[Laparoscopic repair of rectovesical fistula after radical retropubic prostatectomy]. / Riparazione laparoscopica di fistola retto vescicale post prostatectomia radicale retropubica.

INTRODUCTION: We present the video of a laparoscopic repair of a rectovesical fistula after radical retropubic prostatectomy. The rectal lesion had not been detected during the first procedure. The rectal bladder fistula appeared on the 14th post-operative day. After three weeks from the procedure,the patient underwent a laparoscopic repair of the rectovesical fistula. A temporary external colon conduit was performed at the same time. MATERIALS AND METHODS: We performed a cystoscopy before the surgery; it showed a fistula behind the bladder neck at 5 o'clock, distally to the left ureteral orifice. Two ureteral stents were inserted into both the ureters to make sure not to determine any injury to these structures during the operation. With the patient in the supine position, we introduced 5 trocars with the Hasson technique trans-peritoneally. The pouch of Douglas was opened and the bladder was divided from the rectum.The bladder posterior wall was widely opened till reaching the rectal bladder fistula.The fistula was located distally to the left ureteral orifice, very close to the bladder neck. Through a blunt dissection, we divided the margins of the rectal fistula from those of the posterior bladder wall.Indeed, we performed a suture of the rectal wall without any tension. The rectal lesion was closed in a double-layer suture with 3-0 Vicryl.We introduced a probe into the rectum to make sure there was no leakage on the suture. A flap of peritoneum of the Douglas was put between bladder and rectum.We closed the longitudinal opening of the trigone and the bladder posterior wall through a continuous suture.An external colic conduit was packaged to guarantee the closure of the fistula. The left colon was put through the abdominal wall widening the 5 mm trocar opening located on the left pararectal space. RESULTS: The operative time was 240 minutes. There were no post-operative complications. The bladder catheter was removed at 1 month after surgery,only after performing a cystography, which showed no leakage.Two months later, the colostomy was closed. At a 12-month follow-up the patient had no fistula recurrence. CONCLUSIONS: The treatment of arectovesical fistula after radical prostatectomy remains a complex procedure: different types of corrective surgical approaches have been described. The laparoscopic approach is an alternative to standard procedures. The optical magnification allows a good view of the fistula in a very deep and narrow space. It also allows easy performing of the colostomy.

Proposal for reclassification of the TNM staging system in patients with locally advanced (pT3-4) renal cell carcinoma according to the cancer-related outcome.

OBJECTIVES: The optimal stratification of locally advanced renal cell carcinoma (RCC) is controversial, with the prognostic relevance of ipsilateral adrenal gland invasion and cranial extension of vena cava thrombosis being the most debatable issues. We evaluated the prognosis of patients with locally advanced RCC and identified a new model to stratify their outcome. MATERIALS AND METHODS: We analyzed the data of 227 patients who had undergone partial or radical nephrectomy for pT3-4 RCC at two academic centers between 1986 and 2002. The log-rank test and Cox proportional hazards model were used for univariate and multivariate analysis, respectively. RESULTS: At a median follow-up of 29 mo, we censored 108 (47.6%) cancer-related deaths. On univariate analysis, the 2002 T stage was not statistically significant. According to cancer-related outcome, we identified three subgroups of patients with different prognoses: pT3a(n): tumors with perirenal fat invasion or renal vein thrombosis or thrombosis within the vena cava below the diaphragm; pT3b(n): tumors with renal vein thrombosis or thrombosis within the vena cava below the diaphragm and concomitant perirenal fat invasion; pT4(n): adrenal gland or Gerota fascia invasion or thrombosis within the vena cava above the diaphragm. The three subgroups had significantly different prognoses. The new reclassification was an independent predictive variable on multivariate analysis, as well as the pathologic lymph node stage. CONCLUSIONS: The 2002 version of TNM of locally advanced RCC did not stratify patient outcome. The present study suggests the possibility of reclassifying pT3-4 RCC into three categories capable of predicting cancer-specific survival, regardless of all other prognostic factors.