Application of a protocol for enhanced recovery after radical cystectomy: a before-and-after cohort study.

PURPOSE: Radical cystectomy with urinary diversion is a major urological surgery burdened both by a high rate of short- and long-term complications and by a high emotional and psychological impact. Post-operative recovery is extremely important and the application of ERAS protocols can facilitate the return to functional autonomy. The aim of the present study was to verify the efficacy of our ERAS programme on outcomes of recovery after surgery of patients undergoing radical cystectomy with various urinary diversions. METHODS: This is a before-after study comparing the historical group (n. 77) of radical cystectomies following a peri-operative standard of care with the prospective observational group (n. 83) following our ERAS programme. Recovery after surgery outcomes evaluated were length of stay, re-admission rate at 30-90/days and post-operative complications. RESULTS: Patients treated following the ERAS protocol presented less intra-operative blood loss (p < 0.001) and less intra-operative fluid infusions (p < 0.001). Time of first flatus was shorter in the ERAS group, though no difference was found in timing of nasogastric tube removal and defecation. Removal of drainage was done significantly earlier in the ERAS group. The median length of stay decreased from 12 to 9 days (p = 0.003) with a significant reduction also in re-admission rates at 30 and long-term complications at 90 days from surgery. CONCLUSION: The application of an opioid-free ERAS protocol to patients undergoing open radical cystectomy was associated, as compared with prior traditional care, with significant reductions of recovery time and length of stay, number of total in-hospital complications, in particular functional ileus and re-admissions by 30 and 90 days after surgery.

Solitary Fibrous Tumor of the Prostate.

Even though most tumors located in the prostate derive from prostatic glands, there is a long list of malignant and nonmalignant causes for prostatic growths that clinicians should be aware of. Tumors of the prostate can be grouped in epithelial, neuroendocrine, stromal, mesenchymal, hematolymphoid, and miscellaneous. Solitary fibrous tumor of the prostate (SFT), is an extremely rare mesenchymal tumor (only about 20 cases reported in the literature). Histologic features resemble those of the more common variant pleural SFT. Of all, 10%-20% of SFTs, also known as malignant SFTs, behave aggressively. Herein, we describe a case of prostatic SFT in a 66-year-old patient that presented with obstructive urinary symptoms and normal prostate-specific antigen levels.

[Flexible cystoscope for the treatment of urinary stones in intestinal reservoirs.] / Cistoscopia flexible para el tratamiento de las litiasis urinarias en reservorios intestinales.

OBJECTIVE: Stones are common mid- and long-term complications in urinary diversions built with bowel. However the reservoir intestinal loops can lead to difficult endoscopic approach. METHODS: We report two challenging cases with unfavourable anatomy successfully treated by gently handling a flexible cystoscope in a low pressure system. RESULTS: One patient with stones in a continent pouch was cleaned up with a grasping basket through the efferent umbilical limb. Another patient with an orthotopic ileal neobladder not accessible by rigid cystoscope due to high pelvic floor was treated with holmiun laser lithotripsy. CONCLUSIONS: Urologists should consider the versatility of flexible cystoscope to obviate the need for percutaneous lithotripsy or open lithotomy.

OBJETIVO: La aparición de litiasis es una complicación común a medio y largo plazo en las derivaciones urinarias construidas con intestino. Sin embargo, las asas intestinales de los reservorios pueden tener un acceso endoscópico difícil. METODOS: Presentamos dos casos difíciles con anatomía desfavorable tratados con éxito utilizando cuidadosamente un cistoscopio flexible en un sistema de baja presión. RESULTADOS: Un paciente con litiasis en una neovejiga continente quedó libre de litiasis utilizando una cestilla a través del asa eferente umbilical. Otro paciente con una neovejiga ileal ortotópica no accesible por cistoscopio rígido debido a un suelo pélvico elevado, fue tratado con litotricia con láser de Holmio. CONCLUSIONES: Los urólogos deben considerar la versatilidad de la cistoscopia flexible para obviar la necesidad de litotricia percutánea o litotomía abierta.

Renal trauma in adolescent skateboarders.

OBJECTIVE: Kidney is the most commonly injured organ of the genitourinary tract after trauma. Half of blunt renal injuries are caused by traffic accidents, but sport activities are also included as frequent causes. Skatebording is popular among young people but it deserves being considered a potential cause of severe injuries. A number of published medical reports mainly refer to bone, joint and head injuries but no cases have been reported on urologic or kidney trauma. METHODS: We present two cases of renal trauma in adolescent males occurred while doing skateboarding. RESULTS: The first patient had a grade 3 renal trauma with urinary extravasation, managed conservatively with ureteral stenting. The second patient had a grade 4 to 5 renal trauma with cardiovascular instability requiring an urgent nephrectomy. CONCLUSIONS: We would emphasize these cases as an emergent urological warning. Scientific information and medical education should be addressed from physicians to a targeted population, in order to reduce among teens the incidence of injuries of such at-risk activity.

Cancer detection with TRUS-guided 10-core biopsy of the prostate. an institutional assessment at the first, repeated and surgical specimen biopsy.

OBJECTIVES: We retrospectively investigated the results of the 10-core scheme that our institute has adopted for three years. The aim of this study is to evaluate the cancer detection rate in different sets of biopsies (first, second, third and surgical specimen biopsy). MATERIAL AND METHODS: Patients with clinical suspicion of prostate cancer based on abnormal digital rectal examination, increase of PSA or hypoechoic lesion at transrectal ultrasound were subjected to a 10-core biopsy. Ten biopsies were taken following the traditional sextant technique and 4 more biopsies were obtained from the lateral peripheral zone. In addition, a group of 19 specimens of retropubic radical prostatectomy were biopsied immediately following surgery. RESULTS: Of 664 patients 247 (37.2%) were positive for prostate cancer at first biopsy. Eighty-one out of 664 patients were subjected to a second biopsy for persistent elevation or increasing of PSA, or in case of tumor associated histological findings such as high PIN and ASAP. The cancer detection rate in this group was 19.8% (16/81). Of the remaining 65 patients who were negative at second biopsy, 12 received a third biopsy for persistent clinical suspect of cancer, and 2 were positive (16.7%). In 19 surgical specimens, 14 biopsies were confirmed positive and 5 were negative (73.7%). CONCLUSIONS: The extended biopsy such as the 10-core scheme showed to be a reliable protocol, taking an adequate cancer detection rate either at first or repeated biopsy with no increase in morbidity.

Results and complications with the mini-laparotomic incision in 52 consecutive radical retropubic prostatectomies.

OBJECTIVES: We describe a simple mono-institutional study to prospectively assess the benefits and complications of the mini-laparotomic incision for radical retropubic prostatectomy with the anatomic approach. METHODS: Radical retropubic prostatectomy with the anatomical approach, as described by Walsh, was performed through a 4 to 8 cm incision. Median operative time, body weight, prostate weight, pathologic stage, incidence of positive surgical margins, urinary continence, the need for post-operative analgesics, peri-operative complications, are the parameters we assessed. Blood losses were calculated with the aid of a specific formula instead of simply recording the suction or weighing the sponges. RESULTS: 52 patients were consecutively operated on through a mini-laparotomic incision. Median incisional length was 8 cm (range 4 to 8 cm). Median operating time was 116 minutes (105-141), calculated blood loss was 1108.797ml, incidence of positive margins was 14%, urinary continence was observed in 48/50 patients (98%), and there was a complication rate of 4/52 (7.6%). CONCLUSION: The results we obtained with the mini-laparotomic incision are comparable to previous reports of the standard incision, also by our group, though with a lower need for postoperative analgesia. They also compare with laparoscopic prostatectomy in the length of time of catheterization and post-operative analgetic consumption.

Still a place for the classical systematic sextant technique? Cancer detection rates and complications in 1025 consecutive prostatic biopsies.

OBJECTIVES: To verify if there might still be an indication to the sextant biopsy technique we reviewed the cancer detection rate obtained and the complications encountered during a five years interval, at our hospital. METHODS: From January 1997 to December 2002 we have submitted to prostatic biopsy a total of 1025 consecutive patients with a clinical suspect of prostate cancer. A total of six cores were obtained in all the patients with an additional core at suspect lesions. RESULTS: Overall, prostate cancer was present in the biopsies of 444 of 1025 patients giving a detection rate of 43.3%. In patients with serum PSA levels between 4.1 and 10 ng/ml., 169 of 466 biopsies were positive, for a detection rate of 36.3%. An increase in percentage of positivity was observed with increasing decades of age. Overall complication rate was 1.4%. CONCLUSIONS: In patients older than 70 years, and with PSA levels higher than 10 ng/ml, the sextant technique may offer cancer detection rates comparable with techniques using an increased number of cores, and with lower complication rates.