Predictive factors of overall and major postoperative complications after partial nephrectomy: Results from a multicenter prospective study (The RECORd 1 project).

INTRODUCTION AND OBJECTIVES: To analyze postoperative complications and to assess for significant predictive factors during partial nephrectomy (PN) using a large multicenter dataset. METHODS: Patients who underwent PN for clinical T1 renal tumors at 19 urological Italian centers (Registry of Conservative Renal Surgery [RECORd] project) were evaluated between 2009 and 2012. Anthropometric data, comorbidities and perioperative outcomes were analyzed. Complications were divided as intra- and postoperative, medical and surgical, as appropriate. The severity of postoperative complications was graded according to the modified Clavien classification system. Patients who experienced intraoperative complications were excluded from the analyses for the potential confounding effect in the evaluation of predicting factors for postoperative complications. RESULTS: Overall, 979 patients were analyzed: open, laparoscopic and robot-assisted (available since 2011) surgical approaches were used in 522 (56.4%), 286 (30.9%) and 117 (12.6%) cases, respectively. Surgical postoperative complications were reported in 121 (13.1%) cases (32 (3.5%) were Clavien 3), medical were reported in 52 (5.6%) cases (3 (0.3%) were Clavien 3). No Clavien 4 complications were reported. At multivariable analysis, ECOG score ≥1 (OR 1.98; p = 0.002), lower preoperative hemoglobin (OR 0.71; p < 0.0001) and open surgical approach (2.91; p = 0.02) were significant predictive factors of overall surgical postoperative complications, ECOG score ≥1 (OR 1.93; p = 0.04) and surgical approach (p = 0.05) were significant predictive factors of Clavien 3 either surgical or medical postoperative complications. CONCLUSIONS: Comorbidities and surgical approach should be considered in preoperative evaluation of patients undergoing PN, as they resulted to play a significant role in the occurrence of postoperative complications.

A snapshot of nephron-sparing surgery in Italy: a prospective, multicenter report on clinical and perioperative outcomes (the RECORd 1 project).

INTRODUCTION: Nephron-sparing surgery (NSS) has become the standard of care for the surgical management of small and clinically localized renal cell carcinoma (RCC). The conservative management of those RCCs is increasing over time. Aim of this study was to report a snapshot of the clinical, perioperative and oncological results after NSS for RCC in Italy. MATERIAL AND METHODS: We evaluated all patients who underwent conservative surgical treatment for renal tumours between January 2009 and December 2012 at 19 urological Italian Centers (RECORd project). Perioperative, radiological and histopathological data were recorded. Surgical eras (2009 vs 2012 and year periods 2009-2010 vs 2011-2012) were compared. RESULTS: Globally, 983 patients were evaluated. More recently, patients undergoing NSS were found to be significantly younger (p = 0.05) than those surgically treated in the first study period, with a significantly higher rate of NSS with relative and imperative indication (p < 0.001). More recently, a higher percentage of procedures for cT1b or cT2 renal tumours was observed (p = 0.02). Utilization rate of open partial nephrectomy (OPN) constantly decreased during years, laparoscopic partial nephrectomy (LPN) remained almost constant while robot-assisted partial nephrectomy (RAPN) increased. The rate of clampless NSS constantly increased over time. The use of at least one haemostatic agent has been significantly more adopted in the most recent surgical era (p < 0.001). CONCLUSIONS: The utilization rate of NSS in Italy is increasing, even in elective and more complex cases. RAPN has been progressively adopted, as well as the intraoperative utilization of haemostatic agents and the rate of clampless procedures.

Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project).

OBJECTIVES: To compare simple enucleation (SE) and standard partial nephrectomy (SPN) in terms of surgical results in a multicenter dataset (RECORd Project). MATERIALS AND METHODS: patients treated with nephron sparing surgery (NSS) for clinical T1 renal tumors between January 2009 and January 2011 were evaluated. Overall, 198 patients who underwent SE were retrospectively matched to 198 patients who underwent SPN. The SPN and SE groups were compared regarding intraoperative, early post-operative and pathologic outcome variables. Multivariable analysis was applied to analyze predictors of positive surgical margin (PSM) status. RESULTS: SE was associated with similar WIT (18 vs 17.8 min), lower intraoperative blood loss (177 vs 221 cc, p = 0.02) and shorter operative time (121 vs 147 min; p < 0.0001). Surgical approach (laparoscopic vs. open), tumor size and type of indication (elective/relative vs absolute) were associated with WIT >20 min. The incidence of PSM was significantly lower in patients treated with SE (1.4% vs 6.9%; p = 0.02). At multivariable analysis, PSM was related to the surgical technique, with a 4.7-fold increased risk of PSM for SPN compared to SE. The incidence of overall, medical and surgical complications was similar between SE and SPN. CONCLUSIONS: Type of NSS technique (SE vs SPN) adopted has a negligible impact on WIT and postoperative morbidity but SE seems protective against PSM occurrence.

Innovative Approach for Interstitial Cystitis: Vaginal Pessaries Loaded Diazepam-A Preliminary Study.

Bladder pain is a characteristic disorder of interstitial cystitis. Diazepam is well known for its antispasmodic activity in the treatment of muscular hypertonus. The aim of this work was to develop and characterize vaginal pessaries as an intravaginal delivery system of diazepam for the treatment of interstitial cystitis. In particular, the performance of two types of formulations, with and without beta-glucan, was compared. In particular, the preparation of pessaries, according to the modified Pharmacopeia protocol, the setup of the analytical method to determine diazepam, pH evaluation, dissolution profile, and photostability assay were reported. Results showed that the modified protocol permitted obtaining optimal vaginal pessaries, without air bubbles, with good consistency and handling and with good pH profiles. In order to determine the diazepam amount, calibration curves with good correlation coefficients were obtained, by the spectrophotometric method, using placebo pessaries as matrix with the addition of diazepam standard solution. This method was demonstrated sensible and accurate to determine the amount of drug in batches. Dissolution profiles showed a complete diazepam release just after 15 minutes, even if beta-glucan pessaries released drug more gradually. Finally, a possible drug photodegradation after exacerbated UV-visible exposition was evaluated.

Results of endovesical hyaluronic acid/chondroitin sulfate in the treatment of Interstitial Cystitis/Painful Bladder Syndrome.

OBJECTIVES: The aim of our study was to test the effect of a more viscous compound than existent hyaluronic acid formulation in helping to restore a defective glycosaminoglycan layer, and therefore in improving Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) symptoms when administered intravesically in IC/PBS patients. METHODS: A total of 23 female patients completed the study. Patients received endovesical administration of hyaluronic acid and chondroitin sulfate in normal saline, 40 ml, weekly for 12 weeks and then bi-weekly for 6 months, if there was initial response. RESULTS: After 12 weeks treatment both Interstitial Cystitis Symptom and Problem Index (ICSI/ICPI), pelvic pain and Urgency/Frequency Symptom Scale (PUF) showed a mean significant improvement, which was maintained thereafter. The average number of voidings and mean voiding volumes revealed significant improvement after the 12 weeks' treatment period, with a significant reduction and increase, respectively. Mean voiding volume increased from 143 ml to 191, which apparently was not reflected in a corresponding reduction of number of daily voids (from 15,5 to 14). VAS values decreased from 5,4 to 3,6 (pain) and from 6,0 to 3,5 (urgency) after the treatment cycle, showing a significant improvement. CONCLUSIONS: In our preliminary experience, the administration of intravesical hyaluronic acid plus chondroitine sulphate appears to be a safe and efficacious method of treatment in IC/PBS.

Urgency degree and bladder contraction velocity: sequential changes in women with idiopathic detrusor overactivity.

AIMS: In patients with idiopathic detrusor overactivity (DO) who showed storage symptoms worsening with time, we checked whether and which urodynamic parameter changes are associated with an increased urgency degree. MATERIALS AND METHODS: We analyzed retrospectively the urodynamic findings in 54 women -27 with storage symptoms (Group A, mean age 32 +/- 7 years) and 27 controls (Group B, mean age 30 +/- 9 years). These latter had a history of recurrent UTIs (urinary tract infections), but when seen by us had no UTI, DO, lower urinary tract symptoms, or any other pathological finding. Group A had a first urodynamic examination when first referred (time 1) and were re-assessed a mean of 16 months later (time 2) for worsened storage symptoms. RESULTS: In Group A, an idiopathic DO was shown at both times 1 and 2; urgency of voiding could be delayed during cystometry for >or=2 min (= moderate urgency) at time 1 and for <2 min (= severe urgency) at time 2; detrusor contraction strength or contractility proved higher than in Group B (P < 0.001) and increased from time 1 to time 2 (P < 0.001), detrusor shortening velocity being always the major component of the higher contractility levels. CONCLUSIONS: A DO-related increase in bladder contractility may have been further enhanced by severe urgency through a positive feedback mechanism. The urgency degree proved closely associated in DO patients with the level of detrusor shortening velocity rather than with detrusor pressure.

Urgency of micturition and detrusor contractility in men with prostatic obstruction and overactive bladders.

AIMS: In men with prostatic obstruction and detrusor overactivity (DO), to ascertain whether urgency of micturition affects bladder contractility. MATERIALS AND METHODS: We urodynamically assessed five groups of 20 men each who had bladder outflow obstruction (BOO) from benign prostatic enlargement-Groups 1 (with no DO and no urgency), 2 (with DO and no urgency), 3A (with DO and moderate urgency), 3B (with DO and severe urgency), and 4 (with DO, severe urgency and chronic ischemic cerebral lesions). Urgency was graded as moderate or severe by the ability to avert an urgent void at cystometry for > or =2 or <2 min, respectively. BOO was assessed by the "Abrams-Griffiths number" (AG) and bladder contractility by the parameters PIP and WF(max). RESULTS: AG did not differ significantly in Groups 2, 3A, and 3B, proved higher in such groups than in Group 1, and was nearly the same in Groups 1 and 4. PIP and WF(max) were significantly higher in Groups 2, 3A, and 3B than in Groups 1 and 4, had the highest levels in Group 3B, and did not differ significantly in Groups 1-4 and 2-3A. CONCLUSIONS: In DO patients with prostatic obstruction there seems to be a DO-related facilitation of bladder contractility. In the same patients, severe urgency of micturition might over-amplify (i.e., enhance a DO-related facilitation of) bladder contractility, provided there are no neurogenic (chronic ischemic cerebral) lesions.

Voiding urgency and detrusor contractility in women with overactive bladders.

AIMS: To check whether the contractility of overactive bladders would be affected by voiding urgency. METHODS: We urodynamically studied 100 women: 20 normal controls (group 1), 60 patients with idiopathic detrusor overactivity (DO), and 20 with neurogenic DO from intracerebral lesions. The idiopathic DO groups 2A (n = 20), 2B (n = 20), and 3 (n = 20) had moderate, severe, and no voiding urgency, respectively. The neurogenic DO group 4 had severe urgency. The delay time of urgent void at cystometry (2 minutes or more or, respectively, less than 2 minutes) defined moderate or severe urgency. Detrusor contractility was defined by the maximum bladder external voiding power (WF(max)). RESULTS: WF(max) was higher in the idiopathic DO patients than in the controls, had the highest values in group 2B, and did not differ significantly between groups 1-4 and 2A-3. CONCLUSIONS: We inferred from our data that idiopathic DO suggests a facilitation of voiding contractions and that such facilitation might be centrally amplified by severe urgency. This amplifying effect would probably be impaired in cases of neurogenic DO from intracerebral lesions.

Urgency of voiding and abdominal pressure transmission in women with mixed urinary incontinence.

AIMS: To ascertain whether abdominal pressure transmission (a.p.t.) to the urethra would be affected by urgency of voiding in women with mixed urinary incontinence. METHODS: We urodynamically assessed 80 consecutive women. Group 1 (n = 40), with stress incontinence, had stable bladders and no urgency. Group 2 (n = 40), with mixed (stress + urge) incontinence and overactive bladders, were split into Groups 2A (n = 20) and 2B (n = 20) according to the delay time of urgent void at cystometry (CMG) equating at least 2 min (taken as an index of moderate urgency) or, respectively, less than 2 min (taken as an index of severe urgency). Nonparametric statistics checked for significant differences in a.p.t. and in pelvic floor (peri-urethral) muscle strength level. We defined a.p.t. at stress (cough) urethral pressure profilometry (UPP) by the pressure transmission ratio (PTR). Pelvic floor muscle strength was defined at "holding" UPP by the maximum urethral pressure developed during attempts "to hold urine" (hMUP). RESULTS: PTR was reduced in all women, but PTR (and hMUP) proved relatively higher in Group 2, though nonsignificantly different values of PTR (and hMUP) were seen in Groups 2B and 1. CONCLUSIONS: Transmission of abdominal pressure to the urethra was reduced in all of the incontinent women. The mixed incontinence group, however, had a relatively less reduced (active component of) a.p.t., most likely dependent on a greater pelvic floor (peri-urethral) muscle strength level secondary to frequent contractions in response to urgency. Yet, of the same mixed incontinence patients, those with the most severe urgency degrees had relatively low pelvic floor (peri-urethral) muscle strength levels (eventually resulting from muscle fatigue? or primarily due to peri-urethral tissue atrophy?), which prevented (the active component of) a.p.t. from increasing.

Paraurethral leiomyoma in women.

Two rare cases of paraurethral leiomyoma in women are presented. Physical examination and cystourethrography with previous cytourethroscopy revealed the seat of the masses. Surgical approach by means of incision of the anterior vaginal wall allowed for the complete enucleation of the tumors.

Angiosarcoma of the adrenal gland. Case report.

The vascular tumours of the adrenal gland are rare, both the benign and the malignant ones. Twenty two cases from the literature are reviewed in a paper by Kareti et al., 1988, among which only one own case of angiosarcoma the authors deem to be the first to be reported. A second case of angiosarcoma of the left adrenal gland, in a 67 y. old man, is herein reported. Notwithstanding a through surgical removal, a quick fatal progression of the disease ensued. Perhaps, considering the high malignancy of these rare tumours, an adjuvant form of treatment seems to be advisable.

Prognostic value of a combination of IPSS, flow rate and residual urine volume compared to pressure-flow studies in the preoperative evaluation of symptomatic BPH.

OBJECTIVE: Evaluate the predictive value of a combination of IPSS, uroflowmetry and ultrasound determination of residual urine volume in the determination of bladder outflow obstruction (BOO) and in predicting treatment outcome. METHODS: Forty-five out of a group of 60 BPH symptomatic patients were included. Preoperative evaluation: urine culture, PSA, uroflowmetry with sonographic measurement of post-void residual urine, DRE, IPSS with quality of life questions and pressure-flow study. Selection criteria for surgery were IPSS > 16 and Qmax < 10 ml/s. Transurethral resection of the prostate was performed in these patients; the control visit was performed at 3 months. Treatment success was defined as Qmax above 15 ml/s, residual urine of less than 100 ml, a 50% reduction in IPSS and absence of urinary retention. RESULTS: Urodynamic abnormalities were found in 42 patients (93.3%): 19 had detrusor instability, 5 patients showed impaired contractility, 37 patients had proven BOO, and 8 patients were unobstructed or mildly obstructed. The overall success rate was 86% when measured by the IPSS. Its preoperative value was 16.9, and dropped significantly to 4 (P = 0.005). The score improved significantly after surgery only in the obstructed group compared to the non-obstructed group (P = 0.001), however preoperative IPSS did not correlate with objective treatment results. CONCLUSIONS: A high proportion of patients successfully operated (71.1%) had a combination of IPSS > 16 and Qmax < 10 ml/s, although BOO could not be accurately predicted with non-invasive methods alone. Patients with no or mild infravesical obstruction had only minimal improvement of IPSS and uroflowmetry following surgery.

Bilateral ureteral compression by multiple abdominal desmoid tumors in Gardner syndrome: case report and literature review.

A 28-year-old man with Gardner syndrome was admitted to our Department because of multiple abdominal masses. Abdominal computed tomography revealed severe hydronephrosis of both kidneys due to ureteral compression against the pelvic bones exerted by multiple solid abdominal masses. The patient developed oligoanuria. Right percutaneous nephrostomy tube placement was followed by restoration of diuresis and progressive recovery of renal function of the left side. The patient then underwent median laparotomy and removal of five large desmoid tumors originating from the abdominal wall. Bilateral ureteral obstruction due to abdominal desmoid tumors can be a rare urologic complication of Gardner syndrome.

Different clinical presentation of interstitial cystitis syndrome.

The aim of the study was to examine how interstitial cystitis (IC) initiates its clinical course, which changes as the disease progresses from the initial phase to its full clinical manifestation. Patients diagnosed with IC between 1998 and 2003 in our department were evaluated and reviewed regularly. The exact onset of urinary symptoms was recorded. Diagnosis of IC was made by National Institute of Diabetes and Digestive and Kidney Disease (NIDDK) criteria when clinical suspicion of IC was present. The study group included 30 female patients who were 27-69 years old when diagnosis was made. Mean age was 46.7. Seventy percent of patients had only one symptom at onset. The most frequent initial diagnosis was urinary tract infection (UTI). A condition of recurrent bacterial UTIs, with subsequent persistence of symptoms and negative cultures, could be detected as a harbinger of IC in 60% of our patient group. IC may manifest initially with a single symptom in its early stage, when diagnosis is perhaps less easy, but adequate and effective treatment can still be offered to the patient.

Impact of early pelvic floor rehabilitation after transurethral resection of the prostate.

We examined the results of teaching pelvic floor muscle exercises (PME) on micturition parameters, urinary incontinence, post-micturition dribbling, and quality of life in patients after transurethral prostatectomy (TURP). Fifty-eight consecutive patients who were selected to undergo TURP for benign prostatic hyperplasia (BPH) were admitted into the study: 28 were randomly assigned to a control group (A), 30 formed the investigational group (B) during an initial visit conducted before surgery. In group B patients, perineal exercises were demonstrated in detail, and tested for their correct use via simultaneous rectal and abdominal examination. After the removal of the urethral catheter, these patients were instructed to perform pelvic floor muscle exercises at home and were evaluated before the exercises and at weekly intervals postoperatively. The American Urological Association Symptom Score improved significantly after TURP in both groups. The average quality of life score improved more significantly in group B after TURP, from 5.5 to 1.5 (P < 0.001). The grade of muscle contraction strength after 4 weeks of PME increased from 2.8 to 3.8 in group B (P < 0.01); it was unchanged in the group A. The number of patients with incontinence episodes and post-micturition dribbling was significantly lower in the group B at weeks 1, 2, and 3 (P < 0.01). Our results show that pelvic floor muscle re-education produces a quicker improvement of urinary symptoms and of quality of life in patients after TURP. Its early practice reduces urinary incontinence and post-micturition dribbling in the first postoperative weeks. The exercises are simple and easy to perform in the clinical setting and at home, and therefore should be recommended to all cooperative patients after TURP.