Fistulas between lower urinary tract and bowel: our experience in 15 years.

OBJECT: Fistulas between bowel and low urinary tract are not frequent and could be due to different causes. Diagnosis and treatment need a particular care to assure to patient a good result. Authors report their last 15-years experience. MATERIALS AND METHODS: From 1990 and 2005 22 patients have been quite carefully investigated and surgically treated; 17 men and 5 women of age between 39 and 81 years old. In particular 2 vesico-ileal fistulas, 12 colo-vesical have been treated: in all these situations we proceed by intestinal resection and fistulas repairing at the same time. Three rectovesical and 3 recto-urethral fistulas have been treated by fistula's way removal (with different approaches) and in a case by preparing a definitive urinary derivation. Finally, 2 complex fistulas have been treated by preparing a definitive urinary derivation. RESULTS: The typical symptoms presence must be carefully researched because it could be useful in diagnosis; radiological and endoscopic procedures could be useful for treatment planning, also if they have a quite low sensibility. In 20 cases, the treatment has achieved a good and lasting result. In 1 case we had a relapse, in another one patient died for sepsis. CONCLUSION: Diagnosis of fistulas has to be quite careful and it is necessary to plan the treatment, that is always surgical, also considering that sometimes it's leading to serious complications.

[Salvage laparoscopic pyeloplasty in the worst case scenario: after failed open repair and endoscopic salvage]. / Pieloplastica laparoscopica di salvataggio "in the worst case scenario": dopo fallimento sia di pieloplastica open che di endopielotomia.

OBJECTIVES: We present the video of a laparoscopic correction of a left ureteropelvic junction obstruction in a patient who has already undergone previous surgical open pyeloplasty and subsequent acucise for failure of the first surgery. At 8 years after the second surgery, the patient showed a recurrence of the obstruction of the left ureteropelvic junction.
 It was decided to perform the retroperitoneal laparoscopic correction of the obstruction.
 MATERIALS AND METHODS: With the patient placed in a 90° flank position, 4 trocars are placed in the retroperitoneum space by the Hasson tecnique.
 After the creation of the retroperitoneum space, the Gerota's fascia is opened. The posterior layer of the Gerota's fascia appears very thickened at the level of the lower pole of the kidney and is very adherent with the surrounding structures, in particular the psoas muscle.
 Gerota's fascia is incised and removed from the previous surgery and the psoas muscle is identified. The distal lumbar ureter is tenaciously anchored to the psoas muscle. The lower pole of the kidney is freed from the adhesions of the previous surgery. The proximal ureter is hardly isolable for the presence of fibrosis. The renal pelvis is fixed to the psoas due to fibrotic tissue that is cut with scissors. Once the pelvis and the ureter are separated from the psoas, the surgery proceeds with the liberation of the pelvis from the adipose tissue and fibrosis that surround it. The pieloureteral obstruction is not easily identifiable. The renal pelvis is opened at the level of the ureteral junction, the ureter is spatulated on its medial side. The scar tissue is removed until well vascularized tissue is seen. The anastomosis between the ureter and pelvis is performed with 2 semicontinuous running sutures. Once the anterior plate of the anastomosis is completed a cystoscopic retrograde DJ ureteral stent insertion is performed. The procedure ends with the packaging of the posterior plate of the anastomosis with the second running suture.
 RESULTS: The operation lasted 180 minutes. The postoperative course was uneventful, the drain was removed on the second day and the bladder catheter on the 4th. The patient was discharged on the 5th day and the DJ ureteral stent was removed on the 21st post-operative day. 
 DISCUSSION: The laparoscopic reoperation in patients with previous open surgery interventions is definitely difficult. This kind of surgery has to be carried out after having gained considerable laparoscopy experience. Specifically, the reoperation of laparoscopic pyeloplasty after 2 previous intervention poses the following difficulties: the creation of appropriate space, dissection of the ureter and pelvis from the psoas muscle, appropriate mobilization of the lower pole of the kidney to get a "tension free" anastomosis, liberation of the pelvis and ureter from the tenaciously adherent fibrotic tissue, identification of the stenotic ureteropelvic junction.
 CONCLUSIONS: Laparoscopic pyeloplasty after failure of past interventions remains a difficult procedure that should only be performed after major laparoscopic experience. In experienced hands, redo laparoscopic pyeloplasty provides high success rates.

The R.E.N.A.L. nephrometric nomogram cannot accurately predict malignancy or aggressiveness of small renal masses amenable to partial nephrectomy.

INTRODUCTION/BACKGROUND: The prediction of histology of SRM could be essential for their management. The RNN is a statistical tool designed to predict malignancy or high grading of enhancing renal masses. In this study we aimed to perform an external validation of the RNN in a cohort of patients who received a PN for SRM. MATERIALS AND METHODS: This was a multicentric study in which the data of 506 consecutive patients who received a PN for cT1a SRM between January 2010 and January 2013 were analyzed. For each patient, the probabilities of malignancy and aggressiveness were estimated preoperatively using the RNN. The performance of the RNN was evaluated according to receiver operating characteristic (ROC) curve, calibration plot, and decision curve analyses. RESULTS: The area under the ROC curve for malignancy was 0.57 (95% confidence interval [CI], 0.51-0.63; P = .031). The calibration plot showed that the predicted probability of malignancy had a bad concordance with observed frequency (Brier score = 0.17; 95% CI, 0.15-0.19). Decision curve analysis confirmed a poor clinical benefit from use of the system. The estimated area under the ROC curve for high-grade prediction was 0.57 (95% CI, 0.49-0.66; P = .064). The calibration plot evidenced a bad concordance (Brier score = 0.15; 95% CI, 0.13-0.17). Decision curve analysis showed the lack of a remarkable clinical usefulness of the RNN when predicting aggressiveness. CONCLUSIONS: The RNN cannot accurately predict histology in the setting of cT1a SRM amenable to PN.

[Laparoscopic repair of enterovesical fistula in patient affected by left megaureter]. / Riparazione laparoscopica di fistola enterovescicale in paziente portatore di megauretere.

INTRODUCTION: Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. We present the case of EVF secondary to diverticular disease in a male with congenital megaureter. A laparoscopic repair of the colon vesical fistula was performed with colon resection. MATERIALS AND METHODS: With the patient in the Trendelenburg position -30° degrees on the right side, 5 trocars are positioned trans-peritoneally. The exploration of the abdominal cavity shows the sigmoid diverticular disease adhering tenaciously to the posterior wall of the bladder. The intestinal loops are medialized. The inferior mesenteric vein is isolated, clipped and divided. The mesosigma is isolated and the inferior mesenteric artery is closed 2 cm from its emergence from the aorta with EndoGIA™ 45 stapler. The left colon is isolated from its splenic flexure to the mesorectum. The peritoneum between the bladder and sigmoid colon at the site of the tenacious adhesions is incised. The left megaureter is isolated from the diverticular disease and the bladder is opened on the site of the fistula, to permit a wide resection of the fistula. The posterior wall of the bladder is then closed with double running sutures. Section of the rectum with EndoGIA™ 45 stapler. Extraction of 20 cm of sigma comprising diverticular disease by a 5 cm suprapubic laparotomy. The sigma is cut and the proximal head of the circular stapler is inserted and closed with a running suture. The left colon is put back in place into the peritoneal cavity. The laparotomy is closed and the surgery is reconverted into laparoscopy. A colorectal end-to-end anastomosis according to Knight Griffen is performed with ILS 29 circular stapler. The anastomosis is tested for leakage with hydropneumatic test: no evidence of spillage. A laminar drainage is placed close to the anastomosis and the incisions are closed. RESULTS: The operative time was 240 minutes. There were no intra- or post-operative complications. The bladder catheter was removed on day 7 after cystography. The patient was discharged asymptomatic on the 8th post-operative day. CONCLUSIONS: Laparoscopic treatment of enterovesical fistulas for benign disease is a safe and standardized procedure. It remains a difficult procedure with a conversion rate higher than laparoscopy for uncomplicated diverticulitis or malignancy. The procedure in a single session with intracorporeal bowel anastomosis is the standard.

[Laparoscopic removal of polycystic kidney through retroperitoneal approach: technical notes]. / Asportazione laparoscopica di rene policistico per via retroperitoneale: note di tecnica

INTRODUCTION: We present our technique of laparoscopic nephrectomy with intact specimen extraction for patient with autosomal dominant polycystic kidney disease (ADPKD). MATERIALS AND METHODS: A 5-port retroperitoneal laparoscopic approach was used to dissect the involved kidney, which was then removed intact through a Gibson modified incision. RESULTS: The operative time was 110 minutes. Blood loss accounted for 50 mL. There were no intra or post-operative complications. The hospital stay was 4 days. CONCLUSIONS: Laparoscopic nephrectomy for ADKD is technically feasible and clinically safe. The advantages of these technique compared to transperitoneal laparoscopy are the quick access to the hilar vessels and the strict extraperitoneal route, which prevent the risk of sepsis.

[Laparoscopic repair of rectovesical fistula after radical retropubic prostatectomy]. / Riparazione laparoscopica di fistola retto vescicale post prostatectomia radicale retropubica.

INTRODUCTION: We present the video of a laparoscopic repair of a rectovesical fistula after radical retropubic prostatectomy. The rectal lesion had not been detected during the first procedure. The rectal bladder fistula appeared on the 14th post-operative day. After three weeks from the procedure,the patient underwent a laparoscopic repair of the rectovesical fistula. A temporary external colon conduit was performed at the same time. MATERIALS AND METHODS: We performed a cystoscopy before the surgery; it showed a fistula behind the bladder neck at 5 o'clock, distally to the left ureteral orifice. Two ureteral stents were inserted into both the ureters to make sure not to determine any injury to these structures during the operation. With the patient in the supine position, we introduced 5 trocars with the Hasson technique trans-peritoneally. The pouch of Douglas was opened and the bladder was divided from the rectum.The bladder posterior wall was widely opened till reaching the rectal bladder fistula.The fistula was located distally to the left ureteral orifice, very close to the bladder neck. Through a blunt dissection, we divided the margins of the rectal fistula from those of the posterior bladder wall.Indeed, we performed a suture of the rectal wall without any tension. The rectal lesion was closed in a double-layer suture with 3-0 Vicryl.We introduced a probe into the rectum to make sure there was no leakage on the suture. A flap of peritoneum of the Douglas was put between bladder and rectum.We closed the longitudinal opening of the trigone and the bladder posterior wall through a continuous suture.An external colic conduit was packaged to guarantee the closure of the fistula. The left colon was put through the abdominal wall widening the 5 mm trocar opening located on the left pararectal space. RESULTS: The operative time was 240 minutes. There were no post-operative complications. The bladder catheter was removed at 1 month after surgery,only after performing a cystography, which showed no leakage.Two months later, the colostomy was closed. At a 12-month follow-up the patient had no fistula recurrence. CONCLUSIONS: The treatment of arectovesical fistula after radical prostatectomy remains a complex procedure: different types of corrective surgical approaches have been described. The laparoscopic approach is an alternative to standard procedures. The optical magnification allows a good view of the fistula in a very deep and narrow space. It also allows easy performing of the colostomy.

[Laparoscopic removal of voluminous right seminal vesicle neoplasm]. / Asportazione laparoscopica di voluminosa neoplasia della vescicola seminale destra.

INTRODUCTION: We present the case of a male adnexal tumor of probable Wolffian origin occurred to the right seminal vesicle of a 47-year-old man. MATERIALS AND METHODS: The patient presented with a 2-month history of hematospermia. The diagnosis was achieved by transrectal ultrasound, CT of the abdomen and pelvis, and biopsy of both prostate and seminal vesicle. The patient was counseled for laparoscopic excision of the right seminal vesicle. RESULTS: The right seminal vesicle, along with the tumor and the right vas deferens, were excised and clear margins were ensured by frozen section. Total operative time was 180 with 200 mL blood loss. The patient's recovery was uncomplicated and he was discharged on the fourth post-operative day. The histologic examination demonstrated a male adnexal tumor of probable Wolffian origin, which is a rare low-grade malignant neoplasm that has been previously described in the broad ligament, ovaries and retroperitoneum of females. The patient is free of relapse at a 20-month follow-up. CONCLUSIONS: This is the second report of this entity in a male. The laparoscopic approach for the excision of seminal vesicle neoplasms is a good treatment for its obvious benefits of minimal blood loss, short hospital stay and quick return to normal activity. The magnifications of the anatomical details of the pelvic floor help the surgeon in the dissection of the seminal vesicle from the other structures.