Late Recurrences Following Radical Cystectomy Have Distinct Prognostic and Management Considerations.

PURPOSE: Disease recurrence after radical cystectomy generally occurs within 2 years and has a poor prognosis. Less well defined are the outcomes in patients who experience a late recurrence (more than 3 years after radical cystectomy). We report our institutional experience with late recurrences and describe the relationships between time to recurrence, management strategies and survival. MATERIALS AND METHODS: The study cohort comprised 2,315 patients who underwent radical cystectomy for urothelial carcinoma at our center between 2000 and 2014, of whom 617 had a recurrence. Median followup for survivors was 2.6 years after recurrence (IQR 0.95-4.5). For the study we considered disease recurrence as recurrences outside the urinary tract. We compared baseline characteristics and post-recurrence management between those with recurrence 3 or less and more than 3 years after radical cystectomy. RESULTS: A total of 58 patients with late recurrence had significantly lower consensus T stage and lower frequency of nodal involvement. The average 1-year bladder cancer death rate from the time of recurrence declined from 66% to 50% to 33% for patients with recurrence times of 6 months, 2 years, and 5 years after radical cystectomy, respectively. For patients who survived at least 1 year after recurrence, the estimated survival at 5 years after recurrence was 45% for those with late recurrence and 21% for patients who had an early recurrence. Local consolidative therapy (metastasectomy or radiation) was more common in patients with late recurrence (19% vs 3.6%, p <0.0001). Cancer specific survival in early recurring cases was significantly worse than in late recurring cases in the subset receiving local consolidation (p=0.02). CONCLUSIONS: The prolonged lifespan of patients experiencing a late recurrence after radical cystectomy can be leveraged to individualize management. There is strong rationale for investigating the role of metastasectomy in the management of late recurrences.

Urotensin II receptor expression in prostate cancer patients: A new possible marker.

BACKGROUND: Urotensin II receptor has been poorly studied in prostate cancer. To evaluate the expression of urotensin II receptor (UII-R) in patients undergoing radical prostatectomy. METHODS: Overall, we identified 140 patients treated with retropubic radical prostatectomy (RP) in one center. UII-R was evaluated in prostate biopsies with immunohistochemical staining, resulting in a granular cytoplasmic positivity, through automated system using the kit Urotensin II Receptor Detection System provided by Pharmabullet srl. Immunostained slides were independently and blindly evaluated by ten uro-pathologists. To evaluate UTII-R expression three different parameters were considered: localization, granules dimensions and intensity of expression. A score from 0 to 3 was applied to each parameter to obtain a score from 0 to 9. Each parameter and the total score were evaluated as predictors of high grade disease on surgical pathology and of advanced stage disease. Accuracy of total score for the prediction of upgrading and upstaging was analyzed using receiver operator characteristics curve and decision curve analysis (DCA). RESULTS: On radical prostatectomy 92/140 (66%) presented high grade disease on surgical pathology. Patients with high grade disease presented an apical distribution of the receptor, larger granules and a more intense expression when compared to patients with low grade disease. A well they presented a higher total score. Subscores and total scores were found to be predictors of upgrading and upstaging. On ROC analysis total score presented an AUC of 0.72 and 0.70, respectively, for the prediction of upgrading and upstaging. On DCA total score showed a clinical benefit in the prediction of adverse pathological outcomes. CONCLUSION: Urotensin II receptor is a potential marker of adverse pathological outcomes. Further studies should confirm our data and evaluate its role as a prognostic marker.

Primary Malignant Melanoma of the Bladder.

A 81-year-old man was admitted to our university for a second opinion after diagnosis of bladder melanoma in December 2014. His medical history included arterial hypertension, hypothyroidism, peripheral arterial disease treated with a bypass, and corneal transplantation. His medical history was negative for malignant melanoma. He experienced gross hematuria in the absence of any other clinical manifestations, and urine cytology identified atypical cells. The patient underwent transurethral resection of the bladder with diagnosis of melanoma.

Vesicourethral anastomosis using a novel telesurgical system with haptic sensation, the Telelap Alf-X: a pilot study.

Vesicourethral anastomosis is a necessary part of radical prostatectomy and presents technical challenges when performed endoscopically. This study demonstrates the feasibility of the van Velthoven anastomosis method in swine model using a novel telesurgical system with haptic sensation: the Telelap Alf-X. Twenty vesicourethral anastomoses were performed using the system in female swine with two working ports and a camera. With two 2.0 Vicryl, a single knot vesicourethral anastomosis was performed as described by van Velthoven with Telelap Alf-X. The time of each operation was recorded, water tightness and tension were examined at the end of the procedure by irrigation through a 12 Fr catheter. The 1:1 haptic sensation, improved ergonomy, the open architecture of the robotic system, and articulated handles contributed to the easiness of performance and short learning curve, as the time of the procedure decreased by 50% after the first 5 cases. All the anastomoses were functional and proved to be successful and watertight. No leakage occurred. The novel features of the Telelap Alf-X contribute to its ease of use and make the telesurgical performance of vesicourethral anastomosis similar to open surgery, without the disadvantages of the latter.

Experimental Nephrectomies Using a Novel Telesurgical System: (The Telelap ALF-X)-A Pilot Study.

PURPOSE: The SOFAR® Telelap Alf-X (Milan, Italy) is a novel telesurgical system which combines the advantages of both laparoscopy and open surgery. It offers some new features like tactile perception, open site view, eye-tracking control of the camera, and optimal ergonomics. OBJECTIVE: The aim of this study is to examine the feasibility and the safety of nephrectomy using a novel telesurgical system with haptic sensation: the Telelap Alf-X. MATERIALS AND METHODS: Twelve female swine underwent nephrectomies using the Telelap Alf-X system. Data regarding operative times, estimated blood loss (EBL), surgical methodology, and intraoperative complications are presented. RESULTS: The Telelap Alf-X's docking took less than one minute, the system was versatile during each step of the nephrectomy and the operative times have reduced dramatically along the learning curve. One intraoperative complication was recorded (Vena Cava injury-repaired using the robotic system) and the estimated blood loss was minimal. CONCLUSIONS: The Telelap Alf-X proved to be safe and reliable and can be easily used by the surgeon. The porcine model nephrectomies proved to be an excellent way to gain experience and avoid future complications.

York Mason procedure to repair iatrogenic rectourinary fistula: our experience.

BACKGROUND: Rectourinary fistula (RUF) is an uncommon but devastating condition in men. It usually occurs as a complication of prostatic cancer treatment, whether this is by radiation therapy or surgery. It can also occur in patients with benign pathology of the prostate, inflammatory bowel disease, or Fournier's gangrene, and following pelvic trauma. RUF represents a challenge for the surgeon because spontaneous closure is a rare event. Several techniques have been described for surgical repair of fistula. The goal of the present study was to demonstrate that the York Mason posterior, transrectal correction of an iatrogenic RUF is a reliable approach that offers good postoperative outcomes. METHODS: We retrospectively reviewed the medical records of 39 patients who underwent York Mason repair from 1998 to 2012 at the University of Southern California (USC) and Campus Bio-Medico University of Rome (UCBM). The most frequent common causes of RUF were itemized, and statistical analysis was performed to determine correlations between the fistula's etiology and surgical outcome. Patients were then divided into two different cohorts: those who had undergone only one previous procedure (group 1) and those who had undergone two or more surgeries (group 2). We performed a statistical analysis between the two groups and calculated the percentage of fistula repair by means of the posterior trans-sphincteric approach with the York Mason technique in each groups We evaluated the presence of comorbidities (diabetes and infection) and their influence on the surgical outcome. Finally, we reported patient outcomes during follow-up. RESULTS: In the present series, the RUF was iatrogenic in every case. The onset of the fistula followed prostate cancer treatment, most commonly after laparoscopic procedures. The success rate of fistula repair was found to be independent of the fistula's etiology. Diabetes and infections did not influence the surgical outcome. Overall, more than 50 % of patients treated with the York Mason posterior, transanal, transrectal approach remained free of fistula during follow-up. Almost 90 % of those who were previously operated only once remained free of fistula. CONCLUSIONS: The posterior trans-sphincteric approach of the York Mason technique is effective in treating RUF.

Wunderlich syndrome, an unexpected urological complication in a patient with coronavirus disease 2019 (COVID-19): A case report.

We describe the first case of Wunderlich syndrome as a hemorrhagic complication in a patient with severe acute respiratory syndrome coronavirus 2 infection and acute respiratory distress syndrome. The possible underlying pathophysiological mechanisms have been extensively discussed. Emergency management included selective angioembolization of the upper polar arterial branches of the left kidney and discontinuation of thromboprophylaxis. The patient was discharged after 18 days. No other localizations or local recurrence of bleeding occurred during the hospitalization. Our report suggests a broad spectrum of clinical manifestations in patients with coronavirus disease 2019. As observed in our clinical case, in addition to thrombotic complications, bleeding is a significant cause of morbidity in coronavirus disease 2019 patients. Further studies should determine whether these urological bleeding sequelae are a direct manifestation of the infection or an indirect effect of thromboprophylaxis.

Bipolar plasma enucleation of the prostate vs. open prostatectomy in large benign prostatic hyperplasia: a single centre 3-year comparison.

BACKROUND: Aim of our study is to compare the surgery outcomes and safety of button bipolar enucleation of the prostate vs. open prostatectomy in patients with large prostates (> 80 g) in a single-centre cohort study. MATERIALS AND METHODS: All patients with lower urinary tract symptoms due to benign prostatic enlargement undergoing button bipolar enucleation of the prostate (B-TUEP) or open prostatectomy (OP) between May 2012 and December 2013 were enroled in our study. Data on clinical history, physical examination, urinary symptoms, erectile function, uroflowmetry and prostate volume were collected at 0, 1, 3, 6, 12, 24 and 36 months. Early and long-term complications were recorded. RESULTS: Overall, 240 patients were enroled. Out of them 111 patients (46%) performed an OP and 129 patients (54%) performed a B-TUEP. In terms of efficacy, both procedures showed durable results at three years with a reintervention rate of 7.5% in the OP group and 5% in the B-TUEP group. In terms of safety, B-TUEP presented less high-grade complications when compared with OP. CONCLUSIONS: In our single-centre study, B-TUEP represents a valid alternative to OP with excellent outcomes at three years. Further multicentre studies should confirm our results.

Narrow Band Imaging reduces persistence of cancer in patients with pT1 high grade bladder cancer.

PURPOSE: To evaluate persistence rate on repeated transurethral resection of the bladder (re-TURB) 6 weeks after the first TURB in patients with pT1HG disease undergoing resection of the margins and bed on Narrow Band Imaging. MATERIALS AND METHODS: A consecutive series of patients undergoing TURB and a diagnosis of pT1 high grade disease were prospectively enrolled. On initial TURB patients underwent classic white light resection of the tumour followed by narrow band image (NBI) resection of margins and bed. After 6 weeks from the initial TURB, patients underwent a re-TURB under white light. Persistence rates on re-TURB were recorded. RESULTS: Overall 797 patients underwent TURB, out of them 126 patients with pT1 high grade disease were included in the study. The total number of lesions was 226 meaning 1.79 lesions per patient. On re-TURB 24/126 (19%) of the patients presented residual disease with a total of 28/226 (12%) lesions identified. All these patients presented a pTa residual disease. Out of them 8/21 (38%) presented bladder cancer on the resection bed and 13/21 (62%) presented bladder cancer on margins. CONCLUSION: Narrow Band Imaging trans-urethral resection of the bladder is an oncological effective procedure in the treatment of pT1HG disease. The procedure has a 19% of persistence rate which is inferior when compared to the available evidence on white light TURB. Further multicenter studies are needed in order to validate our results.

Robotic "Side Hole" Technique Placement of Ureteral Stent for Ureteral Lesion.

A 67-year-old patient underwent robotic-assisted laparoscopic radical prostatectomy and experienced right ureteral lesion. The laceration was recognized intraoperatively and immediately repaired over the ureteral double J stent. The wire and the stent were first advanced distally to the bladder. Then the wire was pulled with its soft end, cranially through one of the side holes of the proximal end of the stent toward the kidney allowing exact positioning of the stent. Postoperative hospitalization was similar to a classic laparoscopic robotic-assisted prostatectomy. Robotic approach and the "side hole" technique represent an accurate and safe option in case of ureteral laceration management.

Bipolar Plasma Enucleation of the Prostate (B-TUEP) in Benign Prostate Hypertrophy Treatment: 3-Year Results.

OBJECTIVE: To investigate numerous endoscopic techniques that have been described for the treatment of benign prostate enlargement. Plasma-button enucleation of the prostate (B-TUEP) is a successful treatment option because the large surface creates a fast enucleation process, vaporization, and concomitant hemostasis. The aim of this study was to evaluate the efficacy of bipolar button electrode transurethral adenoma enucleation (B-TUEP) in saline solution. The second end point was to determine the change of International Prostate Symptom Score (IPSS), post-void residual urine, International Index of Erectile Function, transrectal ultrasound gland volume evaluation, and prostate-specific antigen. MATERIALS AND METHODS: Between July 2011 and March 2012, 50 consecutive patients underwent B-TUEP in our facility, all performed by a single surgeon (R.G.). All patients were preoperatively assessed with maximum urinary flow rate, single-question quality of life assessment, IPSS and the International Index of Erectile Function questionnaires, transrectal ultrasound gland volume evaluation, prostate-specific antigen, and post-void residual urine. RESULTS: We observed a significant improvement at 12, 24, and 36 months in terms of maximum urinary flow rate (22.3 ± 4.74 mL/s, 23.2 ± 0.30 mL/s, and 23.6 ± 1.26 mL/s, respectively, P <.01) and quality of life (5.28 ± 0.97, 5.69 ± 0.90, and 5.73 ± 0.87). IPSS and IEEF scores improved significantly (P <.05). Gland volume evaluation and post-void residue decreased (P <.001). The prostate-specific postoperative antigen levels were 0.76 ± 0.61 ng/mL, 0.7 ± 0.51 ng/mL, and 0.62 ± 0.18 ng/mL, at 12, 24, and 36 months, respectively. Two patients (4%) had persistent bladder outlet obstruction requiring reoperation. CONCLUSION: After 3-year follow-up, B-TUEP represents an effective, durable, and safe form of surgical intervention. B-TUEP is an alternative treatment for symptomatic benign prostate enlargement.

Robotic-assisted laparoscopic approach in the treatment for Zinner's Syndrome associated with ipsilateral megaureter and incomplete double-crossed ectopic ureter.

To report a rare congenital anomaly of the genitourinary tract, renal dysplasia is associated with ipsilateral incomplete duplicated ectopic ureter and seminal vesicle cyst in an adult, successfully treated with robotic-assisted laparoscopic approach.

Robotic-assisted simple prostatectomy with clamping of bilateral hypogastric arteries.

To present a case of laparoscopic robotic-assisted simple prostatectomy with temporary clamping of the bilateral hypogastric arteries. A 74-year-old patient with large prostatic adenoma (> 80 ml) underwent robotic-assisted laparoscopic transvesical adenoma enucleation according to Sotelo's technique. The hypogastric arteries were isolated just below the ureteral cross with the iliac vessels and bilaterally occluded for 12 minutes during enucleation of the adenoma. The patient's pain was mild after surgery and he required short-term analgesics and antibiotic prophylaxis. Blood loss was 80 ml. The transient occlusion of the internal iliac arteries is a proven maneuver to reduce bleeding during pelvic surgery. We propose the temporary clamping of the bilateral internal iliac arteries as a safe and rapid surgical maneuver to reduce the intraoperative risk of bleeding, especially when performing first procedures.

The differentiation of humane adult mesenchimal stem cells of bone marrow (hMSC) into urothelial cells on bio-engineering support (scaffold): preliminary experience of tissue engineering.

OBJECTIVES: Tissue Engineering can develop scaffolds of Poly-L-Lactic Acid (PLLA) for tissue regeneration. The purpose of the present job is to test the possibility to seed human adult mesenchymal stem cells on a scaffold supplemented with specific grow factors to differentiate them into urothelium. METHODS: The Electrospinning technique was used to realize three scaffolds. The first one was seeded with urothelial cells, of a primary culture, and Keratinocyte serum free medium (KSFM); the second one was seeded with human mesenchymal stem cells (hMSC) and a minimum essential medium (aMEM); the third one was seeded with hMSC and conditioned medium. RESULTS: Electron microscopy showed scaffolds with cellular vitality (>90%) and their cellular proliferation. Moreover, the differentiation of hMSC, seeded in conditioned medium, into urothelial cells was demonstrated through immunofluorescence assays. CONCLUSIONS: Tissue Engineering can develop PLLA scaffolds thanks to the Electrospinning technique. The scaffold is a perfect environment for cellular culture and proliferation; a protocol for the differentiation of hMSC into urothelial cells is now available. Immunofluorescence assays can demonstrate the hMSC differentiation into urothelial cells.