Robotic partial nephrectomy performed with Airseal versus a standard CO2 pressure pneumoperitoneum insufflator: a prospective comparative study.

BACKGROUND: Airseal represents a new generation of valveless and barrier-free surgical trocars that enable a stable pneumoperitoneum with continuous smoke evacuation and carbon dioxide (CO2) recirculation during surgery. The aim of the current study was to evaluate the potential advantages of the Airseal compared to a standard CO2 insufflator in the field of robotic partial nephrectomy (RPN). METHODS: Between October 2012 and April 2015, two cohorts of 122 consecutive patients with clinically localized renal cell carcinoma underwent RPN by a single surgeon, with the use of a standard CO2 pressure insufflator (Group A, 55 patients) or Airseal (Group B, 67 patients) and were prospectively compared. RESULTS: The two groups were similar in baseline, preoperative characteristics. The mean dimension of the lesion, as evaluated by contrast-enhanced CT scan, was 30 (median 28; IQR 2) and 39 mm (median 40; IQR 2) for Groups A and B, respectively (p < 0.05). The complexity of the treated tumors was similar, as indicated by the mean RENAL nephrometry score. Positive surgical margins rate was similar in both groups (3.6 vs 4.5 %, p = 0.8) as well as the need for postoperative blood transfusion (9.1 vs 4.5 %, p = 0.3) and the development of postoperative acute kidney injury (16.4 vs 10.4 %, p = 0.3). Mean operative time and warm ischemia time were significantly shorter in Group B. Moreover, a significant increase in the cases performed as "zero ischemia" was observed in Group B (7.3 vs 30 %, p < 0.01). CONCLUSIONS: This is the first study comparing the Airseal with a standard CO2 insufflator system in the field of the RPN. The preliminary outcomes in terms of overall operative time, warm ischemia time and cases performed as "zero ischemia" are better with respect to standard insufflators. The feasibility, safety and efficacy of combining laser tumor enucleation with the valve-free insufflation systems should be evaluated.

Management of lower urinary tract symptoms associated with benign prostatic hyperplasia in elderly patients with a new diagnostic, therapeutic and care pathway.

INTRODUCTION: Benign prostatic hyperplasia (BPH) resulting in lower urinary tract symptoms (LUTS) is a widespread disease that strongly interferes with the quality of life (QoL) of elderly males. It represents a real clinical and socio-economic problem may be due to the lack of a diagnostic, therapeutic and care pathway (DTCP) tool for LUTS/BPH that considers elderly people population in its whole complexity. The aim of this study was to evaluate the clinical effectiveness of the proposed DTCP LUTS/BPH tool. METHODS: This prospective study was conducted on 278 patients over 75 years old with non-neurogenic LUTS recruited from February to July 2014 by 10 general practitioners (GP) and two assisted sanitary residences (ASR). Only five GPs and one ASR were provided with the complete DTCP LUTS/BPH tool to create two different groups of patients: group A (138 patients) was treated without the aid of the DTCP; group B (140 patients) was treated according to the DTCP. RESULTS: At 1 year of follow-up, the patients of Group B compared with Group A achieved a greater and significant mean reduction in the questionnaires score (International Prostate Symptom Score, Quick prostate test and QoL) linked to a higher increase in the flowmetry parameters (Qmax) and a lower postvoid residual. Furthermore, in Group B compared to Group A, a greater improvement of hydronephrosis, creatinine values and erectile dysfunction (ED) were obtained at 1 year of follow-up. CONCLUSION: The encouraging results obtained from this study are significant and support the use of this diagnostic, therapeutic and care tool (DTCP) as the ideal pathway management for elderly men with LUTS associated to BPH and ED. Further studies with greater number of elderly subjects and long-term follow-up are needed to confirm DTCP utility in the clinical management of LUTS/BPH and ED.

Synchronous primary neoplasms of the bladder, skin and breast in a male patient: a case report.

The incidence of multiple primary malignant neoplasms increases with age, reflecting an increase in overall cancer risk in older patients. Cases of two or more concurrent primary cancers are still rare, although its incidence is increasing. Here, we report the case of a 57-year-old man who was referred to our institution with synchronous squamous cell carcinoma of the skin on the forehead, infiltrating ductal carcinoma of the breast, and transitional cell carcinoma of the urinary bladder. To the best of our knowledge, this is the first reported case in literature of this combination of primary neoplasms.

Evaluation of Sexual Function and Quality of Life in Women Treated for Stress Urinary Incontinence: Tension-Free Transobturator Suburethral Tape Versus Single-Incision Sling.

OBJECTIVE: The aim of this study is to investigate the change in quality of life (QoL) and sexual function in women treated for pure stress urinary incontinence (SUI) using tension-free transobturator suburethral tape (TVT-O) and single-incision sling (SIS) procedures. MATERIALS AND METHODS: From December 2013 to January 2015, a total of 48 female patients with pure SUI and normotonic urethra were consecutively enrolled and randomized into two treatment groups: TVT-O versus SIS. Both groups were homogeneous in the preoperative evaluation of age, body mass index, comorbidities, and pregnancies. Exclusion criteria included urge urinary incontinence, neurogenic bladder, previous surgery for incontinence, and mental or neurological disorders. The female sexual function and QoL were assessed preoperatively and postoperatively (3-12 months follow-up), using the Female Sexual Function Index (FSFI) and the International Consultation on Incontinence Questionnaire. RESULTS: A total of 42 patients completed both the questionnaires (21 patients in the TVT-O group and 21 patients in the SIS group, whereas 6 patients were lost to follow-up). Of the 19/21 (90.4%) of patients who successfully underwent the SIS procedure, 17 (80.9%) reported a complete resolution of SUI, whereas 2 (9.5%) reported an improvement in urinary incontinence at follow-up. In the TVT-O group, 18/21 (85.7%) of patients reported complete recovery, whereas 4.1% patients reported an improvement in the incontinence. The FSFI score increased significantly in both the SIS groups (from 23:51 ± 3.78 to 27.42 ± 3.34; p < 0.001) and TVT-O group (from 23.96 ± 5:56 to 28.09 ± 3.62) with no statistically significant differences between the two treatment groups. CONCLUSION: In our study, both slings showed a high rate of continence without any major complications. The sexual function also improved sharply in all the six FSFI domains, with no statistically significant difference between the two treatment groups.

Combined laparoscopic pyelolithotomy and endoscopic pyelolithotripsy for staghorn calculi: long-term follow-up results from a case series.

PURPOSE: Staghorn renal stones are a challenging field in urology. Due to their high recurrence rates, particularly those associated with an infective process, a complete removal is the ultimate goal in their management. We report our experience with a combined approach of laparoscopic pyelolithotomy and endoscopic pyelolithotripsy, the stone clearance rate, and long-term, follow-up outcomes. METHODS: From June 2012 to October 2014, nine adult patients with large staghorn renal calculi (mean size, 7.2 cm; range, 6.2-9.0 cm) underwent a combined laparoscopic and endoscopic approach. The technique comprised laparoscopic pyelolithotomy and holmium-YAG laser stone fragmentation with the use of a flexible cystoscope introduced through a 12 mm trocar. RESULTS: The average operative time was 140 min (range, 90-190 min). The mean estimated hemoglobin loss was 0.6 mmol/l (range 0.5-0.7 mmol/l). None of the patients required an open- surgery conversion. The mean hospital stay was 4 days (range, 2-6 days). A computed tomography urogram control at 6 months of follow up did not show any stone recurrence. CONCLUSIONS: Laparoscopic pyelolithotomy combined with endoscopic pyelolithotripsy could be a therapeutic option in cases where mini-invasive procedures, that is, extracorporeal shock wave lithotripsy, ureteroscopic lithotripsy, and percutaneous nephrolithotomy (PCNL) have failed. This technique has a high stone-clearance rate (75-100%) comparable with open surgery and PCNL. However, it could be technically demanding and should be performed by skilled laparoscopy surgeons.

Endoscopic rendezvous procedure for ureteral iatrogenic detachment: report of a case series with long-term outcomes.

BACKGROUND AND PURPOSE: Injury to the ureter is the most common urologic complication of pelvic surgery, with an incidence that ranges from 1% to 10%. Most cases of ureteral injuries are related to gynecologic procedures. The ureter is particularly vulnerable to detachment or ligation during hysterectomy because of its position from the lateral edge of the cervix. We report a case series of female patients who underwent the ureteral rendezvous procedure for ureteral detachment. PATIENTS AND METHODS: Between January 2009 and April 2013, 18 ureteral rendezvous procedures were performed for patients with complete detachment. We assessed the operative and clinical outcomes of these patients over a mean follow-up duration of 26.5 months and describe the three most representative cases. RESULTS: The endoscopic rendezvous technique was performed in all cases to manage ureteral detachment. CT urography at discharge and 6 and 12 months after discharge confirmed the restoration of ureteral integrity without any leakage in 66% (12/18) patients, indicated ureteral stenosis in 22% (4/18) patients, and indicated ureteral leakage in 12% (2/18) patients. The overall long-term success rate for all 18 patients was 78% (14/18) at a mean follow-up of 26.5 months. CONCLUSIONS: The endoscopic rendezvous procedure reduces the need for invasive open surgical repair and represents the optimal initial option in patients with iatrogenic ureteral lesions before invasive procedures with higher morbidity are attempted.

Correlation between semiquantitative sonoelastography and immunohistochemistry in the evaluation of testicular focal lesions.

BACKGROUND: Sonoelastography is a novel and promising imaging tool, which has been applied to breast, thyroid, and prostate tissues. The aim of this study was to evaluate focal lesions of the testes with diameters of <10 mm using sonoelastography, B-mode sonography (US), and colour Doppler ultrasonography (CDU). METHODS: Thirty patients who were referred to our outpatient clinics for varicocoeles, scrotal pain, scrotal enlargements, epididymitis, palpable testicular nodules, or infertility, were prospectively enrolled into this study. Ultrasound evaluations had revealed that 27 subjects had focal testicular lesions with diameters of <10 mm and 3 subjects had 10-mm spherical non-homogeneous testicular nodules. All lesions were evaluated using semiquantitative sonoelastography, and the patients underwent orchifunicolectomies. The testicular lesions were examined histopathologically. The vascularization of the lesions and the surrounding testicular parenchyma was evaluated by analysing the immunohistochemical distribution of the cluster of differentiation 31 and by calculating the vascular indices (VI). Potential associations between the strain ratios (stiffness of the lesions) and the VI were tested. RESULTS: Analyses of the strain fields obtained using semiquantitative sonoelastography yielded different values for the masses and the surrounding tissues, which led to significant increases in the strain ratios. Sonoelastography upheld all of the diagnoses that were suspected when the patients were physically examined, when the serum markers were analysed, and after the patients had undergone US and CDU. Histopathological examinations confirmed the neoplastic characteristics of these masses. A significant inverse correlation was determined between the sonoelastographic strain ratio and the VI (Pearson correlation coefficient, r, = - 0.93; P < 0.001). CONCLUSION: Our investigation shows that semiquantitative sonoelastography may provide additional objective information to support the algorithm used to diagnose testicular lesions. This might be of crucial diagnostic importance for lesions with diameters of <10 mm, particularly if they are not palpable, are negative for serum tumour markers, and if the findings from ultrasonography and CDU are equivocal. The findings from semiquantitative sonoelastography might indicate the need for surgical exploration. Further investigations with larger numbers of patients are required to corroborate these data and to support the use of semiquantitative sonoelastography in the evaluation of testicular lesions.

A multistep approach to manage Fournier's gangrene in a patient with unknown type II diabetes: surgery, hyperbaric oxygen, and vacuum-assisted closure therapy: a case report.

INTRODUCTION: Fournier's gangrene is an infectious necrotizing fasciitis of the perineum and genital regions and has a high mortality rate. It is a synergistic infection caused by a mixture of aerobic and anaerobic organisms and predisposing factors, including diabetes mellitus, alcoholism, malnutrition, and low socioeconomic status. We report a case of Fournier's gangrene in a patient with unknown type II diabetes submitted to 24-hour catheterization 15 days before gangrene onset. CASE PRESENTATION: The patient, a 60-year-old Caucasian man, presented with a swollen, edematous, emphysematous scrotum with a crepitant skin and a small circle of necrosis. A lack of resistance along the dartos fascia of the scrotum and Scarpa's lower abdominal wall fascia combined with the presence of gas and pus during the first surgical debridement also supported the diagnosis of Fournier's gangrene. On the basis of the microbiological culture, the patient was given multiple antibiotic therapy, combined hypoglycemic treatment, hyperbaric oxygen therapy, and several surgical debridements. After five days the infection was not completely controlled and a vacuum-assisted closure device therapy was started. CONCLUSIONS: This report describes the successful multistep approach of an immediate surgical debridement combined with hyperbaric oxygen and negative pressure wound therapy. The vacuum-assisted closure is a well-known method used to treat complex wounds. In this case study, vacuum-assisted closure treatment was effective and the patient did not require reconstructive surgery. Our report shows that bladder catheterization, a minimally invasive maneuver, may also cause severe infective consequences in high-risk patients, such as patients with diabetes.

Incidental diagnosis of a retroperitoneal schwannoma in a patient with chronic leukemia undergoing prostatic biopsy.

We present a case of retroperitoneal schwannoma incidentally diagnosed in a patient undergoing surgical drainage of a pelvic abscess as a complication of a prostatic biopsy. A 50-year-old male, suffering from lymphatic leukemia, came to our observation due to lichen ruber planus and ejaculatory pain. The patient underwent a trans-perineal ultrasound-guided biopsy of the right seminal vesicle and of a hypoechoic area documented by ultrasonography. 48 hours after the procedure, the patient had developed: cold sores, shortness of breath with dyspnea, and high fever (40°C). The patient was hospitalized, underwent an emergency CT which documented a right presacral and pararectal liquid mass (abscess). The patient underwent emergency laparotomy and drainage of the abscess. The lesion histological examination revealed a retroperitoneal schwannoma with inflammatory phenomena and hyperplasic lymphadenitis. The retroperitoneal schwannoma is a silent disease whose only clinical manifestation coincides with the compression of adjacent anatomical structures. In many cases, the symptoms, even if present, as in this case (ejaculatory pain with compression of the seminal vesicle), are non-specific, thus delaying diagnosis and the therapeutic approach.