The role of diagnostic ureteroscopy in the era of computed tomography urography.

BACKGROUND: To examine the contemporary role of ureteroscopy in the diagnosis of upper urinary tract urothelial carcinoma. METHODS: We retrospectively evaluated 116 diagnostic ureteroscopies, performed in our institution to rule out primary UTUC. Demographics, cytological findings and interpretation of preoperative imaging were obtained. Ureteroscopic diagnosis and histological results were recorded and the predictive values of diagnostic studies were determined. Follow-up data was reviewed to evaluate the oncological outcomes in patients treated endoscopically. RESULTS: The pre-ureteroscopic evaluation included CTU in 91 (78%) patients. Positive and Negative predictive values of CTU were 76 and 80%, respectively. Typical filling defect on CTU was demonstrated in 38 of 89 patients. UTUC has been ruled out in 9 patients (24%) with suspicious filling defect on CTU. Endoscopic approach was implemented in 7 patients (18%). During a median follow up period of 17 months (IQR, 9-25) none of the followed patients experienced disease progression. CONCLUSIONS: Nephroureterectomy was spared from 42% of patients who underwent diagnostic ureteroscopy for suspected UTUC, demonstrated on CTU. In about half of those patients tumor has been ruled out and the others were managed endoscopically. Therefore, diagnostic ureteroscopy is advised as a crucial step in confirming UTUC and treatment planning.

Laparoscopic partial nephrectomy (LPN) for totally intrarenal tumours.

OBJECTIVE: To evaluate the feasibility and outcomes of laparoscopic partial nephrectomy (LPN) for totally intrarenal tumours (TIT). PATIENTS AND METHODS: TIT were defined as completely intraparenchymatic masses, without any exophytic element. Identification of such a tumour necessitates guidance of intraoperative laparoscopic ultrasonography. Data of patients with TIT who underwent LPN was collected from our Ethical Committee-approved database. Their data was compared with that of patients who underwent LPN for tumours with any degree of exophytic element. The two groups were compared for preoperative data (age, gender, tumour size and location), intraoperative variables (warm ischemia time [WIT], open conversions rate, radical nephrectomy [RN] rate, blood loss and other complications), and postoperative data (renal function, reoperation rates, pathological results, and incidence of positive surgical margins). RESULTS: Among 458 patients who underwent LPN, 41 had TIT. The mean (sd) tumour size was 2.6 (0.8) cm, mean WIT was 22.6 (13.8) min and blood loss was 279 (210) mL. The RN rate was significantly higher in the TIT group compared with the remaining cohort of LPNs (9.7% vs 5.3%). The intra- and postoperative complications, open conversion and positive margin rates were similar between the two groups. Malignant tumours were found in 84.2% and 78.2%, respectively. CONCLUSIONS: LPN for a TIT is technically feasible. TIT carry a significantly higher RN rate due to tumour involvement of vital kidney structures. This aspect should be discussed with the patient preoperatively but TIT should not be considered a definitive indication for RN.

Ex vivo organotypic cultures for synergistic therapy prioritization identify patient-specific responses to combined MEK and Src inhibition in colorectal cancer.

Translating preclinical studies to effective treatment protocols and identifying specific therapeutic responses in individuals with cancer is challenging. This may arise due to the complex genetic makeup of tumor cells and the impact of their multifaceted tumor microenvironment on drug response. To find new clinically relevant drug combinations for colorectal cancer (CRC), we prioritized the top five synergistic combinations from a large in vitro screen for ex vivo testing on 29 freshly resected human CRC tumors and found that only the combination of mitogen-activated protein kinase kinase (MEK) and proto-oncogene tyrosine-protein kinase Src (Src) inhibition was effective when tested ex vivo. Pretreatment phosphorylated Src (pSrc) was identified as a predictive biomarker for MEK and Src inhibition only in the absence of KRASG12 mutations. Overall, we demonstrate the potential of using ex vivo platforms to identify drug combinations and discover MEK and Src dual inhibition as an effective drug combination in a predefined subset of individuals with CRC.

Multidisciplinary team approach to management of severe endometriosis affecting the ureter: long-term outcome data and treatment algorithm.

STUDY OBJECTIVE: To examine the efficiency of laparoscopic ureterolysis for ureteral endometriosis and to describe appropriate treatment. DESIGN: Prospective trial (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Forty-five patients who underwent surgery to treat ureteral endometriosis between 2005 and 2009. INTERVENTION: Laparoscopic ureteral ureterolysis. MEASUREMENTS AND MAIN RESULTS: Long-term follow up of symptoms, urinary tract anatomy and function, and the need for further intervention were performed. Ureteral endometriosis was observed in 14.2% of 315 patients with endometriosis. Of the 45 study patients, 95.5% had dysmenorrhea, 60% had dyspareunia, and 45% were infertile. Half of the patients had previously undergone laparoscopic procedures. Urinary tract symptoms were present in 15.9% of patients. Preoperative hydronephrosis or hydroureter was observed in 10 patients (22.2%), and impaired urinary function in 2 patients (4.4%). Laparoscopy demonstrated left ureteral involvement in 82.2% of patients, and deep infiltrative endometriosis in 80%. Laparoscopic ureterolysis was feasible in 91.1% of patients. In 4 patients, ureterolysis was not feasible, and primary reimplantation of the ureter was performed. Forty-one patients (91.1%) had no symptoms or had marked improvement postoperatively and required no further treatment. Two patients (4.8%) underwent repeat surgery. In 80% of patients with hydroureteronephrosis, the postoperative sonogram was normal. CONCLUSIONS: Ureteral endometriosis can be treated effectively using laparoscopic ureterolysis in almost all patients. Different treatment approaches should be based on the results of preoperative evaluation and operative findings by a multidisciplinary team. Urinary assessment is crucial because most patients demonstrate no urinary tract symptoms and initial renal investigation can prevent irreversible damage.

Dynamic 68Ga-PSMA-11 PET/CT for the Primary Evaluation of Localized Renal Mass: A Prospective Study.

The potential role of prostate-specific membrane antigen (PSMA) PET/CT in non-prostate cancer tumors has shown promising results. We examined the performance of dynamic 68Ga-PSMA-11 PET/CT (DPSMA) for the evaluation of localized renal mass. Methods: A prospective case series of patients with a newly diagnosed renal mass who were referred for surgery was examined. DPSMA was performed in a standardized manner before surgery. The final surgical histology served as the standard of reference. PSMA expression in the tumor vasculature was assessed and staining intensity was scored. Tracer uptake and PSMA expression were compared between benign and malignant tissue. Results: Of 29 enhancing renal masses evaluated in 27 patients, 24 (83%) were malignant lesions. The median SUVmean of benign and malignant lesions was 2.3 (interquartile range [IQR], 2.2-2.7) and 6.8 (IQR, 4.2-10.1), respectively (P = 0.009). Median SUVmax of benign and malignant lesions was 3.8 (IQR, 3.3-4.5) and 9.4 (IQR, 5.4-15.8), respectively (P = 0.015). The median washout coefficient (K2) was significantly lower in malignant lesions than in benign lesions (0.17 vs. 0.70, P = 0.02). Positive PSMA staining was found in 20 of 24 malignant lesions and in 2 of 5 benign lesions (P = 0.04). Conclusion: This pilot study demonstrated DPSMA uptake and kinetics in localized renal masses. Increased 68Ga-PSMA-11 tracer uptake and intratumoral retention correlate with PSMA expression in malignant renal tumors compared with benign renal masses, supporting further assessment of DPSMA as a potential tool for evaluating localized renal masses.

Laparoscopic partial nephrectomy for central tumors: analysis of perioperative outcomes and complications.

PURPOSE: We report our experience with laparoscopic partial nephrectomy for central tumors compared to peripheral tumors to analyze the feasibility and safety of the laparoscopic approach to these complex cases. MATERIALS AND METHODS: Between October 2002 and July 2007, 212 patients underwent laparoscopic partial nephrectomy. In 53 patients the tumor was central and in 159 it was peripheral. The preoperative, intraoperative and postoperative data, the type and incidence of complications, and the quality of excision in terms of surgical margin status were compared between the 2 groups. RESULTS: Mean estimated blood loss (320 and 360 ml, respectively, p >0.05) and mean operative time (126 and 118 minutes, respectively, p >0.05) were similar in the central and peripheral tumor groups. Mean warm ischemia time in the central tumor group was longer (37 and 28 minutes, respectively, p <0.05) but median time was similar (30 and 29 minutes, respectively, p >0.05). The open conversion rate was significantly lower in the study group (1% vs 5.6%, p <0.05). The urological complication rate was similar in the 2 groups (9.4% vs 8.4%, p >0.05). However, different types of complications developed in each group. Four patients (7.5%) with central tumors had late hematuria (arterial pseudoaneurysm) and only 1 (1.9%) had a urine leak. Central tumors were larger (3.2 vs 2.5 cm) and more frequently malignant (94% vs 82%, p >0.05). Positive surgical margins were diagnosed in 0% vs 5% of cases (p <0.05). CONCLUSIONS: Provided that there is adequate laparoscopic expertise the outcome of laparoscopic partial nephrectomy for central tumors is comparable to that of peripheral tumors. The main major complication in this group was late onset hematuria, which necessitated angiographic embolization. This facility should be available at centers where these advanced procedures are performed.

Male infertility associated with adult dominant polycystic kidney disease: a case series.

INTRODUCTION: Although described earlier, the association of male infertility with adult dominant polycystic kidney disease (ADPKD) is quite rare and unfamiliar to some of the multidisciplinary team members caring for affected men. MATERIALS AND METHODS: Infertile men diagnosed to have ADPKD were evaluated by clinical characteristics including testis volume, as well as serum hormone levels, semen analysis, and transrectal ultrasonography (TRUS) because of low volume ejaculate. RESULTS: Semen analysis revealed low-normal volume, normal pH, and azoospermia/virtual azoospermia. Serum hormones were within the normal range. Transrectal ultrasonography demonstrated cystic dilatation of the seminal vesicles in all three men. CONCLUSION: Patients should be referred for andrological evaluation of a presentation similar to obstructive azoospermia. Their potential to achieve paternity by surgical sperm retrieval combined with assisted reproductive technology is another example of cooperation between andrologists and gynecologists.

Laparoscopic surgery for renal stones: is it indicated in the modern endourology era?

PURPOSE: To report the outcomes of laparoscopic surgery combined with endourological assistance for the treatment of renal stones in patients with associated anomalies of the urinary tract. To discuss the role of laparoscopy in kidney stone disease. MATERIALS AND METHODS: Thirteen patients with renal stones and concomitant urinary anomalies underwent laparoscopic stone surgery combined with ancillary endourological assistance as needed. Their data were analyzed retrospectively including stone burden, associated malformations, perioperative complications and outcomes. RESULTS: Encountered anomalies included ureteropelvic junction obstruction, horseshoe kidney, ectopic pelvic kidney, fussed-crossed ectopic kidney, and double collecting system. Treatment included laparoscopic pyeloplasty, pyelolithotomy, and nephrolithotomy combined with flexible nephroscopy and stone retrieval. Intraoperative complications were lost stones in the abdomen diagnosed in two patients during follow up. Mean number of stones removed was 12 (range 3 to 214). Stone free status was 77% (10/13) and 100% after one ancillary treatment in the remaining patients. One patient had a postoperative urinary leak managed conservatively. Laparoscopic pyeloplasty was successful in all patients according to clinical and dynamic renal scan parameters. CONCLUSIONS: In carefully selected patients, laparoscopic and endourological techniques can be successfully combined in a one procedure solution that deals with complex stone disease and repairs underlying urinary anomalies.

Diagnostic Needle Biopsies in Renal Masses: Patient and Physician Perspectives.

BACKGROUND: The utility of renal mass biopsies (RMB) in the diagnosis of kidney tumors remains debatable. OBJECTIVE: To assess patient and urologist preferences regarding the utilization of RMB. DESIGN, SETTING, AND PARTICIPANTS: Seventy-three patients diagnosed with renal tumors and 59 board-certified urologists were asked to participate in an interview-based study. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Using the standard gamble method we determined the minimal accepted accuracy at which RMB would be favored as part of the diagnostic process. Clinical and demographic data with potential to affect participants' preferences were analyzed. RESULTS AND LIMITATIONS: At the time of the study interview, 56 patients (77%) were referred for kidney surgery and 17 (23%) opted for surveillance. Overall, 59% of the patients accepted some level of inaccuracy (1-20%), whereas 27% refuted a biopsy. Anxiety associated with the possibility of missing cancer was the primary determinant (82%) for declining RMB among patients referred for surgery, while fear of complications was the primary reason (58%) among those undergoing surveillance. Having an academic degree was associated with a lower accuracy threshold (p=0.03). Of the 59 participating urologists, 39% were reluctant to recommend RMB, primarily because of its inexorable nondiagnostic rate. CONCLUSIONS: Most patients and urologists would favor RMB to facilitate their definitive treatment decision. Diagnostic accuracy of 95% was acceptable by the majority of study participants. The utility of RMB as part of the diagnostic algorithm for renal tumors should be discussed with patients, emphasizing its potential benefits and limitations. PATIENT SUMMARY: Although needle biopsy seems to be an effective tool to differentiate benign from malignant kidney lesions, it is not commonly used. Our study shows that most patients would opt for a biopsy before definitive treatment decision despite its imperfect accuracy. Hence, the option of undergoing renal biopsy should be discussed with all patients diagnosed with small renal tumors.

Patient Compliance With Maintenance Intravesical Therapy for Nonmuscle Invasive Bladder Cancer.

OBJECTIVE: To assess patient adherence to intravesical instillation therapy for nonmuscle invasive urothelial carcinoma outside of clinical trials. MATERIALS AND METHODS: We reviewed the records of patients from 2000 to 2013 who received intravesical therapy for nonmuscle invasive urothelial carcinoma. Patients with evidence of tumor recurrence or progression were excluded. We performed univariable and multivariable regression analyses to predict adherence to intravesical therapy. RESULTS: A total of 729 patients started 861 induction cycles, 63% with bacillus Calmette-Guèrin (BCG) and 37% with mitomycin C (MMC). The rate of completion of 6 weeks induction therapy with BCG and MMC was similar (86% and 87%, respectively). Within the BCG cohort, 161 (35%) patients commenced the Southwest Oncology Group (SWOG) maintenance protocol after induction and 16 (10%) completed all 21 treatments. A monthly protocol for BCG was started by 87 patients (19%) and 48 (55%) completed all 9 treatments. MMC therapy was started in 270 patients, 97 of whom (36%) commenced monthly maintenance treatment, and 46 (47%) completed treatments. Median number of instillations was 7 for patients undergoing monthly maintenance therapy (MMC or BCG) and 9 for patients allocated to 3 years BCG. On multivariable analysis, recurrence after prior treatment of urothelial carcinoma was predictive of patients' adherence to treatment. CONCLUSION: Compliance with intravesical therapy is low in clinical practice, notably for longer treatment schedules.

Nitric oxide charged catheters as a potential strategy for prevention of hospital acquired infections.

BACKGROUND: Catheter-Associated Hospital-Acquired Infections (HAI's) are caused by biofilm-forming bacteria. Using a novel approach, we generated anti-infective barrier on catheters by charging them with Nitric Oxide (NO), a naturally-produced gas molecule. NO is slowly released from the catheter upon contact with physiological fluids, and prevents bacterial colonization and biofilm formation onto catheter surfaces. AIMS AND METHODS: The aim of the study was to assess the anti-infective properties of NO-charged catheters exposed to low concentration (up to 103 CFU/ml) of microbial cells in-vitro. We assessed NO-charged tracheal tubes using Pseudomonas aeruginosa, dialysis and biliary catheters using Escherichia coli, and urinary catheters using E. coli, Candida albicans or Enterococcus faecalis. Safety and tolerability of NO-charged urinary catheters were evaluated in a phase 1 clinical study in 12 patients. Six patients were catheterized with NO-charged catheters (NO-group), followed by 6 patients catheterized with regular control catheters (CT-group). Comparison of safety parameters between the study groups was performed. RESULTS: NO-charged tracheal, dialysis biliary and urinary catheters prevented P. aeruginosa, E. coli and C. albicans attachment and colonization onto their surfaces and eradicated corresponding planktonic microbial cells in the surrounding media after 24-48 hours, while E. faecalis colonization onto urinary catheters was reduced by 1 log compared to controls. All patients catheterized with an NO-charged urinary catheter successfully completed the study without experiencing NO-related AE's or serious AE's (SAE's). CONCLUSION: These data highlight the potential of NO-based technology as potential platform for preventing catheter-associated HAI's.

Laparoscopic nephrectomy: initial experience in Israel with 110 cases.

BACKGROUND: Data during the last decade show that laparoscopic nephrectomy is becoming an accepted and advantageous minimally invasive alternative to the open procedure. OBJECTIVE: To evaluate the efficacy, safety and reproducibility of laparoscopic nephrectomy in a series of 110 consecutive procedures. METHODS: A total of 110 patients underwent laparoscopic nephrectomy in our institution during the last 3 years. Their data were entered into a database and analyzed, including age, gender, indications for surgery, operative time, blood loss, intraoperative complications, conversion rates, and postoperative complications (defined as complications occurring up to 1 month after surgery). Histologic results and outpatient follow-up were also recorded. RESULTS: Mean age at surgery was 63 years (range 21-89 years). The indications for surgery included solid renal masses in 64 cases, non-functioning kidneys in 35, and collecting system or ureteral tumors in 11; and the procedures performed were radical nephrectomy, simple nephrectomy, or nephroureterectomy, respectively. The mean operative time was 125 minutes (range 70-310 minutes). Intraoperative complications were recorded in eight cases (7.3%), including vascular injuries of the renal artery in two, and of the renal vein, inferior vena cava and right adrenal vein in one case each. Injury of the large bowel and splenic hylus was recorded in one case and malfunction of the vascular endoGIA stapler leading to severe bleeding in one case. Nine cases were converted to open surgery (8.2%), four of them urgently due to intraoperative complications, while in another five cases conversions were elective following poor progression of the laparoscopic procedure. Comparison of the complication rate at follow-up between the initial 50 and the last 60 patients revealed no change. The conversion rate dropped significantly along the learning curve with 7 cases converted among the initial 50 patients, versus 2 in the last 60. There was no perioperative mortality. In two cases we recorded major postoperative complications, including pneumothorax treated by insertion of a thoracic drain and incarcerated inguinal hernia treated by surgery, while minor complications were seen in five patients. Histologic examination showed renal cell carcinoma pT1-T3a in 62 patients, oncocytoma in 5, transitional cell carcinoma T1G2-T3G3N1 in 10, renal sarcoma in 1, metastasis from lung tumor in 1, and end-stage kidney in the remainder. Negative margins were obtained in all cases. CONCLUSIONS: Laparoscopic nephrectomy may be currently considered a routine, safe and effective procedure associated with minimal morbidity. The conversion rate seemed to drop significantly after 50 cases. In view of the inherent benefits for patients, in terms of reduced pain level, faster recovery and improved cosmetic results, the laparoscopic approach has become the standard approach for nephrectomy in our institution.

[The laparoscopic approach to renal tumors outcome of 121 laparoscopic radical and partial nephrectomy procedures].

BACKGROUND AND PURPOSE: We present and review a single center experience with laparoscopic renal surgery for renal cancer including laparoscopic radical and partial nephrectomy. PATIENTS AND METHODS: During the period September 2002 - January 2005, 180 patients underwent laparoscopic renal surgery at our center for several indications. A total of 121 patients underwent radical nephrectomy (76) or partial nephrectomy (45) for solid renal tumors. Their data was recorded and analyzed including age, indication for surgery, operative time, blood loss, intra- and postoperative complications, conversion rates, histological results and outpatient follow-up. RESULTS: The mean age at surgery was 65 years (range: 21-89 years). The indications for surgery were solid, enhancing renal masses. For tumors larger than 4 cm, a radical nephrectomy was performed. Tumors that were smaller than 4 cm were removed by partial nephrectomy. The mean operative time was minutes (range: 70-280 minutes) and the mean blood loss was 220 cc (range: 30-700 cc). The mean blood loss was significantly lower in the radical nephrectomy group (120 cc) than in the partial nephrectomy group (320 cc). In eight patients major intraoperative complications were noted including injury of the hilar vessels (5 cases), inferior vena cava (1 case), large bowel and spleen (one patient) and duodenum (1 case). Conversion to open surgery was needed in nine patients (7.4%), four in the radical nephrectomy and five in the partial nephrectomy group. Major postoperative complications were recorded in two patients who underwent radical nephrectomy (pneumothorax and incarcerated inguinal hernia) and in two patients who underwent partial nephrectomy (urine leakage). The pathological examination demonstrated renal cell carcinoma in 109 cases, oncocytoma in 6 cases, angiomyolipoma in 2 cases, sarcoma of the kidney and metastasis from lung cancer in one case each and a hemorrhagic cyst in one case. In all patients who underwent radical nephrectomy negative surgical margins were obtained, in three patients after partial nephrectomy the surgical margins were focally involved by tumor. The mean tumor size was 5.1 cm and 3.1 cm after radical or partial nephrectomy respectively. During follow-up, none of the patients developed local or distant recurrence. CONCLUSIONS: The laparoscopic approach to kidney cancer seems to be safe and oncologically sound. The low morbidity rate together with the inherent advantages of laparoscopic surgery make this approach attractive and we believe it should be considered the new standard of care for renal cancer.

Simple model for training in the laparoscopic vesicourethral running anastomosis.

PURPOSE: To create a simple model for training in the complex technique of laparoscopic vesicourethral anastomosis after radical prostatectomy. MATERIALS AND METHODS: A model simulating the performance of a laparoscopic running urethrovesical anastomosis was fashioned using skin of a supermarket chicken set in a laparoscopic training box. A circular continuous anastomosis was performed, following exactly the technique we use in vivo for performing a vesicourethral anastomosis after laparoscopic radical prostatectomy. Details regarding the use of the right or the left needle holder, needle positioning, precise stitch position, and use of forehand or backhand stitch were strictly respected in order to reproduce the continuous stitch currently done in vivo in our department. The learning curve was analyzed in terms of the time necessary to perform the task and the quality of the anastomosis. RESULTS: The model was created and used by the junior authors during their year of fellowship in advanced laparoscopic urology. The authors had no previous experience with hands-on laparoscopic suturing but have assisted in a great number of laparoscopic radical prostatectomies. The time required for performing the anastomosis on the model declined from 75 minutes initially to 20 minutes after the trainees had performed 20 anastomoses each. After this training, it was possible to create a watertight running laparoscopic vesicourethral anastomosis in patients in a mean time of 40 minutes (range 30-55 minutes). CONCLUSION: This simple model allows the trainee in laparoscopic urology to acquire the skills necessary to perform a laparoscopic vesicourethral anastomosis, one of the most complex steps in laparoscopic radical prostatectomy, as well as to develop dexterity and facility in laparoscopic manipulation of needles, sutures, and fragile tissues.

Laparoscopic retroperitoneal nephrectomy for Aspergillus-infected polycystic kidney.

BACKGROUND AND PURPOSE: The management of polycystic kidney disease is mostly restricted to conservative measures. However, nephrectomy may be indicated in particular cases, especially when there are infective complications. To decrease the morbidity of the procedure, the laparoscopic approach has become appealing. We present a laparoscopic retroperitoneal approach to complicated polycystic kidney disease in a high-risk patient. CASERESPORT: We performed right retroperitoneal laparoscopic nephrectomy in a 39-year-old man who had autosomal polycystic kidney disease and had undergone heart transplantation. The immunosuppressed patient presented with severe flank pain, generalized signs of infection, and acute renal insufficiency. With the patient in the right lateral decubitus position, the retroperitoneal space was entered by the open technique, and the posterior pararenal space was developed with finger dissection. Five trocars were used. After the renal vessels had been secured and divided, the cysts were successively punctured, gradually shrinking the operative specimen. The kidney was placed in an Endo-catch and removed after morcellation, with no need to enlarge the 2-cm lumbotomy. The operating time was 80 minutes, and the hospital stay was 4 days. Histologic examination revealed a polycystic kidney with Aspergillus infection. CONCLUSION: The laparoscopic approach is a less-invasive option for removing a polycystic kidney when nephrectomy is indicated. The retroperitoneal route has the advantage of minimizing infection risks because of the absence of peritoneal opening.

Are indications for prostatectomy in octogenarians the same as for younger men?

Prostatectomy for benign hypertrophy of the prostate is usually performed to alleviate lower urinary tract symptoms (LUTS). We assessed indications for and risks of prostatectomy in men 80 years of age and compared them to those for younger men in order to determine whether indications for prostatectomy in octogenarians are different than these for younger men. Medical records of 171 men comprised of 84 patients >80 years of age (mean 84.4) and 87 patients <65 years of age (mean 60.6) who underwent prostatectomy for benign prostate hypertrophy were reviewed. Data regarding indications for surgery, American Society of Anesthesiologists system grade, anesthesia and surgery performed, duration of hospitalization and intrahospital postoperative complications were obtained. The respective indications for surgery in the very elderly and younger patients were: urinary retention with indwelling catheter in 46 (55%) and 34 (39%) (p < 0.04), LUTS in 32 (38%) and 52 (59%) (p < 0.005), and gross hematuria in 6 (7%) and 1 (1.2%). Transurethral prostatectomy was performed in 47 elderly patients (56%) and in 30 young patients (34.5%). The other patients in each group underwent open (suprapubic prostatectomy) surgery. The overall complication rate was significantly higher in the elderly group (39% vs 22%, p < 0.05), with major complications occurring only in this group. Indications for surgery were different for octogenarians than for younger men. Morbidity and mortality rates were significantly higher among the elderly men. Age appears to be an independent risk factor for complications associated with prostatectomy.

[Lower urinary tract reconstruction by augmentation cystoplasty and insertion of artificial urinary sphincter cuff only: long term follow-up]. / Reconstruction du bas appareil urinaire par entérocystoplastie d'agrandissement et mise en place isolée d'une manchette de sphincter artificiel.

OBJECTIVES: To review retrospectively our long-term experience with augmentation cystoplasty and simultaneously insertion of artificial urinary sphincter cuff only for lower urinary tract reconstruction in cases of mixed bladder and sphincteric dysfunction. We tried to assess the postoperative continence status, as well as the associated morbidity, focusing upon infections, urethral erosion and revision rates. PATIENTS AND METHODS: Eleven patients with urinary incontinence due to a small capacity and low compliant bladder, combined with incompetent outlet, underwent lower urinary tract reconstruction by augmentation cystoplasty and simultaneous insertion of a bladder neck sphincter cuff only (AMS, model AS-800). Mean age was 29 years (range 18-45). The etiology of voiding dysfunction was a seminal cord injury in 6 patients, myelomeningocele in 2 and spinal cord surgery in 1, bladder exstrophy (1) and pelvic trauma combined with spinal cord injury (1). RESULTS: With mean follow-up period of 115 months (range 45-141), 8 patients (73%) achieved continence on clean intermittent catheterization without any further interventions. Two patients required insertion of sphincter pump and reservoir at a second stage to achieve full continence and subsequently one was removed due to erosion (overall continence rate of 82%). In another patient, the cuff located at the level of the bladder neck has eroded and was removed. None of the patients has experienced an infection of the device in the immediate postoperative period, neither thereafter. CONCLUSIONS: Insertion of sphincter cuff only during augmentation cystoplasty may be sufficient to achieve continence in many incontinent patients who may not be cured by bladder augmentation alone. The procedure is technically easy and is not associated with increased risk of injury to the augmented bladder, neither with subsequent infectious complications.

Simplifying laparoscopic nephrectomy: the inferior approach with en bloc stapling of the renal hilum.

INTRODUCTION: Laparoscopic nephrectomy (LN) is likely the most common laparoscopic procedure performed by general urologists without formal laparoscopic training. The traditional technique is cumbersome because it entails making an early approach to the hilum with the risk of bleeding and need for conversion. We perform a different technique that we believe is simpler to learn and to teach. It consists of a complete dissection of the inferior and posterior aspects of the kidney, followed by en bloc stapling of the renal hilum. The present report is a detailed description of our technique including outcomes and complications. MATERIALS AND METHODS: Perioperative data of 129 consecutive patients who underwent LN between November 2003 and September 2007 were prospectively collected and retrospectively reviewed. Complications were reported using the Clavien classification system, and follow-up was performed according to our institution's protocol and included physical examination, blood count, blood chemistry, and renal function tests at every visit, in addition to abdominal computed tomography scan six months after surgery. Additional imaging was scheduled according to disease stage and grade. RESULTS: Mean patient age, tumor size, and operative time were 63±15.6 years, 6.3±2.4 cm, and 128±41.4 minutes, respectively. Median estimated blood loss was 0 mL (0.200). Conversion to open surgery occurred in 3.1% of patients, and 8% of the patients had a blood transfusion. Complications were recorded in 26% of the patients; 91% of them had Clavien grade scores of 1 or 2. CONCLUSION: We present a standardized technique for LN. Its main advantage is that postpones any manipulation of the hilum to a later step during the procedure when it is easy to identify and control. This decreases early bleeding and main vascular complications.