Robotic surgery in the management of complex pelvic endometriosis.

INTRODUCTION: Endometriosis consists in the proliferation of endometrial tissue outside of the uterine cavity, predominantly in the ovaries but also in the urinary bladder or bowel. About 10% of fertile women are affected and the main symptoms are pain, menstrual disorders and infertility. Surgery is the treatment option for those symptomatic patients in which medical treatment had no success. MATERIAL AND METHODS: We report on a case of a 43 - years - old patient without urologic personal history submitted to our office because of a grade - III right - hydronephrosis. The patient, with an endometriosis diagnosis since years, presents chronic pelvic pain with the daily necessity of strong opioids intake. CT scan revealed several endometriosis implants in the uterine wall and rectum that caused right ureteral entrapment. Renography revealed a 24% function in the right kidney. After right nephrostomy a multidisciplinary committee decided surgical intervention. With robotic approach, we performed an hysterectomy with right salpingo - oophorectomy; release, resection and right ureteral reimplantation; anterior resection of the rectum and protective ileostomy. Vaginal extraction of the specimen. In this video we show the key steps of the procedure. RESULTS: Total operative time: 330 minutes. Total bleeding: 250 cc. Nephrostomy removal: 4 th day. Urethral catheter removal: 5 th day. Patient was discharged in the 7 th day. Ureteral JJ - stent removal: 30 th day. CT urography reveals a permeable ureteral tract with no urine leakage. Renography shows a progressive improvement of the kidney function. CONCLUSIONS: Robotic surgery allows a correct handling of endometriosis, mainly in complex cases. It is a safe and reproducible technique with correct outcomes in selected patients. A multidisciplinary team is required.

Neoadjuvant chemotherapy with dose-dense MVAC in muscle-invasive bladder cancer: a tertiary center experience.

PURPOSE: Neoadjuvant chemotherapy in muscle-invasive bladder cancer (MIBC) patients has proven beneficial in overall survival. However, the optimal regimen is still a matter of debate. MATERIALS AND METHODS: In this retrospective analysis, we evaluate the results obtained in 42 patients treated in our center with 4 cycles of neoadjuvant dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (dd-MVAC) followed by radical cystectomy from August 2015 to October 2020. All patients had cT2 or higher non-metastatic MIBC. Clinical and pathological outcomes are reported. RESULTS: Of the 42 patients, 90.5% were men (n = 38) and the mean age was 65 years. All of them had ECOG 0-1 at diagnosis and most tumors had an initial clinical stage T2N0 (76%). Thirty-six patients (85.7%) completed 4 cycles of neoadjuvant treatment, and 21.4% required a dose reduction. The most frequent adverse event (AE) was grade 1-2 asthenia (81%), while neutropenia was the most frequent grade 3 or higher AE (38%). Complete pathological response (ypT0, ypN0) was achieved in 50% of patients (n = 21), and down-staging was observed in 57.1% (n = 24). Only one patient presented radiological progressive disease during neoadjuvant treatment (2.4%), and after a mean follow-up time of 31.5 months, 33.3% of patients experienced disease recurrence. CONCLUSIONS: Neoadjuvant chemotherapy with 4 cycles of dd-MVAC is an effective regimen with high rates of pathological complete responses and down-staging along with an acceptable toxicity profile. DD-MVAC should be considered as an alternative to cisplatin and gemcitabine in patients with good clinical performance status.

Testicular reconstruction after testicular rupture and review of the literature.

OBJECTIVE: To report a clinical case of testicular rupture and review of the literature published. METHOD: A 15 years old male with a testicular rupture after a sports injury was diagnosed by Doppler ultrasound. RESULTS: Surgical exploration was performed and the tear was repaired. He had a benign postoperative course. The patient presents a normal size testicle after a year of follow-up. CONCLUSIONS: Testicular rupture is an uncommon but important entity that may occur. It is essential early diagnosis and e management to avoid orchiectomy.

[Experience with third, fourth and fifth kidney transplants and their complications.] / Experiencia en terceros, cuartos y quintos trasplantes renales y sus complicaciones.

OBJECTIVES: Kidney transplant may be a good choice to treat chronic renal failure even in patients with two or more previous renal grafts. However, there might be several surgical complications and other difficulties we have to deal with. The aim of this report is to analyze the third, fourth and fifth transplants performed in our center focusing on the surgical complications and graft and patient survivals. METHODS: We performed a retrospective analysis of the 73 third, fourth and fifth kidney transplants performed in our center between February 1975 and December 2015. Statistical analysis has been performed with IBM SPSS 23.0 software. RESULTS: 62 patients received a third graft, 10 received a fourth one and one patient received a fifth graft. The median age of the recipients was 48 years, while for donors it was 50. Median cold ischemia time was 21 hours. Transplantectomy was not necessary in 49.31% of the cases. In 59.7% of the cases the graft vessels were anastomosed to the external iliac vessels. There were 21 cases of relevant postoperative complications (27.4% of the total grafts). Vascular thrombosis appeared in 5.5%. After 49 months of follow-up, the 1-, 3-, and 5-year graft survival were 64.3%, 56.16% and 50.69%, respectively. CONCLUSIONS: A new renal transplant in patients with two or more previous grafts is feasible, being necessary to individualize the cases. In spite of being more complex operations than previous transplants with a higher complication rate, we can obtain both acceptable graft and patient survival outcomes with an appropriate approach.

Incidental bladder lipoma: a case report and review of the literature.

Conventional lipoma is the most common benign mesenchymal neoplasm in adults. However, bladder lipoma is a rare tumor. We report an incidental 0.5-cm, mucosal, bladder lipoma in a 75-year-old man, successfully treated with endoscopic excision. The tumor was found during the extension study of a high-grade urothelial carcinoma of the renal pelvis. A review of the published cases, including the present report, yielded a total of 16. Conclusions on this review are presented. The case is being reported because its rarity and to highlight the importance of complete workup to clarify associated disorders that may suggest extension of a malignant process.

About a case report of giant hydronephrosis.

Introduction. Our objective is to report a case of an infrequent entity as the giant hydronephrosis. Case Report. We report the case of an 82-syear-old male referred for a poor general condition. A radiological study revealed a great left hydronephrosis secondary to an urothelial carcinoma. The patient died due to his poor general condition. A histological diagnosis revealed a transitional cell carcinoma of renal pelvis and ureter and atrophic renal parenchyma. Conclusion. Giant hydronephrosis represents a very often entity to be taken into account in cases with big cystic abdominal masses in absence of unilateral or bilateral kidney. Simple nephrectomy is the treatment of choice in most cases. Nevertheless, in cases of nonsubsidiary surgery, percutaneous drainage may be necessary.

Incidental lipoma-like hibernoma arising from the adrenal gland: a well-differentiated liposarcoma mimicker.

Hibernomas are uncommon benign lipomatous tumors which show differentiation toward brown fat. To our knowledge, only one case of adrenal hibernoma has been previously reported. We describe a 55-year-old woman showing an incidental, 1.7 cm-hibernoma associated with a 2.6 cm-cortical adenoma producing primary hyperaldosteronism (Conn's syndrome), both in the left adrenal gland. The hibernoma was composed predominantly of univacuolated mature fat cells admixed with small vessels. Scattered areas composed of large multivacuolated pale cells with central or paracentral nuclei, mimicking lipoblasts, accounting for less than 30% of the tumor, were found. These cells lacked nuclear hyperchromasia or marked atypia, were S100-positive, and showed numerous mitochondria reactive with the anti-mitochondrial antibody. A diagnosis of lipoma-like hibernoma was made. Pathologists should be aware of this variant of hibernoma to avoid misdiagnosis and excessive treatment.