year-old man, shearing the right corpus cavernosum and crossing the ipsilateral thigh and gluteal muscles. Prompt surgical exploration with meticulous debridement and corporeal reconstruction through a degloving incision led to excellent cosmetic and functional results.

Multifocal and bilateral renal oncocytoma: a case report and review of the literature

A 78-year-old man presenting with synchronous, multifocal and bilateral renal oncocytomas underwent a staged nephron-sparing surgery with removal of six lesions. At 14-month follow-up the renal function was preserved and no recurrent disease was evident. A literature review demonstrated 17 similar cases, treated either with watchful waiting or with complete surgical removal. Reasons to prefer the surgical option are herein substantiated.

Continuing or Discontinuing Low-Dose Aspirin Before Transrectal Prostate Biopsy: Results of a Prospective Randomized Trial

OBJECTIVES

To determine whether the incidence and duration of bleeding complications after transrectal prostate biopsy (PB) in patients not discontinuing low-dose aspirin (LDA) are greater than in those discontinuing it.

METHODS

A total of 200 consecutive subjects taking chronic LDA were enrolled in a prospective trial and were randomly assigned to undergo transrectal PB while continuing LDA (group 1, n = 67), replacing LDA with low-molecular-weight heparin (group 2, n = 67), or discontinuing LDA (group 3, n = 66). The incidence and duration of hematuria, rectal bleeding, and hematospermia for each group were assessed with a self-administered questionnaire. On days 14 and 30 after PB, all men were evaluated with an outpatient visit and a telephone interview, respectively.

RESULTS

The cohort comprised 196 assessable subjects. The median number of biopsy cores taken was 10 (range 6 to 10). The overall bleeding rate was 78.5%, 69.7%, and 81.5% in groups 1, 2, and 3, respectively (P = 0.26). No significant difference was found for hematuria, rectal bleeding, or hematospermia among the groups. No severe bleeding complications occurred. The median duration of hematuria and rectal bleeding was significantly greater statistically in groups 1 and 2 compared with group 3 (6, 4, and 2 days versus 3, 2, and 1 days, respectively; P <0.0001). The proportion of men still reporting hematospermia at 30 days after PB was 21.4%, 18.5%, and 9.3% in groups 1, 2, and 3, respectively (P = 0.2).

CONCLUSIONS

The continued use of LDA in men undergoing transrectal PB did not increase the incidence of mild bleeding complications, although it prolonged the duration of self-limiting hematuria and rectal bleeding. Its effect, however, on severe bleeding remains to be determined.

Long-term followup after elective testis sparing surgery for Leydig cell tumors: a single center experience

PURPOSE

Although most Leydig cell tumors are benign, radical orchiectomy is currently considered the standard therapy. We retrospectively analyzed the long-term followup of a series of patients with Leydig cell tumors electively treated with testis sparing surgery.

MATERIALS AND METHODS

Between November 1990 and December 2005, 17 consecutive patients with Leydig cell tumors underwent testis sparing surgery on an elective basis. Preoperative evaluation included physical examination, serum markers for germ cell tumors, scrotal ultrasound, abdominal computerized tomography, chest x-ray and hormonal profile if clinically required. Testis sparing surgery was performed via an inguinal approach with spermatic cord clamping. Frozen section examination was performed in all cases, revealing Leydig cell tumors. Followup consisted of physical examination, scrotal ultrasound, abdominal computerized tomography and chest x-ray every 6 months for the first 2 years, then annually. Tumor recurrence and survival were evaluated.

RESULTS

Mean patient age was 41.6 years (range 28 to 55). Medical referral was prompted by symptoms/signs such as infertility, gynecomastia or self-palpation of scrotal mass in 11 patients (64.7%), while in the remaining 6 (35.3%) the lesions were incidentally diagnosed. Hormonal profile was performed in 9 patients, showing abnormalities in all. Mean tumor diameter was 13.4 mm (range 5 to 31). Definitive pathological examination confirmed benign Leydig cell tumor in all cases. After a mean followup of 91 months (range 12 to 192), neither local recurrence nor distant metastases have been detected and all patients are alive without evidence of disease.

CONCLUSIONS

In patients with Leydig cell tumors testis sparing surgery with frozen section examination provides an excellent long-term oncological outcome.

Granular cell tumour of the urinary bladder: a case report and review of the literature

Granular cell tumor of the urinary bladder is an exceedingly rare disease, with only 10 cases reported so far in literature. We report a case of granular cell neoplasm of the bladder incidentally found in a 44-year-old woman during an abdominal ultrasound examination for evaluation of stress urinary incontinence. The patient underwent a transurethral resection of the mass and histological examination revealed the presence of a granular cell tumor. Immunohistochemical staining for neuron-specific enolase and S100 protein was positive. At a 6-month follow-up the patient is free of bladder recurrence.

Value of image fusion in the staging of prostatic carcinoma

PURPOSE

We assessed the value of image fusion in the staging of prostatic cancer in a series of 32 patients who underwent preoperative evaluation with transrectal colour-Doppler ultrasonography (TRUS) and magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Colour-Doppler TRUS exams were performed using a 7.5-MHz biplanar probe. MRI exams were done with a scanner operating at 1.5 Tesla (T) using an endorectal coil. All patients underwent radical prostatectomy within 2 weeks from the imaging assessment. Whole-mount sections were prepared from the surgical specimens and were subsequently digitised by using a high-resolution scanner. The Digital Imaging and Communications in Medicine (DICOM) TRUS and MR images as well as the digitised pathological images were transferred to a graphic workstation to perform image fusion.

RESULTS

Image fusion was technically possible in 25/32 cases in which axial TRUS images were available. The following fusion images were obtained: TRUS + pathological sections; MRI + pathological sections; TRUS + MRI + pathological sections. The final pathological staging concerning the T status was: four pT2b, fourteen pT2c, three pT3a and four pT3b. The three types of image fusion led to the following results: TRUS + pathological sections, correct staging in 20/25 cases (accuracy 80%); MRI + pathological sections, correct staging in 22/25 cases (accuracy 88%); TRUS + MRI + pathological sections, correct staging in 23/25 cases (accuracy 92%).

CONCLUSIONS

Our study suggests that by using image fusion between colour-Doppler TRUS and endorectal MRI, it is possible to improve the accuracy of pathological staging in patients who are candidates for radical prostatectomy.

Lidocaine–Prilocaine Administration during Transrectal Ultrasound-Guided Prostatic Biopsy: A Randomized, Single-Blind, Placebo-Controlled Trial

BACKGROUND AND PURPOSE

As many as 96% of patients report some kind of discomfort/pain during transrectal ultrasonography (TRUS)-guided prostate biopsy, and when pain is severe, it may be necessary to decrease the planned number of biopsies or interrupt the procedure. Various modalities have been recommended to alleviate the pain, but reports on efficacy are contradictory. We assessed the possible benefit of intrarectal and perianal lidocaine-prilocaine (EMLA) cream.

PATIENTS AND METHODS

A series of 98 patients without active anal and prostatic conditions underwent TRUS and, 10 to 31 days later, TRUS-guided biopsy. They were asked to grade their discomfort/pain using a 10- point linear visual analog pain scale (VAS). After TRUS, patients were divided into three groups on the basis of the VAS scores. Group 1 (N = 8) had pain scores <or=2 (mild pain/discomfort). Group 2 (N = 75) had pain scores between 2 and 5 (moderate pain/discomfort). Group 3 (N = 15) had pain scores >or=5 (severe pain/discomfort). Each group was then randomized to receive local anesthesia with intrarectal and anal EMLA cream (subgroup A) or intrarectal and anal ultrasound gel as placebo (subgroup B). Pain scoring was repeated after the biopsy.

RESULTS

In group 1, there were no significant differences in pain scores between subgroups A and B. In group 2, we could not complete the biopsy in one patient of subgroup B. A statistically significant difference was noticed between the VAS scores of subgroup A and subgroup B (P < 0.0001). In group 3, we were not able to complete biopsy in 5 patients of subgroup B. We noticed significantly higher VAS scores in subgroup B between TRUS and prostate biopsy (P < 0.0001), whereas similar scores were observed in subgroup A (P = NS). A statistically significant difference (P < 0.0001) was noticed between subgroup A and subgroup B scores during biopsy.

CONCLUSIONS

In patients with high tolerance for simple TRUS, needle trauma does not significantly alter tolerability, and anesthetic provides little benefit for prostatic biopsy. However, the opposite is true in patients presenting moderate to significant pain/discomfort at TRUS, who may benefit from intrarectal/anal administration of EMLA during prostate biopsy.