Application of a protocol for enhanced recovery after radical cystectomy: a before-and-after cohort study.

PURPOSE: Radical cystectomy with urinary diversion is a major urological surgery burdened both by a high rate of short- and long-term complications and by a high emotional and psychological impact. Post-operative recovery is extremely important and the application of ERAS protocols can facilitate the return to functional autonomy. The aim of the present study was to verify the efficacy of our ERAS programme on outcomes of recovery after surgery of patients undergoing radical cystectomy with various urinary diversions. METHODS: This is a before-after study comparing the historical group (n. 77) of radical cystectomies following a peri-operative standard of care with the prospective observational group (n. 83) following our ERAS programme. Recovery after surgery outcomes evaluated were length of stay, re-admission rate at 30-90/days and post-operative complications. RESULTS: Patients treated following the ERAS protocol presented less intra-operative blood loss (p < 0.001) and less intra-operative fluid infusions (p < 0.001). Time of first flatus was shorter in the ERAS group, though no difference was found in timing of nasogastric tube removal and defecation. Removal of drainage was done significantly earlier in the ERAS group. The median length of stay decreased from 12 to 9 days (p = 0.003) with a significant reduction also in re-admission rates at 30 and long-term complications at 90 days from surgery. CONCLUSION: The application of an opioid-free ERAS protocol to patients undergoing open radical cystectomy was associated, as compared with prior traditional care, with significant reductions of recovery time and length of stay, number of total in-hospital complications, in particular functional ileus and re-admissions by 30 and 90 days after surgery.

Value of bimodal (18)F-choline-PET/MRI and trimodal (18)F-choline-PET/MRI/TRUS for the assessment of prostate cancer recurrence after radiation therapy and radical prostatectomy.

Between 27% and 53% of all patients who undergo radical prostatectomy (RP) or radiation therapy (RT) as the first-line treatment of prostate cancer (PCa) develop a biochemical recurrence. Imaging plays a pivotal role in restaging by helping to distinguish between local relapse and metastatic disease (i.e., lymph-node and skeletal metastases). At present, the most promising tools for assessing PCa patients with biochemical recurrence are multiparametric magnetic resonance imaging (mpMRI) and positron emission tomography (PET)/computed tomography (CT) with radio-labeled choline derivatives. The main advantage of mpMRI is its high diagnostic accuracy in detecting local recurrence, while choline-PET/CT is able to identify lymph-node metastases when they are not suspicious on morphological imaging. The most recent advances in the field of fusion imaging have shown that multimodal co-registration, synchronized navigation, and combined interpretation are more valuable than the individual; separate assessment offered by different diagnostic techniques. The objective of the present essay was to describe the value of bimodal choline-PET/mpMRI fusion imaging and trimodal choline-PET/mpMRI/transrectal ultrasound (TRUS) in the assessment of PCa recurrence after RP and RT. Bimodal choline-PET/mpMRI fusion imaging allows morphological, functional, and metabolic information to be combined, thereby overcoming the limitations of each separate imaging modality. In addition, trimodal real-time choline-PET/mpMRI/TRUS fusion imaging may be useful for the planning and real-time guidance of biopsy procedures in order to obtain histological confirmation of the local recurrence.

Age is predictive of immediate postoperative urinary continence after radical retropubic prostatectomy.

INTRODUCTION: Immediate continence is a goal to take into consideration for better patient satisfaction after radical prostatectomy. Factors predicting urinary continence at catheter removal were investigated. MATERIALS AND METHODS: We evaluated preoperative, operative, clinical, hormonal and pathological variables in a homogeneous series of radical retropubic prostatectomies (RRPs) following the principles of urinary sphincter restoration technique. RESULTS: The study included 201 patients who underwent RRP. The overall immediate continence rate at catheter removal was 67.7% (136 patients); 28.8% (58 patients) were using one protective pad daily and 3.5% (7 patients) were incontinent. At 6-month follow-up incontinence had reached the lowest level of 2.5% (5 patients) and at 12 months the patients using one pad daily had decreased to 11.9% (24 patients). Multivariate logistic analysis showed that the only two factors independently associated with immediate continence were age <65 years (OR = 2.63, 95% CI 1.13-5.88, p = 0.02) and potency (OR = 3.6, 95% CI 1.2-10.7, p = 0.01) adjusting for D'Amico risk group, surgical margins, extracapsular extension, clinical stage, PSA, testosterone, LH and FSH. No significant association was noted for PSA, hormonal levels, hospital stay, prostate size, clinical stage, risk group, TNM stage, pathological Gleason score or extracapsular extension. CONCLUSIONS: In our series age <65 years was associated with immediate continence after RRP. Moreover, patients who were immediately continent had a 3.6-fold probability to be potent within 12 months.

Recurrence and progression in patients with non-muscle invasive bladder cancer: prognostic models including multicolor fluorescence in situ hybridization molecular grading.

OBJECTIVE: To test the prognostic value of multicolor fluorescence in situ hybridization analyses of tumor cells in urine for prediction of the recurrence and progression of tumor in patients with intermediate risk non-muscle invasive bladder cancer. METHODS: A total of 168 patients with non-muscle invasive bladder cancer were included in the study. Fluorescence in situ hybridization was carried out on the bladder wash urine collected before resection. Tumors were classified as low molecular grading if they had a diploid chromosomal pattern or only a loss of p16 or ch3 aneuploidy, and as high molecular grading if they showed aneuploidy of ch7 or 17. Cox regression models assessed the added prognostic value of fluorescence in situ hybridization for primary tumor recurrence or progression, respectively. RESULTS: Median follow up was 67 months. A total of 57% of tumors were classified as low molecular grading. The 2- and 5-year recurrence-free survival was 68% and 49% for low molecular grading, and 47% and 30% for high molecular grading, respectively. The 2- and 5-year progression-free survival was 95% and 84% for low molecular grading, and 79% and 58% for high molecular grading tumor patients, respectively. Molecular grading (hazard ratio 1.60; P = 0.03) was associated with recurrence, when also accounting for histopathology and a patient's characteristics. Both cancer severity score (hazard ratio 1.51; P < 0.01) and molecular grading (hazard ratio 2.53; P < 0.01) independently and positively predicted progression in multivariable models. The C-index for predicting recurrence increased from 0.58 to 0.61 when molecular grading fluorescence in situ hybridization was included in the model, and from 0.68 to 0.72 when predicting progression. CONCLUSIONS: Fluorescence in situ hybridization-based molecular grading increases the accuracy of a prognostic model, predicting both recurrence and progression in patients with intermediate risk non-muscle invasive bladder cancer.

Practical implications of androgen receptor inhibitors for prostate cancer treatment.

Antiandrogens have been used for the treatment of prostate cancer as a single agent or in combination with hormone deprivation therapy. New generation antiandrogens act like androgen receptor inhibitors (ARIs). Their binding complex blocks the pathways of cellular proliferation and differentiation of the prostate. Enzalutamide, apalutamide and darolutamide are the new ARIs that demonstrated acceptable tolerability and toxicity, both active in hormone-sensitive and castration-resistant prostate cancer (CRPC). There is no evidence of superiority of one drug over the other, therefore the therapeutic choice depends on the safety profile in relation to the individual patient, their comorbidities and clinical condition. ARIs have also shown promising results in association with new drugs that are active on patients with metastatic CRPC carrying the mutated breast cancer gene (BRCA). Before undergoing new antiandrogenic therapies, patients should be evaluated for cardiological and metabolic risk and possible drug interactions.

Improving Patient Outcomes in Abdominal Surgery.

Post-operative acute kidney injury (PO-AKI) is a frequent complication described in 15% of non-cardiac surgeries, 30% of cardiac surgeries, and 52% of patients requiring intensive post-operative care [...].

Perioperative Intravenous Amino Acid Infusion in Major Urologic Surgery.

Post-operative acute kidney injury (PO-AKI) is a serious complication that may occur after major abdominal surgery. The administration of intravenous perioperative amino acids (AAs) has been proven to increase kidney function and has some beneficial effects to prevent PO-AKI. The aim of this study was to establish if the perioperative infusion of AAs may reduce the incidence of PO-AKI in patients undergoing major urological minimally invasive surgery. From a total of 331 patients, the first 169 received perioperative crystalloid fluids and the following 162 received perioperative AA infusions. PO-AKIs were much higher in the crystalloid group compared to the AA group (34 vs. 17, p = 0.022) due to a lower incidence of KDIGO I and II in the AA group (14 vs. 30 p = 0.016). The AA group patients who developed a PO-AKI presented more risk factors compared to those who did not (2 (2-4) vs. 1 (1-2), p = 0.031) with a cut-off of 3 risk factors in the ROC curve (p = 0.007, sensitivity 47%, specificity 83%). The hospital length of stay was higher in the crystalloid group (p < 0.05) with a consequent saving in hospital costs. Perioperative AA infusion may help reduce the incidence of PO-AKI after major urological minimally invasive surgery.

Low Intra-Abdominal Pressure with Complete Neuromuscular Blockage Reduces Post-Operative Complications in Major Laparoscopic Urologic Surgery: A before-after Study.

Most urological interventions are now performed with minimally invasive surgery techniques such as laparoscopic surgery. Combining ERAS protocols with minimally invasive surgery techniques may be the best option to reduce hospital length-of-stay and post-operative complications. We designed this study to test the hypothesis that using low intra-abdominal pressures (IAP) during laparoscopy may reduce post-operative complications, especially those related to reduced intra-operative splanchnic perfusion or increased splanchnic congestion. We applied a complete neuromuscular blockade (NMB) to maintain an optimal space and surgical view. We compared 115 patients treated with standard IAP and moderate NMB with 148 patients treated with low IAP and complete NMB undergoing major urologic surgery. Low IAP in combination with complete NMB was associated with fewer total post-operative complications than standard IAP with moderate NMB (22.3% vs. 41.2%, p < 0.001), with a reduction in all medical post-operative complications (17 vs. 34, p < 0.001). The post-operative complications mostly reduced were acute kidney injury (15.5% vs. 30.4%, p = 0.004), anemia (6.8% vs. 16.5%, p = 0.049) and reoperation (2% vs. 7.8%, p = 0.035). The intra-operative management of laparoscopic interventions for major urologic surgeries with low IAP and complete NMB is feasible without hindering surgical conditions and might reduce most medical post-operative complications.

Two-stage functional and aesthetic reconstructive surgery in melanoma in situ of the glans penis and urethra.

Melanoma in situ including glans penis and fossa navicularis is unique and represents a challenging dilemma since surgery should not be very aggressive. We present a case of melanoma in situ treated with a two-stage penile and urethral reconstructive surgery, with emphasis on functional and aesthetic results. At the first-stage surgery an anatomic glansectomy was perfomed, and combined preputial and full-thickness skin grafts were used to prepare the urethral plate and restore the aesthetic aspect of the corpora cavernosa. After 6 months, the distal urethra was repaired including the configuration of an orthotopic meatus and a neo-glans.

Management of Prostate Cancer with Systemic Therapy: A Prostate Cancer Unit Perspective.

The scenario of systemic therapy for prostate cancer is rapidly evolving, with new drugs and new treatment options. To update the background knowledge of shared uro-oncologic practice, we reviewed current statements and landmarks in systemic therapy. A number of new agents are under investigation in non-metastatic and metastatic disease. Similarly, new target imaging technologies are under development to improve the detection rate of true non-metastatic and true metastatic patient. Five new drugs have shown to be effective on progression-free and overall survival in metastatìc prostate cancer. However, the optimal sequencing of these treatments requires further investigation. The tolerability and side effects of the new drugs are also crucial issues to be discussed, as well as their activity against the disease. The uro-oncologic team has to stay updated about new medical therapies in order to be confident in debating with other professionals involved in prostate cancer decision making. Different points of view and nuances should be shared during multidisciplinary group discussions to achieve a balanced decision in disease management.

Non-secreting adrenal myelolipoma in a middle-aged male patient manifesting with sudden onset of severe lower back pain.

Adrenal myelolipoma (AML) is a rare benign tumor, usually non-functioning and asymptomatic until it reaches large size. AML is mostly detected incidentally by imaging and is composed of adipose tissue and hematopoietic elements. Only symptomatic tumor needs surgical excision. We report the case of a large non-functioning adrenal tumor discovered by means of combined imaging techniques in a middle-aged male patient who complained the sudden onset of severe lower back pain; successful laparoscopic removal was performed, and AML was diagnosed at histopathology.

Functional and oncological outcomes of 3D clampless sutureless laparoscopic partial nephrectomy for renal tumors with low nephrometry score.

BACKGROUND: Renal cell carcinoma still represents 2-3% of all tumors but its mortality is decreased in the last decades due to the early detection of small masses and to the innovative surgical techniques. The aim of our study was to evaluate safety and feasibility of clampless and sutureless laparoscopic partial nephrectomy (CSLPN) in terms of intra- and postoperative functional results, complication rate and oncological outcome. METHODS: We evaluated patients undergoing CSLPN between July 2013 and December 2019. Inclusion criteria were single, organ confined tumor with size ≤4 cm, intraparenchymal depth ≤1.5 cm, renal nephrometry score between 4 and 6 and no close contact with the collecting system. RESULTS: Overall, 62 patients underwent CSLPN. Mean operative time was 105 minutes, mean intraoperative blood loss was 165 mL. Mean drain time and hospital stay were respectively 2.5 and 4.2 days. Mean 24 hours hemoglobin (Hb) decrease was 2.5 g/dL. No significative variations are described in pre- and postoperative renal function. Twelve patients had postoperative complications. At a median follow-up of 38.5 months all the patients are alive and disease free. CONCLUSIONS: Different techniques have been proposed to reduce warm ischemia time (WIT). In our experience we found many benefits in an off-clamp procedure: it gives an ischemia-related advantage, reduces the overall operating time, eliminates the risks associated with the isolation of hilar vessels. In conclusion CSLPN is a safe and effective procedure for selected renal masses; it does not increase complication rate and offers excellent functional and oncological outcomes.

Non-invasive removal of self-locking entrapped nephrostomy tubes.

INTRODUCTION: The removal of an encrusted nephrostomy tube can be a challenging maneuver. Urological literature is very bare in detailing techniques for removal of entrapped percutaneous catheters. We present a simple, safe and non-invasive technique of nephrostomy removal using a vascular introducer sheath, useful to manage complicated situations such as nephrostomies blocked for severe encrustations or disabled in their self-locking system. SURGICAL TECHNIQUE: The nephrostomy tube is cut and the stump is passed with a suture needle. The suture is passed through the inner vascular introducer sheath tip, and the introducer is then removed. The introducer sheath is advanced over the nephrostomy until joining the pigtail segment, under fluoroscopy guidance. Thus the suture is pulled out with strenght to contrast the opposite stiffness of the encrusted coil, until the nephrostomy has safely come out. COMMENT: The sheath exchange technique is quick, involves less manipulation through the perirenal fascia and kidney, and is suitable for different conditions of entrapped nephrostomies.

Short-time ureteral catheterization after operative ureteroscopic lithotripsy: an alternative to stent versus no stent evaluated in a retrospective study.

OBJECTIVES: Stent-less procedure following ureterolithotripsy needs a definition for patient selection and procedure criteria. To mediate stenting versus no stenting, a retrospective study was performed to evaluate the insertion of an ureteral open-tip catheter for 24 hours. MATERIAL AND METHOD: From 2002 to 2006 255 ureterolithotripsy were performed (176 male - 79 female, mean age 51.5 y.o.). Stone was in the upper ureter in 101 cases, in the mid in 89 and the lower in 65. Patients were retrospectively separated into 3 groups: in Group A a stent was placed because of complicated lithotripsy and left for 15 days. In Group B an open-tip catheter was placed for 24 hours. In Group C no catheter was left. All patients were evaluated for symptoms as need of antalgic substances. RESULTS: In Group A 134 patients were stented. The mean stone dimensions were 8.7mm. Flank pain was reported in 52 patients (38%) on post-op 15 days, 77 patients (57.4%) referred lower urinary tract symptoms, 2 patients reported hematuria. In Group B 105 patients (41.1%) were stented with open-tip catheter. The mean stone dimension was 6.3 mm. Pain was referred in 43 patient (40.9%) after the catheter removal. In 12 cases (11.4%) hospital readmission was necessary due to pain. Group C was represented by 16 patients (6.27%). Mean stone dimension was 6mm. No postoperative pain was reported. A statistical difference (p < 0.005) is significative comparing the operative time for the stent vs open-tip group. CONCLUSIONS: No rules establish if it is correct to stent or to avoid this procedure, so trying to resolve the dilemma by inserting an open tip catheter for 24 hours seems a good response. The operating time is reduced for no stenting or positioning catheter vs stenting. To reduce immediate post-ureteroscopy complication placing an open-tip catheter for 24 hours seems to be a simple and cheap procedure.

[Flexible cystoscope for the treatment of urinary stones in intestinal reservoirs.] / Cistoscopia flexible para el tratamiento de las litiasis urinarias en reservorios intestinales.

OBJECTIVE: Stones are common mid- and long-term complications in urinary diversions built with bowel. However the reservoir intestinal loops can lead to difficult endoscopic approach. METHODS: We report two challenging cases with unfavourable anatomy successfully treated by gently handling a flexible cystoscope in a low pressure system. RESULTS: One patient with stones in a continent pouch was cleaned up with a grasping basket through the efferent umbilical limb. Another patient with an orthotopic ileal neobladder not accessible by rigid cystoscope due to high pelvic floor was treated with holmiun laser lithotripsy. CONCLUSIONS: Urologists should consider the versatility of flexible cystoscope to obviate the need for percutaneous lithotripsy or open lithotomy.

OBJETIVO: La aparición de litiasis es una complicación común a medio y largo plazo en las derivaciones urinarias construidas con intestino. Sin embargo, las asas intestinales de los reservorios pueden tener un acceso endoscópico difícil. METODOS: Presentamos dos casos difíciles con anatomía desfavorable tratados con éxito utilizando cuidadosamente un cistoscopio flexible en un sistema de baja presión. RESULTADOS: Un paciente con litiasis en una neovejiga continente quedó libre de litiasis utilizando una cestilla a través del asa eferente umbilical. Otro paciente con una neovejiga ileal ortotópica no accesible por cistoscopio rígido debido a un suelo pélvico elevado, fue tratado con litotricia con láser de Holmio. CONCLUSIONES: Los urólogos deben considerar la versatilidad de la cistoscopia flexible para obviar la necesidad de litotricia percutánea o litotomía abierta.

Current perioperative management of radical cystectomy with intestinal urinary reconstruction for muscle-invasive bladder cancer and reduction of the incidence of postoperative ileus.

Major abdominal surgery, and also radical cystectomy, is followed by a delayed return of bowel function attributable to postoperative ileus (POI), which, in addition, stands out as one of the most frequent complications that causes increased length of stay (LOS). Some variability exists in the definition of POI since time to return of peristalsis and time to first passage of flatus, which are commonly referred to as indicators of bowel activity, have their own weaknesses, observer dependent and time dependent, among other variables. A number of causes have been recognized to induce or maintain the condition of ileus. Some among them are part of the perioperative period. The practices of mechanical bowel preparation (MBP) and of fasting before surgery have been challenged and can be safely abandoned. The perception of pain is an acknowledged promoter of POI; therefore, providing complete pain control constitutes the rationale in favor of administering anesthesia and analgesia combined, both in the form of concurrent general and epidural anesthesia (i.e., at the thoracic level, T9, T11), and represents the mainstay of intraoperative measures. Hypovolemia is also associated with an increased risk of POI. The use of nasogastric tubing (NGT) has been associated with increased pulmonary complications; moreover, bowel resection can be performed safely without postoperative NGT. Early postoperative provision of artificial nutrients has shown beneficial effects, both in the form of total parenteral and enteral nutrition (PEN, EN). We devised a perioperative care regimen, adopting a multimodality approach aimed at minimizing the effects of the above listed factors to ascertain if they could contribute to preventing or reducing POI and the complications associated with radical cystectomy and intestinal urinary diversion. In addition, we investigated the impact of early artificial nutrition, combining PEN and EN via a jejunal nutrition cannula. Time to return of bowel movements, time to reinstitution of a regular diet, presence and duration of POI, and incidence and nature of complications constituted the study end points. Of 143 consecutive patients, 107 who underwent radical cystectomy with intestinal urinary reconstruction were able to be evaluated for results and complications. The male to female ratio was 86:21, the mean age was 74 years, and more than two-third belonged to the American Society of Anesthesiologists categories II and III. Pathologic stages of disease were bladder confined in 48 patients, locally advanced in 33, and extravesical in 26. Urinary diversion with intestine consisted in the configuration of heterotopic reservoirs in 39 patients, orthotopic substitution in 38, and uretero-ileo-cutaneostomy in 30. Bowel movements returned after a median time of 2 days (range, 1-6), and the median time to reinstitution of a regular diet was 4 days (range, 3-9). POI beyond postoperative day 4 was observed in 17.7% of the patients. Overall, a total of 28 patients (26.1%) experienced complications, specifically, medical complications in 19 patients and surgical complications leading to relaparotomy in 11. The mortality rate was 3.7%. No effects were observed on postoperative protein depletion, despite the provision of early artificial nutrition. Our results suggest that a short median time of return of both peristalsis and flatus, and to regular diet resumption with a low incidence of POI, can be obtained in the majority of patients with a perioperative regimen aimed at reducing the effect of some of the causes associated with induction or maintenance of POI. Further studies of multimodality perioperative care plans, similar to that used in the present study, are required.