Ureterocystoplasty (bladder augmentation) in a 16 year-old boy with Goldenhar syndrome.

The use of the dilated ureter for bladder augmentation is universally accepted for its lower rate of complications compared to the use of gastrointestinal segments. We report the case of a 16 yearold boy affected by Goldenhar syndrome who presented with neurogenic bladder with small-capacity, 5° grade vescico-ureteral reflux (VUR) with megaureter and bilateral hydronephrosis. Bladder augmentation using the distal dilated ureter, transuretero-ureterostomy left to right and Mitrofanoff's appendicovescicostomy were performed. Six months after surgery voiding cystourethrogram (VCUG) revealed a compliant bladder with a functional capacity of 400 ml. Ureterocystoplasty is a safe and effective method of augmenting small capacity urinary bladder. We suggest using the ureter, when available, instead of using gastrointestinal segments.

Laparoscopic transposition of lower pole crossing vessels in children with extrinsic pelvi-ureteric junction obstruction: a worthy alternative to dismembered pyeloplasty.

Pelviureteric junction obstruction (PUJO) due to intrinsic or extrinsic causes is a common problem in childhood. Extrinsic compression by a lower pole-crossing blood vessel can present symptomatically in older children. In these cases, laparoscopies Vascular Hitch can represent a valid alternative to pyeloplasty dismembered. We analyzed the data of 4 children affected by extrinsic PUJO treated at our institution with the laparoscopic Vascular Hitch procedure modified by Chapman. Surgical indications included presence of clinical symptoms, worsening of intermittent hydronephrosis, signs of obstruction on the MAG-3 scan, clear or suspected images of polar crossing vessels on CT scan or Uro-MRI. All procedures were completed laparoscopically. No complications occurred. Mean follow-up was 13 months with resolution of symptoms and PUJ obstruction and significant improvement of hydronephrosis in all cases. When blood vessels crossing lower pole represent the pure mechanical cause of UPJ obstruction the laparoscopic Vascular Hitch procedure represents an excellent alternative to dismembered pyeloplasty. It is less technically demanding then pyeloplasty and is associated with a lower complication rate. The main challenge is to intraoperatively ascertain the absence of associated intrinsic stenosis.

Congenital renal anomalies imaging: a valuable tool for pediatricians.

The purpose of this article is to review the main congenital anomalies of kidneys and urinary tract that can be diagnosed prenatally and postnatally by imaging technique. The incidence of congenital anomalies of the kidney and urinary tract during the past decade has been estimated to be 0.4 to 4.0 cases per 1000 births. Congenital kidney disease can evolve in chronic disease in childhood and in adulthood. A diagnostic imaging of the various congenital renal and urological conditions allows pediatricians to make a correct diagnosis and treatment. Because of the concerns about long-term effects of ionizing radiation, the most commonly and first used imaging modality for evaluation of the urinary system is ultrasound.

Laparoscopic nephrectomy in children with Wilms tumor. Considerations after 10 years of experience.

Despite laparoscopy in children is considered safe and is routinely used for several procedures, even in neonates and in pediatric oncology, its role in the treatment of pediatric renal tumors is still controversial. This study analyzes the results of laparoscopic nephrectomy for Wilms Tumor (WT) in pediatric age compared with open nephrectomy after 10 years of experience in a single centre. From 1993 in our center of reference for pediatric oncology, 30 patients with WT have been treated. We performed 21 open nephrectomy and in the last 10 years 9 laparoscopic nephrectomy. In all patients treated laparoscopically, the same technique made by the same equip was used. Compared with patients treated by open surgery, we did not find a significant difference in terms of outcome and survival. In the open surgery group, two patients had lung relapse while in the other group there was one local relapse. These three children obtained and maintained a second complete remission with chemotherapy. Open surgery complications were a tumor rupture in two cases, and an episode of pancreatitis 10 days after surgery. In the laparoscopic group, there were two conversions to open surgery not considered as complications but a surgical choice for cystic areas present in the tumor. As far as complications and oncologic outcomes are concerned, both techniques showed similar results. In experienced hands, laparoscopy proves to be an attractive alternative to open surgery for pediatric renal tumors.

Transurethral resection of prostate: technical progress by bipolar Gyrus plasma-kinetic tissue management system.

AIM: We report our experience about bipolar plasma-kinetic resection of the prostate for the treatment of bladder outlet obstruction due to benign prostatic hyperplasia (BPH), considering intraoperative variables and short-term METHODS: Three hundred and eighty-nine patients affected by symptomatic BPH, underwent transurethral resection of prostate using the bipolar plasma-kinetic technique from Decem-ber 2001 to July 2004 in a prospective fashion. Bipolar resections of the prostate were performed using Plasma-Kinetic Tissue Management System (Gyrus Medical Ltd., UK). Preoperative, digital rectal examination, haemoglobin level, total PSA, transrectal ultrasound, International-Prostate Symptom Score (I-PSS) and uroflowmetry parameters were recorded. Patients were assessed for safety and efficacy, evaluating intraoperative and postoperative complications and measuring both the IPSS and the maximum flow rates (Qmax) after 12 months. RESULTS: The mean operative time was 89 min (range 48-121 min); the mean prostatic resected weight (measured by an electronic scales) was 49.6 g (3267 g). The mean decrease of haemoglobin level was 1.1 g/dL (range 0.5-1.9), with a mean catheterization time of 1.3 days (range 1-5). Qmax increase ranged from 120 to 230% (mean 190%) 12 months after surgery. Correspondingly, IPSS decrease ranged from 48% to 86% (mean 79%). Postoperative acute urinary retention, urethral strictures, bladder neck sclerosis and urinary incontinence were recorded in 1.57%, 2.57%, 1.28% and 0.77%, respective. CONCLUSION: The transurethral resection of prostate using a bipolar plasma-kinetic device represent a safe and effective option for the treatment of symptomatic BPH.

Role of Ca 15-3 in patients with biochemically suspected prostate cancer and multiple negative ultrasound-guided prostate biopsies.

Ca 15-3 is an aspecific tumor marker characteristic of cancer proliferation. Elevated serum levels seem to be closely correlated with cancer progression in non-urological tumors. This study assessed the role of Ca 15-3 as an aspecific tumor marker in patients with borderline prostate-specific antigen (PSA) biochemically suspected of prostate cancer (PCa) and with multiple negative prostate biopsies. The study is based on prospective analysis of 103 patients: (a) 33 patients (group A) presented lower urinary tract symptoms secondary to BPH with normal serum PSA values, DRE and TRUS negative for suspected PCa; (b) 31 patients (group B) with histologically diagnosed PCa; (c) 39 patients (group C) with borderline serum PSA values, DRE and TRUS normal, two ultrasound (US)-guided random prostate biopsies negative for PCa. Ca 15-3 was determined in the entire study series by the IRMA method, using as range the values proposed for the investigated non-urological tumors (38 UI/l).Ca 15-3 was within normal range in all group A patients (control), while the values were elevated in 27/31 of group B patients (PCa) and in 11/39 of group C (PCa suspected) patients. A third biopsy was performed in all 39 group C patients with borderline PSA and it was PCa-positive in 13 patients (33.3%, subgroup C3). In this series Ca 15-3 was increased in 9 of 13 patients (subgroup C3alpha), while the remaining four patients (subgroup C3beta) presented values within the normal range. On 26 group C patients who were negative for PCa to third biopsy (subgroup C4), 24 patients had Ca 15-3 levels within normal range (subgroup C4alpha) with histologic findings of BPH in 23 cases and granulomatous chronic prostatitis in one case, while two patients (subgroup C4beta) had elevated Ca 15-3 concentrations associated with lymphoplasmacytic chronic prostatitis. We hypothesize that Ca 15-3, as a specific tumor marker, could be an interesting and inexpensive second step diagnostic tool for PCa in patients with borderline PSA and multiple negative prostate biopsies, as it could indicate whether a repeated biopsy should be performed in a short time, having excluded other concomitant tumors. However, further prospective studies will be necessary to confirm this hypothesis.

Transuretral resection of the bladder (TURB): analysis of complications using a modified Clavien system in an Italian real life cohort.

INTRODUCTION: To evaluate the applicability of a modified Clavien classification system (CCS) in grading postoperative complications of transurethral resection of bladder tumours (TURB). MATERIALS AND METHODS: A series of patients undergoing monopolar TURB from April 2011 to March 2012 at five Italian centers were enrolled. All complications occurring within the first 30-day postoperative period were prospectively recorded and graded according to the CCS. RESULTS: Overall, 275 patients were included. Median age was 71 (63/78) years; median BMI was 28 (25.4/30.8) Kg/m(2), median tumour size was 2 (1-3) cm; median number of tumour lesions was 1 (1-3). Median operative time was 30 (20/45) min. Fifty-seven complications were recorded in 43 patients. Overall postoperative morbidity rate was 16%. Most of the complications were not serious and classified as Clavien type I (42 cases; 74%) or II (8 cases, 14%). Higher grade complications were scarce: CCS IIIa in 1 case (2%) and CCS IIIb in six cases (10%). No TURB related death was reported. Six patients were re-operated due to significant bleeding or clot retention on postoperative days 2-7. On univariate (73.5 ± 38 versus 36.7 ± 21.6 min) and multivariate analysis longer operative time was an independent predictor of complications (OR: 1.06 per min, 95%CI 1.04-1.08, p = 0.001). CONCLUSIONS: A modified CCS can be used as a standardized tool to objectively define the complications of TURB which confirms to be a safe procedure with a low surgical morbidity. This tool can be used to aid in patient counselling and to facilitate scientific assessment.

Analysis of radical cystectomy and urinary diversion complications with the Clavien classification system in an Italian real life cohort.

INTRODUCTION: Standardized methods of reporting complications after radical cystectomy (RC) and urinary diversions (UD) are necessary to evaluate the morbidity associated with this operation to evaluate the modified Clavien classification system (CCS) in grading perioperative complications of RC and UD in a real life cohort of patients with bladder cancer. MATERIALS AND METHODS: A consecutive series of patients treated with RC and UD from April 2011 to March 2012 at 19 centers in Italy was evaluated. Complications were recorded according to the modified CCS. Results were presented as complication rates per grade. Univariate and binary logistic regression analysis were used for statistical analysis. RESULTS AND LIMITATIONS: 467 patients were enrolled. Median age was 70 years (range 35-89). UD consisted in orthotopic neobladder in 112 patients, ileal conduit in 217 patients and cutaneous ureterostomy in 138 patients. 415 complications were observed in 302 patients and were classified as Clavien type I (109 patients) or II (220 patients); Clavien type IIIa (45 patients), IIIb (22 patients); IV (11 patients) and V (8 patients). Patients with cutaneous ureterostomy presented a lower rate (8%) of CCS type ≥IIIa (p = 0.03). A longer operative time was an independent risk factor of CCS ≥III (OR: 1.005; CI: 1.002-1.007 per minute; p = 0.0001). CONCLUSIONS: In our study, RC is associated with a significant morbidity (65%) and a reduced mortality (1.7%) when compared to previous experiences. The modified CCS represents an easily applicable tool to classify the complications of RC and UD in a more objective and detailed way.

A case of prostatic rhabdomyosarcoma in childhood.

▪ ABSTRACT: : Rhabdomyosarcoma of the prostate is rare, especially in childhood. The treatment of this neoplasm has been destructive surgery with adjuvant chemotherapy or radiotherapy. These treatment recommendations have been revised to suggest conservative surgery plus adjuvant chemotherapy and radiotherapy. We report treatment of prostatic rhabdomyosarcoma in a child with a long-term follow-up. ▪.

Immunohistochemical and molecular analysis in recurrent urethral stricture.

The authors have analyzed the most recent additions to the literature of immunohistochemical and molecular assessment of acquired urethral strictures and report on their data obtained in a selected clinical series. Innovative immunohistochemical studies in patients presenting with plurirecurrent symptoms suggest that urethral mesenchymal changes caused by tissue de-epithelialization may be the underlying cause of stricture. This condition may be congenital or acquired. It may determine aberrant connective tissue formation induced by abnormal fibroblastic activation with formation of over abundant hyperdense collagen scar tissue.