Feasibility and outcomes regarding open and laparoscopic radical prostatectomy in patients with previous synthetic mesh inguinal hernia repair: meta-analysis and systematic review of 7,497 patients.

INTRODUCTION: The purpose of this article is to contribute information to the interpretation of the feasibility and outcomes regarding open, laparoscopic and robotic strategies of radical prostatectomy in patients with previous synthetic mesh inguinal hernia repair. MATERIALS AND METHODS: A bibliographic search covering the period from January 1980 to September 2012 was conducted in PubMed, MEDLINE and EMBASE. Database searches yielded 28 references. This analysis is based on the eleven studies that fulfilled the predefined criteria. RESULTS: A total of 7,497 patients were included. In the study group, there were 462 patients. The surgical prostatectomy techniques were open in five studies, laparoscopic in three and robotic in the remaining three. The control group consisted in 7,035 patients. The comparison of the open procedure performed in patients with a previous mesh herniorrhaphy and controls shows that the number of lymph nodes removed resulted significantly lower and hospital stay with catheterization time results statistically longer. The comparison of the laparoscopic procedure does not evidence a statistically significant difference in terms of blood loss, operative time and catheterization time, while the comparison with the robotic group could not be performed for the lack of data. CONCLUSION: All patients need an adequate informed consent regarding the multitude of aspects which may be influenced by the mesh such as the possibility of hernia recurrence, mesh infection, need for mesh explantation, possibility of mesh erosion into the bowel or bladder, bladder neck contractures or postoperative urinary incontinence and a compromised nodal staging.

Risks and complications of transurethral resection of bladder tumor among patients taking antiplatelet agents for cardiovascular disease.

BACKGROUND: Urologists have not reached a consensus regarding the pre-, intra-, and postoperative management of patients taking antiplatelet agents. This study aimed to evaluate the clinical course of patients receiving antithrombotic monotherapy with acetylsalicylic acid (ASA) 100 mg who underwent transurethral resection of bladder cancer. METHODS: This study was designed to compare the surgical outcomes for 108 transurethral resections of bladder cancer performed for patients taking antiplatelet therapy and for 105 procedures performed for patients who had never taken antiplatelet agents before surgery. Antiaggregant therapy was maintained according to criteria evaluated by a urologist, surgeon, anesthesiologist, and cardiologist. Variables were described using the mean as the location index and using standard deviation as a dispersion index if continuous percentages were used elsewhere. Group comparisons were performed using the t test or the chi-square test for categorical data, and Fisher's exact test was used where appropriate. RESULTS: The mean operative time for patients taking ASA was 31 min (range 10-65 min), whereas it was 26 min (range 5-60 min) for control subjects. The difference between pre- and postoperative hemoglobin values was -0.6 g/dl in the group receiving antiplatelet therapy and -0.8 g/dl in the control group (p = 0.0720). Transfusional support was required during four procedures performed for patients taking antiplatelet therapy and during two procedures for the control group (p = 0.242). No adverse cardiac events or anesthesia-related complications occurred. Three patients in the treatment group and two patients in the control group required reintervention to ensure hemostasis during the postoperative period. None of the patients in either group underwent rehospitalization for hematuria after leaving the hospital. CONCLUSION: The current results suggest that continued use of anti-aggregant monotherapy does not increase the risk of overall bleeding or reintervention for patients undergoing transurethral resection of bladder neoplasms and that suspending aspirin before such a procedure is therefore unnecessary.

Is stone diameter a variable in the decision process of employing a ureteral stent in patients undergoing uncomplicated ureterorenoscopy and associated intracorporeal lithotripsy?

INTRODUCTION: A number of randomized trials and meta-analysis in patients who underwent ureteroscopic stone removal investigated the effects of placing a ureteral stent at the end of the procedure on complication rates. However, none of these investigates the stone diameter and its possible influence on complication rates and, as such, if it should be considered a possible variable in the decision process of placing or not a ureteral stent. MATERIALS AND METHODS: A bibliographic search covering the period from January 1990 to March 2012 was conducted in PubMed, MEDLINE and EMBASE. This analysis is based on the fifteen remaining studies which fulfilled the predefined inclusion criteria. All statistical evaluations were performed using SAS version 9.2. and by RevMan 5.0. RESULTS: A total of 1,416 patients were included. All the studies were published after 2000. Mean stone diameter ranged between 5.3 and 13.3 mm in the non-stented group and between 6.26 and 13.28 mm in the stented group. Meta-analysis showed that stone diameter was not statistically different for stented or non-stented subgroups, whereas surgical operative time was shorter for the non-stented subgroup. The effect of stone diameter, irrespectively if patients were operated with or without stents were grouped or considered separately, did not influence complications of fever, haematuria, unplanned medical visits after surgery and urinary tract infections. CONCLUSIONS: Stone diameter is not a variable in the pre- or intraoperative decision process of placing or not placing a ureteral stent in patients undergoing uncomplicated ureterorenoscopy with intracorporeal lithotripsy.

Upper urinary tract recurrence following radical cystectomy for bladder cancer: a meta-analysis on 13,185 patients.

PURPOSE: Patients who undergo radical cystectomy for urothelial cancer are at risk for upper urinary tract disease in the remnant transitional tissue. Previous studies have identified several risk factors for upper urinary tract recurrence but the predictive value of each factor remains controversial. Furthermore, the schedule for surveillance of the upper urinary tract with imaging techniques and cytology has not been established. International guidelines do not address these topics and refer only to isolated works with a large case based analysis. We performed this meta-analysis to evaluate the effective incidence of upper urinary tract recurrence after cystectomy for bladder cancer, to analyze the risk factors so we can create subgroups of patients at high risk for recurrence and to investigate the real role of screening in the detection of upper tract lesions at an early stage. MATERIALS AND METHODS: A bibliographic search covering the period from January 1970 to July 2010 was conducted using PubMed®, MEDLINE and EMBASE®. This analysis is based on the 27 studies that fulfilled the predefined inclusion criteria. Data were analyzed using a fixed effect logistic regression approach and classic meta-analysis. RESULTS: A total of 13,185 participants were included in the analysis. Followup was described in 22 studies and ranged from 0.36 to 349.2 months. The overall prevalence of upper tract transitional cell cancer after cystectomy ranged from 0.75% to 6.4%. Recurrence appeared at a range of 2.4 to 164 months, and in an advanced (64.6%) or metastatic state (35.6%) as reflected in poor survival rates. Patients with low grade vs high grade lesions at cystectomy showed as strong a significant difference in incidence as those with carcinoma in situ and superficial cancer vs invasive cancers and as strong as in those without lymph node involvement, with multifocal disease, with a history of multiple urothelial recurrences, with positive ureteral margins, with positive urethral margins, with urethral involvement and a history of upper urinary tract urothelial cancer. Data do not support a statistically significant difference in recurrence among patients with a history of carcinoma in situ, solitary lesion and among various types of urinary diversion adopted. In 24 studies the followup schedule included periodic radiological assessment of the upper urinary tract and in 20 it included urinary cytology. In 14 studies in 63 of 166 patients (38%) upper urinary tract recurrence was diagnosed by followup investigation whereas in the remaining 62% diagnosis was based on symptoms. When urine cytology was used in surveillance the rate of primary detection was 7% and with upper urinary tract imaging it was 29.6%. Of 5,537 patients who underwent routine cytological examination, recurrence was diagnosed in 1.8/1,000 and of those who underwent upper urinary tract imaging recurrence was diagnosed in 7.6/1,000. CONCLUSIONS: The recurrence values could appear low when considering the pan-urothelial field defect theory, but these values reflect, in part, the mortality associated with the initial bladder cancer. Based on anamnesis and pathological examination of cystectomy specimens, a group of patients is at high risk. Extensive regular followup with cytology, urography and loopgraphy yields insufficient benefits. Periodic computerized tomography with urography combines the ability to study the upper urinary tract oncologically and functionally, and the identification of any parenchymal, osseous or lymph node secondary lesion.

Urgent shock wave lithotripsy as first-line treatment for ureteral stones: a meta-analysis of 570 patients.

The rationale for the use of immediate shock wave lithotripsy (SWL) after a renal colic episode is to obtain maximum stone clearance in the shortest possible time with associated early detection of lithotripsy failures which can be treated with auxiliary procedures. The aim of this meta-analysis is to understand the role of this treatment option in the emergency setting as first-line treatment and to compare such an immediate procedure to a delayed one in terms of stone-free and complication rates. A bibliographic search covering the period from January 1995 to September 2010 was conducted in PubMed, MEDLINE and EMBASE. Database searches yielded 48 references. This analysis is based on the seven studies that fulfilled the predefined inclusion criteria. A total of 570 participants were included. The number of participants in each survey ranged from 16 to 200 (mean 81.42). Six studies were published after 2000 and one in the 1990s. All studies reported participants' age with mean of 40.9 years, and range between 11 and 88 years. All patients presented with unilateral lithiasis, as such the number of total stones treated was 570. Mean stone diameter ranged between 6.38 and 8.45 mm. According to the logistic regression applied stone-free rates were 79 % (61-95) for the proximal ureter, 78 % (69-88) for the mid ureter, 79 % (74-84) for the distal ureter and 78 % (75-82) for overall. Stone-free rates do not evidence a statistically significant difference compared to those described in the AUA and EAU guidelines for elective management. SWL management of ureteral stones in an emergency setting is completely lacking in the international guidelines and they results disperse in the literature in few works. According to our meta-analysis, immediate SWL for a stone-induced acute renal colic seems to be a safe treatment with high success rate. This evidence will be validated by further randomized studies, with a larger series of patients.

Urgent ureteroscopy as first-line treatment for ureteral stones: a meta-analysis of 681 patients.

There are various recent studies on the use of ureteroscopy and debate on whether this should be the first-line treatment for patients with ureteral stones. The aim of this meta-analysis was to understand the role of this surgical procedure in the emergency setting as first-line treatment and to compare the immediate procedure with a delayed one in terms of stone-free rate and complications. A bibliographic search covering the period from January 1980 to March 2010 was conducted in PubMed, MEDLINE and EMBASE. This analysis is based on the six studies found that fulfilled the predefined inclusion criteria. A total of 681 participants were included. The number of participants in each of the studies considered ranged from 27 to 244 (mean 113). Stone-free rates were 81.9% (72.0-91.8) for the proximal ureter, 87.3% (82.6-92.0) for the mid-ureter, 94.9% (92.1-97.6) for the distal ureter and 89.5% (86.5-92.5) overall according to the logistic regression applied. These values are not statistically significantly different from those reported in the AUA and EAU guidelines. The stone diameter seems to affect the stone-free rate. An increase of the stone diameter of 1 mm beyond 8 mm corresponded to a reduction of stone-free rate of 5% (2.4-8.0) and 8.1% (3.8-12.1) for the distal and proximal ureters, respectively. There is a complete lack of information in international guidelines on the ureteroscopic management of ureteral stones in an emergency setting and the currently available results are dispersed in a few studies in the literature. The rationale for using emergency ureteroscopy is more rapid stone clearance and relief from colic pain. According to our meta-analysis, immediate ureteroscopy for ureteral stone colic seems to be a safe treatment with a high success rate. This evidence will be validated by further randomized studies, with larger series of patients.

Surgical subinguinal approach to varicocele combined with antegrade intraoperative sclerosis of venous vessels.

Varicocele is treated by different surgical techniques, none of which is yet acknowledged as the "gold standard." Some of these techniques, especially microsurgical techniques, are very time consuming and thus expensive, and the treatment of varicocele still causes some complications and recurrences. Marmar and Kim's technique presents some indisputable advantages: it allows the preservation of the arteries and seems to offer the highest percentage of success and lowest number of complications. The authors modified and simplified the microsurgical technique of Marmar and Kim, using a subinguinal approach with intraoperative antegrade sclerotherapy of dilated veins. After the cord has been clamped, 1.5 to 3 mL of 3% aetoxisclerol mixed with 0.5 mL of air is injected. Commonly, minor complications can occur. The most common complication is transient penile lymphangitis, the cause of which is unclear. As the procedure allows selective sparing of the lymphatic vessels, it avoids hydrocele due to the performed procedure.

Endoscopic resection of bladder cancer in patients receiving double platelet antiaggregant therapy.

BACKGROUND: Approximately 5% of patients who have undergone coronary artery stenting require noncardiac surgery within a year of their cardiac intervention. European cardiological guidelines and recommendations from the U.S. Food and Drug Administration on platelet antiaggregant therapy following coronary artery stenting are for dual treatment with acetylsalicylic acid and clopidogrel, which should be continued for at least 12 months. The aim of this study was to evaluate the clinical course in patients receiving double platelet antiaggregant therapy who underwent transurethral resection of bladder cancer. METHODS: Between September 2007 and April 2010, twelve patients receiving double antithrombotic therapy (clopidogrel+acetylsalicylic acid) underwent transurethral resection of bladder cancer. In two cases the operation was "urgent". The mean age of the patients was 71.25 years (range, 52-83 years). In nine cases the bladder cancer was newly diagnosed. RESULTS: The patients' preoperative mean hemoglobin concentration was 11.4 g/dl (range=5.2-13.4 g/dl), and on the first postoperative day it was 10.2 g/dl (range=9.6-12.6 g/dl). The mean duration of the intervention was 32 min (range=20-60 min). There were no cardiac complications in either the perioperative or the postoperative period. No patient required reintervention for hemostatic purposes. Three episodes of clot-related acute urinary retention occurred after removal of the bladder catheter, all of which were resolved with replacement of the catheter without needing reintervention. CONCLUSION: Despite the high number of complications related to cardiac problems that suspension of these drugs causes, this urological intervention, carried out during dual antithrombotic therapy, was feasible and without major complications. Given the high proportion of complications due to clot-related urinary retention, it is advisable to leave the urinary catheter in place for a longer period.

Transrectal ultrasound-guided prostate biopsies in patients taking aspirin for cardiovascular disease: A meta-analysis.

INTRODUCTION: The management of anti-platelet therapy in the peri-operative period is a source of great concern. The dilemma is between whether to stop these agents peri-operatively in order to reduce the risk of bleeding complications, or to continue them in order not to compromise the protection they afford against the risk of cardiovascular events. MATERIALS AND METHODS: The aim of this systematic review and meta-analysis was to understand whether continued aspirin therapy is a risk factor for bleeding complications after ultrasound-guided biopsy of the prostate. A bibliographic search covering the period from January 1990 to May 2011 was conducted in PubMed, MEDLINE and EMBASE. We also included our own series in the analysis. RESULTS: A total of 3218 participants were included. Haematuria was statistically more frequent (P=0.001) among patients taking aspirin than in the control group with an odds ratio estimate of 1.36 [1.13;1.64]. This increased risk was, however, due to minor bleeding. The occurrence of rectal bleeding and haematospermia was not statistically increased (P=0.33 and P=0.24, respectively) in patients taking aspirin compared to in the control group with odds ratios estimate of 1.24 [0.80;1.93] and 1.52 [0.75;3.08], respectively. DISCUSSION: There is limited information of the relationship between continued use of aspirin and haemorrhagic complications after transrectal ultrasound-guided biopsy of the prostate. This is the first comprehensive analysis on this topic. CONCLUSION: Continued use of aspirin does not increase the risk of overall bleeding or moderate and severe haematuria after prostatic biopsy, and thus stopping aspirin before such biopsies is unnecessary.

Azoospermia and severe oligospermia in testicular cancer.

UNLABELLED: OBJECTIVE of the study is a prospective evaluation of the severe oligospermic and azoospermic patients at the moment of testicular cancer diagnosis and following curative therapies. MATERIALS AND METHODS: Between January 2003 and December 2006 thirty-five testicular cancers were diagnosed at our institution. As soon as a testicular mass was diagnosed patients were requested to cryo-conserve a semen specimen before orchiectomy. Overall 20 patients adhered to our recommendation. The remaining 15 patients did not follow this recommendation only due to strictly personal and psychological reasons. RESULTS: Ten patients presented severe oligospermia or azoospermia at the moment of testicular cancer diagnosis. Nine months following testicular tumour removal 9 recovered or improved their fertility passing form an azoospermia status to a mean 5.68 x 10(6) spermatozoa/ml. One patient remained azoospermic. DISCUSSION AND CONCLUSION: In 1999 Petersen stated that the presence of so many infertile patients at the time of testis tumoural diagnosis was linked with defined genetic alterations in the other testis. These alterations were linked with severe oligospermia or azoospermia. Our study evidences how a considerable percentage of azoospermic and oligospermic patients recover fertility following definite testicular cancer therapies even if these are potentially harmful for spermatogenesis.

Giant renal cyst complicated with acquired crossed renal ectopia, hypertension and renal cell carcinoma: case report and review of the literature.

Simple renal cysts are acquired kidney lesion that are described as spherical, smoothed surfaced, with a serous, sub-yellow content. They are generally considered as a harmless anomaly, however cases of complicated renal cysts have been reported. We present a case of an enormous renal cyst (the biggest ever described) containing more than 25 L of fluid mimicking ascites, complicated with controlateral displacement of ipsilateral functional kidney and intra-abdominal organs, renal cell carcinoma and hypertension. Particular attention is carried in the analysis of the literature about different aspects of giant renal cysts like the ability to grow to a very giant size, the association with hypertension and renal cell carcinoma, the sensibility of the most important examinations to reveals malignancy and management.

Numb chin syndrome: the presenting symptom of a metastatic prostate carcinoma.

Numb chin syndrome is a sensory neuropathy characterized by numbness involving the distribution of the mental nerve that could be an uncommon manifestation of metastatic malignancy. Bony metastases are common in patients with advanced prostate carcinoma and involving preferentially vertebrae, sternum, pelvic bones, ribs and femurs. We report a case in an 82-year-old man presenting a history of mental neuropathy as the isolated presenting symptom of a widespread metastatic prostate cancer Numb chin syndrome was describe in some reviews as a late component of a previously diagnosed disease but this report underline the importance of this neuropathy as the isolated presenting symptom of a widespread metastatic prostate cancer. This event is very rare and enumerates four cases in the world literature.

Complete genital prosthetization in patients treated with bilateral orchiectomy for metachronous testicular cancer.

UNLABELLED: Testicular malignant tumours represent 1% of neoplasms. The probability of developing a contralateral tumour is between 3% and 7%. We report two cases of complete genital prosthetization in two patients treated with bilateral orchiectomy for metachronous testicular cancer. In our knowledge no previous case is reported in literature. CASE REPORTS: A 46-year-old patient and a 49-year-old patient underwent bilateral radical orchiectomy for metachronous cancers of the testis. The first patient complained the complete loss of libido and complete impotence. For this reason he began a substitutive hormonal therapy with testosterone esters obtaining re-establishment of the masculine phenotype. With the reappearance of the libido and physical efficiency, the patient showed the intention to recover sexual activity and he was treated first by phosphodiesterase type 5 (PDE-5) inhibitors and then he began a cycle of prostaglandin El1(PGE1) but unfortunately without a satisfactory sexual performance. The second man maintained libido, lost sexual efficiency and showed hypogonadism. Substitutive therapy with testosterone enanthate obtained normalization of testosterone values. A psychosexual assessment highlighted a depressive state related to the absence of sexual performance due to an erectile deficit, that was treated first by PDE-5 inhibitors and then by intracavernous injections of PGEI without benefits. After individual and couple counselling both of the patients submitted both semirigid mono component penile prosthesis and bilateral testicular prostheses implantation by means of a single penile-scrotal incision. Both the patients regained sexual activity and were satisfied with the cosmetic appearance. CONCLUSION: We underline the importance of the collaboration between the andrologist and the psycho-sexologist and the on-going collaboration with the patient. This allows the clinician to appraise the situation completely and to work out a common solution built around the patient to obtain a full recovery of his identity.

Follow-up of elderly patients with urogenital cancers: Evaluation of geriatric care needs and related actions.

OBJECTIVES: To investigate a comprehensive geriatric assessment (CGA) with subsequent investigation of healthcare patterns in older patients with urological cancers undergoing initial surgery or radiotherapy, to verify the usefulness of the incorporation of geriatric principles in future care plans. MATERIAL AND METHODS: This is a prospective cohort study. From November 2011 to March 2015, CGA was offered to all patients aged 70+ years treated with radiotherapy or surgery at seven tertiary centers. Patients were classified as fit, vulnerable, or frail according to Balducci's definition. CGA and follow-up data were collected by two trained evaluators at 6 and 12months. The information collected was not available to the caring physicians during follow-up. RESULTS: CGA was performed in 453 patients with prostate cancer (295), bladder cancer (126), or kidney cancer (32). 40% of patients with prostate cancer were fit, 47% vulnerable, and 13% frail. The corresponding values for renal cancer were 25%, 40%, and 34%, and for bladder cancer, 21%, 42%, and 37%. During follow-up, 60% of patients with cardiac diseases, 42% of those with diabetes/other metabolic disorders, 35% of those with hypertension, and 35% of those with respiratory diseases were followed by a specialist (for these severe/extremely severe comorbidities). Of 16 patients with ADL impairment and 63 with IADL impairment, only 4 (25%) and 6 (10%), respectively, were referred to a rehabilitation service. Only one case was referred to a geriatrician. CONCLUSIONS: Appropriate clinical care patterns are advisable to improve quality of survivorship in older patients with urological cancers.

Thulium Laser Prostate Enucleation in Refractory Urinary Retention: Operative and Functional Outcomes in a Large Cohort of Patients.

OBJECTIVE: To evaluate the functional and operative results of thulium laser enucleation of the prostate (ThuLEP) in patients with indwelling catheters for refractory urinary retention. METHODS: Patients with indwelling catheter, undergoing ThuLEP for benign prostate hyperplasia, were prospectively enrolled. Every episode of urinary retention was treated with urinary catheter positioning followed by at least 2 attempts of catheter removal. Patients were investigated with flowmetry and the self-administered International Prostate Symptom Score questionnaire at 30 and 90 days following ThuLEP. RESULTS: Three hundred eighty-one patients underwent ThuLEP, and 99 of these had indwelling catheters, but only 93 (24%) were eligible according to the inclusion criteria. In 46 patients the bladder catheter was removed on the first postoperative day, in 31 patients on the second postoperative day, in 5 patients on the third postoperative day, in 6 patients on the fourth postoperative day, in 1 patient on the fifth postoperative day, and in 2 patients each on the sixth and seventh postoperative days. The average hospital stay was 2.3 (±1.7) days. No patients undergoing ThuLEP, at the 90-day follow-up, required further catheterization. Flowmetry showed significant improvement in all parameters, and the mean International Prostate Symptom Score dropped from 21.33 preoperatively to 3.2 (P = .004) at 90 days postoperatively. CONCLUSION: This prospective study shows that ThuLEP is a safe and effective approach in refractory urinary retention patients. In our case series, no patients required postoperative intermittent catheterization. All functional outcomes investigated reported a statistical significant improvement.