Elective segmental ureterectomy for transitional cell carcinoma of the ureter: long-term follow-up in a series of 73 patients.

UNLABELLED: What's known on the subject? and What does the study add? Upper Urinary Tract (UUT) Transitional Cell Carcinoma (TCC) is an uncommon disease and represents approximately 5% of all urothelial carcinomas. We report our series on 73 patients treated with Kidney Sparing Surgery for UUT TCC. Good results have been achieved in terms of oncological outcome comparing this conservative approach to the radical nephrourectomy. OBJECTIVES: • To report the long-term oncological outcome in patients with transitional cell carcinoma of the ureter electively treated with kidney-sparing surgery. • To compare our data with the few series reported in the literature. PATIENTS AND METHODS: • We considered 73 patients with transitional cell carcinoma of the distal ureter treated in five Italian Departments of Urology. • The following surgeries were carried out: 38 reimplantations on psoas hitch bladder (52%), 21 end-to-end anastomoses (28.8%), 11 direct ureterocystoneostomies (15.1%) and three reimplantations on Boari flap bladder (4.1%). • The median follow-up was 87 months. RESULTS: • Tumours were pTa in 42.5% of patients, pT1 in 31.5%, pT2 in 17.8% and pT3 in 8.2%. • Recurrence of bladder urothelial carcinoma was found in 10 patients (13.7%) after a median time of 28 months. • The bladder recurrence-free survival at 5 years was 82.2%. • The overall survival at 5 years was 85.3% and the cancer-specific survival rate at 5 years was 94.1%. CONCLUSION: • Our data show that segmental ureterectomy procedures do not result in worse cancer control compared with data in the literature regarding nephroureterectomy.

Robotic laparoscopic surgery: cost and training.

The advantages of minimally invasive surgery are well accepted. Shorter hospital stays, decreased postoperative pain, rapid return to preoperative activity, decreased postoperative ileus, and preserved immune function are among the benefits of the laparoscopic approach. However, the instruments of laparoscopy afford surgeons limited precision and poor ergonomics, and their use is associated with a significant learning curve and the amount of time and energy necessary to develop and maintain such advanced laparoscopic skills is not insignificant. The robotic surgery allows all laparoscopists to perform advanced laparoscopic procedures with greater ease. The potential advantages of surgical robotic systems include making advanced laparoscopic surgical procedures accessible to surgeons who do not have advanced video endoscopic training and broadening the scope of surgical procedures that can be performed using the laparoscopic method. The wristed instruments, x10 magnifications, tremor filtering, scaling of movements and three-dimensional view allow the urologist to perform the intricate dissection and anastomosis with high precision. The robot is not, however, without significant disadvantages as compared with traditional laparoscopy. These include greater expense and consumption of operating room resources such as space and the availability of skilled technical staff, complete elimination of tactile feedback, and more limited options for trocar placement. The current cost of the da Vinci system is $ 1.2 million and annual maintenance is $ 138000. Many studies suggest that depreciation and maintenance costs can be minimised if the number of robotic cases is increased. The high cost of purchasing and maintaining the instruments of the robotic system is one of its many disadvantages. The availability of the robotic systems to only a limited number of centres reduces surgical training opportunities. Hospital administrators and surgeons must define the reasons for developing a robotic surgical program: it is very important to show that robotics will add a dimension that will benefit the hospital, the patient care and institutional recognition. Another essential task to overcome is the important education of the operating room nursing staff, a significant difference between this modality and traditional surgery. Without operating room environment support, most surgeons will revert to traditional methods even after a few successful robotics cases. As the field of robotic surgery continues to grow, graduate medical education and continuing medical education programs that address the surgical robotic learning needs of residents and practicing surgeons need to be developed.

Systematic review and meta-analysis of non RCT's on health related quality of life after radical cystectomy using validated questionnaires: Better results with orthotopic neobladder versus ileal conduit.

PURPOSE: The current literature on the impact of different urinary diversions on patients' health related quality of life (HR-QoL) showed a marginally better quality of life scores of orthotopic neobladder (ONB) compared to ileal conduit (IC). The aim of this study was to update the review of all relevant published studies on the comparison between ONB and IC. MATERIALS AND METHODS: Studies were identified by searching multiple literature databases, including MEDLINE, CINAHL, the Cochrane Library, PubMed Data were synthesized using meta-analytic methods conformed to the PRISMA statement. RESULTS: The current meta-analysis was based on 18 papers that reported a HR-QoL comparison between IC and ONB using at least a validate questionnaire. Pooled effect sizes of combined QoL outcomes for IC versus ONB showed a slight, but not significant, better QoL in patients with ONB (Hedges' g = 0.150; p = 0.066). Patients with ileal ONB showed a significant better QoL than those with IC (Hedges' g = 0.278; p = 0.000); in case series with more than 65% males, ONB group showed a slight significant better QoL than IC (Hedges' g = 0.190; p = 0.024). Pooled effects sizes of all EORTC-QLQ-C30 aspects showed a significant better QoL in patients with ONB (Hedges' g = 0.400; p = 0.0000). CONCLUSIONS: This meta-analysis of not-randomized comparative studies on the impact of different types of urinary diversions on HR-QoL showed demonstrated a significant advantage of ileal ONB compared to IC in terms of HR-QoL.

Acute peritonitis due to introital stenosis and perforation of a bowel neovagina in a transsexual.

BACKGROUND: Stenosis of the neovagina is a late postoperative complication of male-to-female sex reassignment surgery when patients do not have frequent sexual intercourse or do not perform vaginal dilation. CASE: A 39-year-old male-to-female transsexual who had sex reassignment surgery, in which a segment of sigmoid colon was used for neovagina construction, developed total introital stenosis and subsequent peritonitis caused by bowel perforation of the colon conduit. CONCLUSION: To avoid stenosis of the neovagina, an inflatable silicon vaginal stent should be used all day for 30 days, then for 3 months overnight or until sexual function is regular.

Value of selective parathormone radioimmunoassay in primary hyperparathyroidism.

Nine cases of primary hyperparathyroidism (PHP) in patients with urinary calculi are reported and discussed. Selective venous catheterization and parathormone (PTH) radioimmunoassay confirmed the diagnosis in all cases, preoperatively discriminated between adenoma and diffuse parathyroid hyperplasia, and permitted exact preoperative localization of 5 of 7 adenomas. The interest of the urologist in PHP and the usefulness of selective PTH radioimmunoassay are discussed and emphasized.

Usefulness of preoperative transcatheter embolization in kidney tumors.

In recent years preoperative transcatheter embolization has been used widely in the management of kidney tumors. However, the effective clinical usefulness of this method has not yet been proved. Forty cases of kidney tumors treated by preoperative embolization and radical nephrectomy are reviewed and compared with a homogeneous group of patients who did not undergo preoperative embolization. Intraoperative blood loss, postoperative complication, and survival rate were statistically evaluated according to tumor stage. Advantages and disadvantages of preoperative transcatheter embolization of kidney tumors are reviewed.

Long-term results with Nesbit's procedure as treatment of Peyronie's disease.

The objective was to assess sexual function at long-term follow-up after the Nesbit operation for Peyronie's disease. One hundred and fifty seven out of 213 patients treated between 1986 and 1998 using the Nesbit procedure were reassessed by means of IIEF-5 questionnaire together with two questions about residual deformity and treatment satisfaction. The results from this questionnaire together with the patient case records constitute the basis of this paper. After an average 72-month follow-up subjective patient determination of satisfaction indicated that 87.9% were satisfied with the results of surgery, 136 patients (86.7%) had good erectile function (IIEF-5 > 21). Shortening of the penis (from 1.5 to 3 cm) occurred in 22 patients (14%), but only in 2 (1.3%) was intercourse difficult because of excessive shortening. In conclusion, the Nesbit's operation results in the greatest amount of patient satisfaction about sexual function. When penile shortening occurs, it has not been a significant problem for patients who are properly counselled.

Saphenous vein harvesting by 'stripping' technique and 'W'-shaped patch covering after plaque incision in treatment of Peyronie's disease.

Harvesting of the saphenous vein tract by means of leg stripping is proposed in the treatment of Peyronie's disease. The technique of W-shaped saphenous vein after plaque incision to correct severe penile deformity associated with Peyronie's disease is described. Graft material was obtained from the lower saphenous vein by means of distal 'leg short stripping' technique. The size and number of tunical incisions depended on the size of the plaque. A 15 cm venous segment is generally sufficient to cover the defect. The venous segment used was W-shaped, assembled with 6/0 polydioxanone (PDS) uninterrupted sutures and then sutured to the albuginea defect. In our preliminary series of eight patients, penile shortening and erectile dysfunction is absent. Complete correction of penile deformity was achieved in seven patients (87.5%). One patient had minimal residual curvature (<20 degrees ) which did not result in difficulty with intromission. Saphenous harvesting by the stripping technique is not an invasive procedure and is quick and simple to perform. The W-shaped assembling technique is safe because the piece of saphena is kept intact and may be suited properly to the albuginea defect.

Monolateral tubulovasostomy. Report of four cases.

After conventional vasoepididymostony, the epididymal lumen may become occluded or obstructed, resulting in recurring azoospermia. Recently, two-layer direct anastomosis has been advocated on the basis of experimental models of tubulovasostomy performed in rats. Monolateral tubulovasostomy was performed in four cases under 16-40 times magnification. Nylon or 11/0 Vycril was used as suture material for the internal layer of the anastomosis, and 10/0 Ethilon was used for the external layer. After three and six months, semen samples were evaluated for sperm count and motility. The presence of spermatozoa in all the samples confirmed 100% patency of the duct. Three patients had a number of spermatozoa compatible with fertility, and one pregnancy occurred.

Tubulovasostomy in the rat. A new experimental model.

Tubular patency is the primary concern in the evaluation of procedures for epididymovasostomy. The epididymal lumen easily becomes occluded or obstructed, with the resulting recurrence of azoospermia. Recently, two-layer direct anastomosis has been advocated. The aim of the present study was to present an experimental model of tubulovasostomy in the rat. Microsurgery was performed in 18 rats (16-40 X magnification). Suture material used was 11/0 Vycryl or nylon for the internal layer of the anastomosis and 10/0 Ethilon for the external layer. After 6 and 12 weeks, semen samples were obtained by electroejaculation and evaluated for sperm count and motility.

[Transcatheter hypogastric embolization in life-threatening bladder hemorrages: immediate and long-term results (author's transl)]. / Die Embolisation der Arteria iliaca interna bei Karzinomen mit lebensbedrohlichen Blasenblutungen: Sofort- und Langzeitergebnisse.

Transcatheter embolization of the hypogastric arteries has become a more and more largely used therapeutic approach in mastering unrestrainable hemorrages in bladder cancer patients. In this paper the Authors report their experience with this method based on 9 cases, which could be followed for 1 year or until patient's death. The immediate and long-term results are presented and discussed. The Authors conclude that transcatheter hypogastric embolization is the best non-invasive method to handle neoplastic pelvic hemorrages.

Aneurysm of the abdominal aorta in a young woman. Atherosclerotic or inflammatory in origin?

The case is described of a 27 year old woman with aneurysms of the abdominal aorta. In the absence of any signs of atherosclerotic disease, an inflammatory aetiology was suspected, a view that was supported by the macroscopic intraoperative findings and preoperative autoimmune assays. The literature on this rare pathology is examined.

[Bilateral abdominal testicles in the adult. Microsurgical and laparoscopic therapy]. / Testicoli addominali bilaterali nell'adulto. Terapia microchirurgica e laparoscopica.

B. L. a 27 year old bilaterally cryptorchid patient underwent right testicular autotransplantation in the presence of a quite normal testis. After one year the patency of microsurgical anastomosis was confirmed by means of Doppler flowmetry and scrotal echography demonstrated the presence in the scrotum of a testis provided will normal echogenicity. Left laparoscopic orchiectomy was planned. A small semilunar skin incision was made just below the rim of the umbilicus. Veress needle was introduced: as soon as the needle pierced the parietal peritoneum, its spring mechanism was released allowing the sharp needle point to retract leaving only the blunt tip protruding. Carbon dioxide gas was insufflated through the side part of the Veress needle until adequate abdominal distension was achieved. After having removed the Veress needle, the laparoscope on its sharp-pointed trocar was introduced into the peritoneal cavity and left testis was easily localized. Four trocars were introduced up to proceed to laparoscopic orchiectomy. The patient was discharged two days after. In our opinion in the presence of a bilateral cryptorchism in the adult, is better to plan a monolateral autotransplantation. After having verified the long-term result of microsurgery we can decide if a contralateral orchiectomy has to be planned.

Microlaparoscopy in sex reassignment surgery.

Sex reassignment (male to female surgery) is a standard operation which is aimed at constructing female genitalia and obtaining a cosmetic and functional result that is similar to that of a normal female subject. The ideal surgical procedure has not yet been described, but the various techniques which have been proposed in the literature are similar. The most cumbersome maneuver of the procedure is that of creating a neovaginal cavity inside the perineum. This step is generally carried out by means of blunt dissection between the rectal wall and the prostate, but most of the surgery is blindly performed without visual control. In these conditions, the risk of rectal injury is high, and may lead to severe intraoperative complications. Microlaparoscopy allows for a direct observation of the perineal dissection from inside the peritoneal cavity, thus avoiding risk of rectal injury. The technique is simple to perform, is non-invasive, and only 15 minutes are added to the operation.

Microsurgery in urology.

Microsurgery is becoming increasingly widely accepted in the field of urology, and microsurgical training well become an integral part of the programs for Residents in University Schools of Urology. In this paper we outline the present clinical application of microsurgery in urology and perspectives, for example: workbench surgery, testis transplantation, vasovasostomy, revascularization for impotence, penis replantation, microsurgery of the urinary tract.

[Composite bypass using endarterectomized autologous superficial femoral artery. A valid concept in the extension of lower limb salvage surgery]. / By-pass composito con arteria femorale superficiale autologa endoarterectomizzata. Un valido concetto nell'estensione della chirurgia di salvataggio dell'arto inferiore.

Saphenous vein is nowadays the material of choice performing on femoro-distal revascularisation; when this is not available, it is important to use a material which gives the closest approximation of an ideal conduit and for same time an easy handling during the execution of the anastomosis. Although vein's degenerative alterations are very rare, it has now been shown that there is widespread destruction of the endothelium among infrainguinal vein grafting, producing a relatively thrombogenic surface. These factors may contribute to the initial failure rate of these bypasses. For this reason we suggest to employ a segment of thromboendarterectomized SFA (superficial femoral artery) as a distal part of a composite bypass. Twenty-four composite bypasses were performed using three different methods over a total of 123 femoro-distal revascularizations. Eighteen months follow-up showed more than 50% and more than 75% patency rate comparing type B (graft or thromboendarterectomized SFA + autogenous saphenous vein) and type C (thromboendarterectomyied SFA + graft). We believe, waiting for a wider follow-up, that this technique could be a valid alternative to a femoro-distal revascularization when saphenous vein is not available.

Temporary embolization in urological practice: myth or reality?

Clot embolization through percutaneous transcatheter technique has proved to be a highly effective and reliable method for stopping bleeding from renal or pelvic areas. The recanalization of the embolized vessels is constant and the recovery of the renal function quite satisfactory. In case of priapism temporary embolization may be very useful in selected cases.

Acute hyperparathyroidism successfully treated by total parathyroidectomy and parathyroid autotransplantation.

Acute hyperparathyroidism occurs infrequently and sometimes represents a diagnostic problem in urological patients. We report a case of acute hyperparathyroidism successfully treated by total parathyroidectomy and parathyroid autotransplantation.

Immediate and long-term results of parathyroid autotransplantation in primary hyperparathyroidism.

The authors review the experience of total parathyroidectomy with microsurgical autotransplantation with reference to the long-term results. This method--after further control investigations--may be envisaged for making a definitive evaluation of the results.

[PTH radioimmunoassay on selective venous samplings as a method of localization of parathyroid adenomas in primary hyperparathyroidism (author's transl)]. / Die selektive Parathormonbestimmung als Lokalisationsmittel der Nebenschilddrüsenadenome beim primären Hyperparathyreoidismus.

Preoperative localization of parathyroid adenomas by various methods is today in increasing clinical use. The practical value of the methods is discussed, with particular reference to the PTH radioimmunoassay on selective venous samplings, which is the most reliable. The authors report on their 38 cases with suspected primary hyperparathyroidism during the last six years.