Initial experience with robot-assisted ureteroscopy with Ily® Robot.

The aim of this study is to present the first Italian experience with robotic-assisted retrograde intrarenal surgery (rRIRS) using the Ily® platform. Procedures were performed for renal stones using the Ily® Robot (STERLAB, Vallauris, France), which is a ureteroscope holder with multiple degrees of freedom that can be controlled remotely through a wireless controller. In March 2023, consecutive patients with indications for rRIRS were included in the study. Demographic variables and stone characteristics were collected, and standard perioperative data were assessed. The one-month stone-free rate (SFR, i.e. no residual fragments) was evaluated using ultrasound. All participating surgeons filled out a Surgeons' Satisfaction Questionnaire (SSQ) based on a Likert-type scale. The questionnaire focused on: 1) ease of use; 2) ergonomics during renal cavity exploration; 3) stability during stone fragmentation. Among the patients, one had bilateral stones, while two had stones on the right side. The mean stone size was 13 mm. The average operative time was 70 minutes and the mean docking time was three minutes. No perioperative complications were recorded, and all patients were discharged on the first postoperative day. The one-month SFR was 100%. The SSQ scores were as follows: 1) ease of use: 4/5; 2) ergonomics: 5/5; 3) stability during stone fragmentation: 5/5. Based on the initial experience, the results indicate the feasibility, safety, and effectiveness of rRIRS. The ergonomic efficiency of the system was highly appreciated by the surgeons. While a cost-effectiveness analysis within clinical trials is necessary, rRIRS shows the potential for a more sustainable future for endoscopists and an improved workplace environment.

Percutaneous Kidney Puncture with Three-dimensional Mixed-reality Hologram Guidance: From Preoperative Planning to Intraoperative Navigation.

BACKGROUND: Despite technical and technological innovations, percutaneous puncture still represents the most challenging step when performing percutaneous nephrolithotomy. This maneuver is characterized by the steepest learning curve and a risk of injuring surrounding organs and kidney damage. OBJECTIVE: To evaluate the feasibility of three-dimensional mixed reality (3D MR) holograms in establishing the access point and guiding the needle during percutaneous kidney puncture. DESIGN, SETTING, AND PARTICIPANTS: This prospective study included ten patients who underwent 3D MR endoscopic combined intrarenal surgery (ECIRS) for kidney stones from July 2019 to January 2020. A retrospective series of patients who underwent a standard procedure were selected for matched pair analysis. SURGICAL PROCEDURE: For patients who underwent 3D MR ECIRS, holograms were overlapped on the real anatomy to guide the surgeon during percutaneous puncture. In the standard group, the procedures were only guided by ultrasound and fluoroscopy. MEASUREMENTS: Differences in preoperative and postoperative patient characteristics between the groups were tested using a χ2 test and a Kruskal-Wallis test for categorical and continuous variables, respectively. Results are reported as the median and interquartile range for continuous variables and as the frequency and percentage for categorical variables. RESULTS AND LIMITATIONS: Ten patients underwent 3D MR ECIRS. In all cases, the inferior calyx was punctured correctly, as planned using the overlapping hologram. The median puncture and radiation exposure times were 27 min and 120 s, respectively. No intraoperative or major postoperative complications occurred. Matched pair analysis with the standard ECIRS group revealed a significantly shorter radiation exposure time for the 3D MR group (p < 0.001) even though the puncture time was longer in comparison to the standard group (p < 0.001). Finally, use of 3D MR led to a higher success rate for renal puncture at the first attempt (100% vs 50%; p = 0.032). The main limitations of the study are the small sample size and manual overlapping of the rigid hologram models. CONCLUSIONS: Our experience demonstrates that 3D MR guidance for renal puncture is feasible and safe. The procedure proved to be effective, with the inferior calyx correctly punctured in all cases, and was associated with a low intraoperative radiation exposure time because of the MR guidance. PATIENT SUMMARY: Three-dimensional virtual models visualized as holograms and intraoperatively overlapped on the patient's real anatomy seem to be a valid new tool for guiding puncture of the kidney through the skin for minimally invasive treatment.

Robot-assisted-radical-cystectomy with total intracorporeal Y neobladder: Analysis of postoperative complications and functional outcomes with urodynamics findings.

OBJECTIVES: To describe our robotic Y intracorporeal neobladder (ICNB) technique and to report its post-operative complications and urodynamics (UD) findings. SUBJECTS: and Methods: In this prospective study we enrolled patients affected by MIBC (T1-T4N0-N1M0) from 01/2017 to 06/2021 at our Centers. All the patients underwent robotic radical cystectomy (RARC) with Y-ICNB reconfiguration. Early and late complications were collected and classified according to Clavien-Dindo. Continence and potency at 1, 3, 6 and 12 months were evaluated. At the 3rd month of follow-up patients underwent UD. Finally, in a retrospective match paired analysis the functional outcomes of Y RARC patients were compared with a cohort of open Y radical cystectomy. RESULTS: 45 patients were enrolled. Overall 30-day complications were observed in 25 (55,5%) patients and 30 to 90-days complications in 4 (8,9%). 9 patients (20%) had Clavien ≥3 complications. UDs revealed median neobladder capacity of 268 cc, with a median compliance of 13 ml/cm H20; the voiding phase showed a voiding volume and a post void residual (PVR) of 154 cc and 105 cc respectively. At 12 months of follow-up 4.4%, 15.5% and 4.4% of the patients experienced urge, stress and mix urinary incontinence respectively. The comparison between Y RARC and Y open RC revealed a higher neobladder capacity with open approach (p = 0.049) with subsequent better findings during the voiding phase in terms of maximum flow (p = 0.002), voiding volume (p = 0.001) and PVR (p = 0.01). Focusing on continence recovery, a slight trend in favor of RARC was shown without reaching the statistical significance. CONCLUSIONS: Robotic Y-ICNB is feasible and safe as shown by the low rate of postoperative complications. Satisfying UD functional outcomes are achievable, both during filling and voiding phase.

Yield Response and Physiological Adaptation of Green Bean to Photovoltaic Greenhouses.

The cultivation of the horticultural crops inside photovoltaic greenhouses (PVG) should be studied in relation to the shading cast by the photovoltaic (PV) panels on the roof. This work evaluated the green bean cultivation inside PVGs with a percentage of the greenhouse area covered with PV panels (PV cover ratio, PV R ) ranging from 25 to 100%. Three dwarf green bean cycles (Phaseolus vulgaris L., cv. Valentino) were conducted inside an iron-plastic PVG with a PV R of 50%. The average yield was 31% lower than a conventional greenhouse. Adverse effects on quality were noticed under the PV roof, including a reduction of pod weight, size, and caliber. Negative net photosynthetic assimilation rates were observed on the plants under the PV roof, which adapted by relocating more resources to the stems, increasing the specific leaf area (SLA), leaf area ratio (LAR), and the radiation use efficiency (RUE). The fresh yield increased by 0.44% for each additional 1% of cumulated PAR. Based on the linear regressions between measured yield and cumulated PAR, a limited yield reduction of 16% was calculated inside a PVG with maximum PV R of 25%, whereas an average yield loss of 52% can occur with a PV R of 100%. The economic trade-off between energy and green bean yield can be achieved with a PV R of 10%. The same experimental approach can be used as a decision support tool to identify other crops suitable for cultivation inside PVGs and assess the agricultural sustainability of the mixed system.

Emerging trends in the photodynamic inactivation (PDI) applied to the food decontamination.

The food and drink manufacturing industry is constantly seeking for alternative sanitation and disinfection systems that may achieve the same antimicrobial efficiency of conventional chemical sanitisers and at the same time be convenient in terms of energy and water savings. A candidate technology for this purpose is the use of light in combination with photosensitisers (PS) to generate a bioactive effect against microbial agents in a process defined as photodynamic inactivation (PDI). This technology can be applied to the food processing of different food matrices to reduce the microbial load of foodborne pathogens such as bacteria, fungi, viruses and protozoa. Also, the PDI can be exploited to increase the shelf-life period of food by inactivation of spoiling microbes. This review analyses new developments in the last five years for PDI systems applied to the food decontamination from foodborne pathogens. The photosensitisation mechanisms and methods are reported to introduce the applied technology against microbial targets in food matrices. Recent blue light emitting diodes (LED) lamp systems for the PDI mediated by endogenous PS are discussed as well PDI technologies with the use of exogenous PS from plant sources such as curcumin and porphyrin-based molecules. The updated overview of the most recent developments in the PDI technology both in wavelengths and employed PS will provide further points of analysis for the advancement of the research on new competitive and effective disinfection systems in the food industry.

Fog, phenolic acids and UV-A light irradiation: A new antimicrobial treatment for decontamination of fresh produce.

This study evaluates synergistic interactions of food grade phenolic acids (gallic and ferulic acid) and UV-A light to achieve decontamination of fresh produce using a fog to improve dispersion of the phenolic acids on produce surface. Nonvirulent strains of Escherichia coli O157:H7 and Listeria innocua were used as model bacteria and spinach was selected as a model fresh produce. Synergistic combination of a fog deposited phenolic acid and a UV-A light treatment achieved reduction in bacterial plate count up to 2 log CFU/cm2 independently of the initial load of the bacteria (104 or 106 CFU/cm2). Following the treatment, fog deposited gallic and ferulic acid could be easily removed from the surface of produce by immersion in water and the treatment did not significantly alter the total endogenous phenolic content of spinach. The treatment also did not affect the texture, but impacted the color of the spinach leaves on a Hunter's Lab scale although the visual color changes were small. Overall, this technology may aid in developing alternative approaches for decontamination processes using food grade compounds.

Diagnostic Pathway with Multiparametric Magnetic Resonance Imaging Versus Standard Pathway: Results from a Randomized Prospective Study in Biopsy-naïve Patients with Suspected Prostate Cancer.

BACKGROUND: An approach based on multiparametric magnetic resonance imaging (mpMRI) might increase the detection rate (DR) of clinically significant prostate cancer (csPCa). OBJECTIVE: To compare an mpMRI-based pathway with the standard approach for the detection of prostate cancer (PCa) and csPCa. DESIGN, SETTING, AND PARTICIPANTS: Between November 2014 and April 2016, 212 biopsy-naïve patients with suspected PCa (prostate specific antigen level ≤15 ng/ml and negative digital rectal examination results) were included in this randomized clinical trial. Patients were randomized into a prebiopsy mpMRI group (arm A, n=107) or a standard biopsy (SB) group (arm B, n=105). INTERVENTION: In arm A, patients with mpMRI evidence of lesions suspected for PCa underwent mpMRI/transrectal ultrasound fusion software-guided targeted biopsy (TB) (n=81). The remaining patients in arm A (n=26) with negative mpMRI results and patients in arm B underwent 12-core SB. OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS: The primary end point was comparison of the DR of PCa and csPCa between the two arms of the study; the secondary end point was comparison of the DR between TB and SB. RESULTS AND LIMITATIONS: The overall DRs were higher in arm A versus arm B for PCa (50.5% vs 29.5%, respectively; p=0.002) and csPCa (43.9% vs 18.1%, respectively; p<0.001). Concerning the biopsy approach, that is, TB in arm A, SB in arm A, and SB in arm B, the overall DRs were significantly different for PCa (60.5% vs 19.2% vs 29.5%, respectively; p<0.001) and for csPCa (56.8% vs 3.8% vs 18.1%, respectively; p<0.001). The reproducibility of the study could have been affected by the single-center nature. CONCLUSIONS: A diagnostic pathway based on mpMRI had a higher DR than the standard pathway in both PCa and csPCa. PATIENT SUMMARY: In this randomized trial, a pathway for the diagnosis of prostate cancer based on multiparametric magnetic resonance imaging (mpMRI) was compared with the standard pathway based on random biopsy. The mpMRI-based pathway had better performance than the standard pathway.

Multiparametric-Magnetic Resonance/Ultrasound Fusion Targeted Prostate Biopsy Improves Agreement Between Biopsy and Radical Prostatectomy Gleason Score.

AIM: To investigate if targeted prostate biopsy (TBx) has superior performance to standard untargeted biopsy (SBx) in determining the optimal agreement between biopsy and surgical Gleason Score (GS). PATIENTS AND METHODS: An analysis of our institutional longitudinal database identified 683 consecutive patients who underwent either SBx (18-20 standardized transrectal ultrasound peripheral/transitional zone cores) or TBx alone (4-6 cores for each multiparametric magnetic resonance suspicious lesion, Prostate Imaging Reporting and Data System [(PI-RADS)≥3] after a previous negative first SBx. A total of 246 consecutive patients with diagnosis of prostate cancer (117 SBx and 129 TBx diagnoses) who underwent robot-assisted radical prostatectomy between January 2014 and December 2015, were enrolled. The concordance of biopsy GS to pathological GS, as well as the association between categorical variables [age, digital rectal exam (DRE), TNM, PI-RADS], were analyzed by Fisher's exact test. RESULTS: Prostate cancer was diagnosed in 32.0% of the SBx group and in 49.3% of TBx. The rate of correctly classified, up-graded and down-graded GS was 53.8% vs. 91.5%, 39.3% vs. 7.8% and 6.8% vs. 0.8% for SBx and TBx, respectively (p<0.001). The GS concordance rates for SBx and TBx cohorts were: 14.3% vs. 41.7% for GS 6, 61.0% vs. 83.8% for GS 3+4, 56.3% vs. 75.0% for GS 4+3, 27.3% vs. 100% for GS 8 and 80% vs. 100% for GS 9, respectively. CONCLUSION: TBx ensured a higher of accuracy of prostate cancer detection and a better performance in discriminating significant from insignificant prostate cancer, when compared to SBx. TBx significantly reduced the risk of GS up-/down-grading at radical prostatectomy for all histopathological categories. This is a notable advance in the selection of candidates for active surveillance.

[Ureteroscopy: is it the best?]. / Ureteroscopia: risolve molto di più?

Over the last 40 years the treatment of urolithiasis passed from open surgical therapies to minimally invasive approaches. From the introduction of the first ureteroscopes in '80s many technological improvements allowed to reduce endourological instruments' size, ensuring in the meanwhile an increasingly high success rate in the resolution of the urolithiasis. The purpose of the study is to review the current role of the ureteroscopy(URS) in the treatment of urinary stones. A non-systematic review was performed considering the most recent Guidelines and results from Literature. The results confirm that, considering ureteral calculi, the stone-free rate (SFR) for URS is significantly higher than for ESWL in the treatment of distal ureteral stones <10 mm and >10 mm. Endoscopy has a first-line role also in the treatment of proximal ureteral stones >10 mm, together with ESWL. Retreatment rate and ancillary procedures are also lower in patients treated with URS, despite it is more invasive if compared with ESWL. Recent data are available in Literature about the treatment of nephrolithiasis with Retrograde Intra-Renal Surgery (RIRS). RIRS is the first-line treatment, together with ESWL, for stones <20 mm, and second choice for stones >20 mm. However, for large renal stones the role of RIRS is still being discussed. In conclusion, the majority of urinary stones can be treated by rigid or flexible URS. Further studies are required to clarify the role of endoscopy in the treatment of large stones, especially if compared to percutaneous approaches.

Endoscopic combined intrarenal surgery in Galdakao-modified supine Valdivia position: a new standard for percutaneous nephrolithotomy?

BACKGROUND: Percutaneous nephrolithotomy (PCNL), the gold standard for the management of large and/or complex urolithiasis, is conventionally performed with the patient in the prone position, which has several drawbacks. Of the various changes in patient positioning proposed over the years, the Galdakao-modified supine Valdivia (GMSV) position seems the most beneficial. It allows simultaneous performance of PCNL and retrograde ureteroscopy (ECIRS, Endoscopic Combined Intra-Renal Surgery) and has unquestionable anaesthesiological advantages. OBJECTIVE: To prospectively analyse the safety and efficacy of endoscopic combined intrarenal surgery (ECIRS) in GMSV position for the treatment of large and/or complex urolithiasis. DESIGN, SETTING, AND PARTICIPANTS: From April 2004 to December 2007, 127 consecutive patients who were followed in our department for large and/or complex urolithiasis were selected for surgery (American Society of Anesthesiologists [ASA] score 1-3, no active urinary tract infection [UTI], any body mass index [BMI]). INTERVENTION: All the patients underwent ECIRS in GMSV position. Technical choices about percutaneous access, endoscopic instruments and accessories, and postoperative renal and ureteral drainage are detailed. MEASUREMENTS: Patients' mean age plus or minus standard deviation (+/- SD) was 53.1 yr+/-14.2. Of the 127 patients, 5.5% had congenital renal abnormalities, 3.9% had solitary kidneys, and 60.6% were symptomatic for renal colics, haematuria, and recurrent UTI. Mean stone size+/-SD was 23.8mm+/-7.3 (range: 11-40); 33.8% of the calculi were calyceal, 33.1% were pelvic, 33.1% were multiple or staghorn, and 4.7% were also ureteral. RESULTS AND LIMITATIONS: Mean operative time+/-SD was 70min+/-28, including patient positioning. Stone-free rate was 81.9% after the first treatment and was 87.4% after a second early treatment using the same percutaneous access during the same hospital stay (mean+/-SD: 5.1 d+/-2.9). We registered overall complications at 38.6% with no splanchnic injuries or deaths and no perioperative anaesthesiological problems. CONCLUSIONS: ECIRS performed in GMSV position seems to be a safe, effective, and versatile procedure with a high one-step stone-free rate, unquestionable anaesthesiological advantages, and no additional procedure-related complications.

Transcystic videolaparoscopy for choledocholithiasis with holmium: YAG laser lithotripsy. A case report.

Randomised prospective studies have shown that single-stage management of cholecysto-choledocholithiasis yields results equal or superior to sequential treatment, with a lower incidence of complications primarily associated with choledochotomy. We report the first case of transcystic Holmium:YAG laser lithotripsy using a flexible ureteroscope. The method was found to be a valuable aid in reducing the percentage of choledochotomies when calculi are too large to be retrieved from the common bile duct with normal graspers.

Treatment of the pyelocalyceal tumors with laser.

Transitional cell carcinoma of the upper urinary tract (UUT-TCC) is relatively uncommon, accounting for 2-5% of all urothelial tumors. Its incidence appears to be increasing as a result of progress in imaging, endoscopy, and improved survival from bladder cancer. Renal pelvis tumors represent 10% of all renal cancers. Pyelic neoplasms occur at a rate twice to four times the incidence of tumors in the ureter, where the common site is the distal tract (about 70%). One third of UUT-TCC ore multifocal, and about 1% are simultaneous and bilateral. The introduction of lasers represented a big step in the diagnosis and endoscopic treatment of upper urinary tract tumors. A successful laser treatment is defined by the careful selection of the patients affected by urinary tract lesions. Usually, only patients affected by low grade and papillary lesion should be treated endoscopically with laser. Patients with high grade and invasive lesions should rather be submitted to surgical procedure. Actually, the urologist has a wide choice in laser technology (Holmium laser, Thulium laser). For a correct and safe treatment of ureteral and pyelic lesions with lasers it is mandatory to respect some technical advises. First of all, an adequate access for a good vision of ureter and renal pelvis is imperative. In fact, the urologist should always work in safety, with an optimal control of the instrumentation. Then, it is important to define the laser type and its energy level. The development in laser technology (i.e. small and flexible laser fibers) allows also a radical, safe and minimally invasive treatment of urothelial lesions using flexible ureteroscopes. Of course it is mandatory to evaluate the grade and stage of the tumors by means of the ureteroscopic biopsies: invasive tumors must be treated by immediate nephroureterectomy while the endoscopic treatment should be reserved to those patients with a solitary kidney, renal failure, bilateral tumors, severe comorbities or affected by a solitary tumors with <15 mm in diameter and of low-grade/stage.

Combined endoscopic and laparoscopic en bloc resection of the urachus and the bladder dome in a rare case of urachal carcinoma.

Urachal carcinoma is a rare neoplasm treated with surgical resection. We report a case of adenocarcinoma of the urachus treated with a new surgical technique. In a 44-year-old man affected by urachal carcinoma we performed a combined endoscopic-laparoscopic surgical en bloc resection of the urachus and bladder dome. The procedure lasted 240 min, and no postoperative complications were recorded. The patient was discharged on fourth day and the catheter was removed on eighth day. Bladder capability resulted normal with no evident physical change. Multiple bladder biopsy and computed tomography scans at 6, 12 and 18 months proved negative.

Fast and safe closing of urethra during laparoscopic radical cystectomy.

PURPOSE: To present a simple alternative technique to close the membranous urethra during laparoscopic radical cystectomy. PATIENTS AND METHODS: A series of 18 laparoscopy-assisted cystectomies were performed in our institute from November 2002 to May 2005. In order to prevent neoplastic-cell spillage, in 14 of these patients, the membranous urethra was closed with Hem-o-lok clips after careful dissection of the urethra and withdrawal of the bladder catheter. RESULTS: In all cases, one or two Hem-o-lok clips were easily, safely, and quickly positioned. The remaining length of the membranous urethra was sufficient for anastomosis with the neobladder if appropriate. In follow-up (mean 14 months), no local recurrence has been recorded. CONCLUSION: The closing of the membranous urethra with Hem-o-lok clips during laparoscopy-assisted cystectomy is in our experience a simple, fast, safe, and effective alternative that should be considered when laparoscopic radical cystectomy is performed.

Supra-ampullar cystectomy and ileal neobladder.

OBJECTIVE: This article describes both the open and laparoscopic operative techniques of supra-ampullar cystectomy (SAC). METHODS: Both open (photographs and drawings) and laparoscopic (attached DVD) SAC are explained step by step. RESULTS: Between May 1984 and December 2005, 31 patients with bladder tumour underwent SAC with ileal orthotopic neobladder (2 Camey I, 26 Camey II, and 3 Y). Three patients underwent laparoscopy. Preoperatively, 26 patients had superficial high-risk transitional cell carcinoma (TCC). Median follow-up was 95.0 mo (range: 5-260 mo). The 10-yr cause-specific survival rate was 76.7%. Two patients had local recurrence. Potency was preserved in 28 patients (90.3%); 15 patients (48.3%) also maintained antegrade ejaculation, allowing procreation in 3 cases. In one patient the Camey I neobladder was converted into an ileal conduit (high postvoid residual, recurrent pyelonephritis). None of the remaining patients had daytime incontinence, eight had nightime urinary incontinence, and six performed intermittent self-catheterisation. CONCLUSION: SAC with detubularised ileal orthotopic neobladder allows preservation of sexual function and maintenance of urinary continence in most patients, without compromising oncologic outcome. The key element is the very strict and careful preoperative selection of the patients.

Transcapsular adenomectomy(Millin): a comparative study, extraperitoneal laparoscopy versus open surgery.

OBJECTIVE: To demonstrate the safety of the Millin extraperitoneal laparoscopic adenomectomy by comparing the laparoscopic and open approaches. METHODS: From January 2003 to April 2005, patients, with indication of prostatic adenomectomy, were offered the chance to choose between 2 types of procedure: Millin adenomectomy with open or extraperitoneal laparoscopic approach. Forty patients were included in this prospective non-randomised study. The patients were divided into 2 Groups. Group A (20 patients) underwent extraperitoneal laparoscopic adenomectomy, while Group B (20 patients) was treated by open surgery. Pre-operative, peri-operative and post-operative parameters were evaluated. Group A was subdivided in two sub-groups (first ten and last ten) and peri-operative parameters were considered in order to determine the learning curve. RESULTS: In terms of pre-operative parameters considered, the 2 study groups are comparable (p>0.3). As far as peri and post-operative parameters are concerned: mean blood loss for Group A was 411.6+/-419 ml, for Group B 687.5+/-298.6 ml (p=0.004). For all the other parameters no significant statistical differences were recorded (p>0.4). Mean operative time was 107.2+/-34.9 min in Group A, and 95.5+/-22.5 min in Group B. Mean adenoma weight in Group A was: 69,5+/-21.5 g, in Group B: 88.1+/-43.8 g. Mean haemoglobin levels in Group A was: 11.2+/-1.8 g/dl, Group B: 11.6+/-1.2 (10-13.4) g/dl. Mean Analgesic consuming (Tramadol) during the post-operative stay was 385+/-36 mg in Group A, versus 430+/-108 mg in Group B. Mean catheterization time was 6.3+/-3.7 days in Group A, 5.6+/-1.1 days in Group B. The mean hospital stay was 7.8+/-4.1 days in Group A, and 7+/-1.6 days in Group B. One patient (5%) from Group A was re-operated for bleeding and clot retention, whilst in Group B patients did not present complications which required any further intervention. As far as peri-operative and post-operative parameters of the two sub-Groups A (first ten patients and last ten patients) are concerned, the statistical evaluation shows a significant difference only on operative time (p=0.01). The p-value for the other parameters was not significant (p>0.1). CONCLUSIONS: The extraperitoneal laparoscopic adenomectomy is a safe technique presenting results comparable to open surgery with the advantage of significantly lower peri-operative blood loss.

Real time ultrasound in laparoscopic bladder diverticulectomy.

We describe our technique of laparoscopic diverticulectomy under ultrasound (US) guidance after a transurethral resection of prostate (TURP) in the treatment of patients with benign prostatic hyperplasia and bladder diverticulum. A standard TURP is performed with an Iglesias resectoscope. A 12-Fr Foley catheter is positioned in the diverticulum and the catheter balloon is then inflated with 30 mL of water; then a Tiemann catheter is placed through the urethra into the bladder. A US probe is inserted through the 12 mm port placed in the right side by the surgeon, then laparoscopic transperitoneal bladder diverticulectomy is performed under US guidance. In our experience, the use of endolaparoscopic US makes identification and dissection of the diverticulum easy, safe and effective, even when the procedure has to be performed in disadvantageous anatomic conditions such as lateral-posterior diverticulum or post-TURP imbibition of pelvic tissue.

Early ligature of renal artery during radical laparoscopic transperitoneal nephrectomy: description of standard technique and direct access.

PURPOSE: We compared two techniques of early ligature of the renal artery during transperitoneal laparoscopic radical nephrectomy: a standard technique and a direct approach to the artery. PATIENTS AND METHODS: Of 100 patients undergoing transperitoneal laparoscopic radical nephrectomy at our institution, in the last 70, we used early renal-artery ligature. Of these, the standard technique after exposure of the vascular pedicle was used in 45 patients (group A), and ligature with a direct access to the renal artery was attempted in 25 patients (group B). RESULTS: No statistical differences were noted between the two groups in terms of age, lesion size, operative time, estimated blood loss, or intraoperative and postoperative complications. There were no recurrences of disease by CT evaluation in either group during follow-up (range 1-46 months). CONCLUSIONS: Transperitoneal laparoscopic radical nephrectomy with direct access to renal artery for early ligature is technically difficult but feasible and safe.