Stone centers: a national survey on surgical techniques performed in Italy.

BACKGROUND: Recurrent and complex stone disease may be considered a challenging disease. In 2018, the Calculus group of the SIU (Italian Society of Urology) set itself the goal of establishing the minimum requirements for a center that could continuously manage urolithiasis pathology, named a Stone Center. In this study we present the results of a pilot survey carried out in 2019 with the aim of drawing a map of the situation of Italian urological centers dealing with urinary stones. METHODS: A total of 260 national urology departments dealing with urolithiasis surgery were contacted for this study. A survey was issued to each of the centers to determine the number of patients treated for urinary stones and the amount of procedures performed per year: 1) extracorporeal shock wave lithotripsy ESWL; 2) ureterorenoscopy URS; 3) retrograde intrarenal surgery RIRS; 4) percutaneous nephrolithotomy PCNL. RESULTS: Out of 260 centers contacted, 188 fulfilled the survey. Outcomes were quite variable, with approximately 37% of the centers lacking a lithotripter, and 46% of those that did have it performing fewer than 100 treatments per year. In terms of endoscopic procedures, more than 80% of the centers contacted performed URS or RIRS; however, when it came to percutaneous lithotripsy, these numbers dropped significantly; 33% of the centers contacted did not perform PCNL, and of those who did, 18% had less than 5 years of experience as a center. CONCLUSIONS: Our survey shows a very heterogeneous national picture about urolithiasis treatments. Our goal is to create national paradigms to be able to define stone centers where the patient suffering from complex urinary stones can find a network of professionals with an adequate armamentarium suitable for the management of their pathology.

The effect of married status on cancer-specific mortality in nonmetastatic pelvic liposarcoma patients according to sex.

BACKGROUND: In nonmetastatic pelvic liposarcoma patients, it is unknown whether married status is associated with better cancer-control outcome defined as cancer-specific mortality (CSM). We addressed this knowledge gap and hypothesized that married status is associated with lower CSM rates in both male and female patients. METHODS: Within the Surveillance, Epidemiology, and End Results database (2000-2020), nonmetastatic pelvic liposarcoma patients were identified. Kaplan-Meier plots and univariable and multivariable Cox regression models (CRMs) predicting CSM according to marital status were used in the overall cohort and in male and female subgroups. RESULTS: Of 1078 liposarcoma patients, 764 (71%) were male and 314 (29%) female. Of 764 male patients, 542 (71%) were married. Conversely, of 314 female patients, 192 (61%) were married. In the overall cohort, 5-year cancer-specific mortality-free survival (CSM-FS) rates were 89% for married versus 83% for unmarried patients (Δ = 6%). In multivariable CRMs, married status did not independently predict lower CSM (hazard ratio [HR]: 0.74, p = 0.06). In males, 5-year CSM-FS rates were 89% for married versus 86% for unmarried patients (Δ = 3%). In multivariable CRMs, married status did not independently predict lower CSM (HR: 0.85, p = 0.4). In females, 5-year CSM-FS rates were 88% for married versus 79% for unmarried patients (Δ = 9%). In multivariable CRMs, married status independently predicted lower CSM (HR: 0.58, p = 0.03). CONCLUSIONS: In nonmetastatic pelvic liposarcoma patients, married status independently predicted lower CSM only in female patients. In consequence, unmarried female patients should ideally require more assistance and more frequent follow-up than their married counterparts.

Surgically treated pelvic liposarcoma and leiomyosarcoma: The effect of tumor size on cancer-specific survival.

INTRODUCTION: In soft tissue pelvic liposarcoma and leiomyosarcoma, it is unknown whether a specific tumor size cut-off may help to better predict prognosis, defined as cancer-specific survival (CSS). We tested whether different tumor size cut-offs, could improve CSS prediction. MATERIALS AND METHODS: Surgically treated non-metastatic soft tissue pelvic sarcoma patients were identified (Surveillance, Epidemiology, and End Results 2004-2019). Kaplan-Meier plots, univariable and multivariable Cox-regression models and receiver operating characteristic-derived area under the curve (AUC) estimates were used. RESULTS: Overall, 672 (65 %) liposarcoma (median tumor size 11 cm, interquartile range [IQR] 7-16) and 367 (35 %) leiomyosarcoma (median tumor size 8 cm, IQR 5-12) patients were identified. The p-value derived ideal tumor size cut-off was 17.1 cm, in liposarcoma and 7.0 cm, in leiomyosarcoma. In liposarcoma, according to p-value derived cut-off, five-year CSS rates were 92 vs 83 % (≤17.1 vs > 17.1 cm). This cut-off represented an independent predictor of CSS and improved prognostic ability from 83.8 to 86.8 % (Δ = 3 %). Similarly, among previously established cut-offs (5 vs 10 vs 15 cm), also 15 cm represented an independent predictor of CSS and improved prognostic ability from 83.8 to 87.0 % (Δ = 3.2 %). In leiomyosarcoma, according to p-value derived cut-off, five-year CSS rates were 86 vs 55 % (≤7.0 vs > 7.0 cm). This cut-off represented an independent predictor of CSS and improved prognostic ability from 68.6 to 76.5 % (Δ = 7.9 %). CONCLUSIONS: In liposarcoma, the p-value derived tumor size cut-off was 17.1 cm vs 7.0 cm, in leiomyosarcoma. In both histologic subtypes, these cut-offs exhibited the optimal statistical characteristics (univariable, multivariable and AUC analyses). In liposarcoma, the 15 cm cut-off represented a valuable alternative.

Other-cause mortality in incidental prostate cancer.

BACKGROUND: In incidental prostate cancer (IPCa), elevated other-cause mortality (OCM) may obviate the need for active treatment. We tested OCM rates in IPCa according to treatment type and cancer grade and we hypothesized that OCM is significantly higher in not-actively-treated patients. METHODS: Within the Surveillance, Epidemiology, and End Results database (2004-2015), IPCa patients were identified. Smoothed cumulative incidence plots as well as multivariable competing risks regression models were fitted to address OCM after adjustment for cancer-specific mortality (CSM). RESULTS: Of 5121 IPCa patients, 3655 (71%) were not-actively-treated while 1466 (29%) were actively-treated. Incidental PCa not-actively-treated patients were older and exhibited higher proportion of Gleason sum (GS) 6 and clinical T1a stage. In smoothed cumulative incidence plots, 5-year OCM was 20% for not-actively-treated versus 8% for actively-treated patients. Conversely, 5-year CSM was 5% for not-actively-treated versus 4% for actively-treated patients. No active treatment was associated with 1.4-fold higher OCM, even after adjustment for age, cancer characteristics, and CSM. According to GS, OCM reached 16%, 27%, and 35% in GS 6, 7, and 8-10 not-actively-treated IPCa patients, respectively and exceeded CSM recorded for the same three groups (2%, 6%, and 28%, respectively). CONCLUSION: Our results quantified OCM rates, confirming that in not-actively-treated IPCa patients OCM is indeed significantly higher than in their actively-treated counterparts (HR: 1.4). These observations validate the use of no active treatment in IPCa patients, in whom OCM greatly surpasses CSM (20% vs. 5%).

Other-Cause Mortality, According to Partial vs. Radical Nephrectomy: Age and Stage Analyses.

INTRODUCTION: We tested the association between other-cause mortality and partial vs. radical nephrectomy in patients with T1a, T1b, and T2 renal cell carcinoma, across all patient ages. MATERIAL AND METHODS: Within the Surveillance, Epidemiology, and End Results database (2010-2020), patients with localized renal cell carcinoma stages (T1a-T1b-T2, N0, M0), who underwent partial or radical nephrectomy were identified. Only patients with tumor size 2 to 10 cm were included. Cumulative incidence plots and multivariable competing risks regression models were used. RESULTS: Of 68,195 patients, 28,845 (42%) underwent partial nephrectomy vs. 39,350 (58%) radical nephrectomy. In T1a patients, 5-year other-cause mortality rates were 6% for partial nephrectomy vs. 11% for radical nephrectomy (Δ=5%). In T1a patients, partial nephrectomy independently predicted lower other-cause mortality, across all ages (HR: 0.73, P < .001). In age category subgroup analyses addressing T1a patients, in all age categories, partial nephrectomy invariably predicted lower other-cause mortality than radical nephrectomy: ≤59 years (HR: 0.67, P < .001); 60 to 69 years (HR: 0.70, P < .001); and ≥70 years (HR: 0.79, P < .001). Finally, in T1b patients, as well as in T2 patients, no other-cause mortality advantage was recorded for partial vs. radical nephrectomy: T1b (8 vs. 10%, Δ=2%); T2 (8 vs. 9%, Δ=1%). CONCLUSIONS: Relative to radical nephrectomy, partial nephrectomy is associated with lower other-cause mortality in stage T1a renal cell carcinoma patients across all age categories, including the oldest patients. Conversely, no clinically meaningful other-cause mortality benefit was associated with partial nephrectomy in stages T1b or T2, regardless of age, including youngest patients.

Nephroureterectomy with or without Bladder Cuff Excision for Localized Urothelial Carcinoma of the Renal Pelvis.

BACKGROUND: Few studies examined the rates of guideline implementation and the survival effect of bladder cuff excision (BCE) at nephroureterectomy (NU). OBJECTIVE: To assess the rates of guideline implementation regarding NU with BCE relative to NU without BCE in patients with upper tract urothelial carcinoma (UTUC) and to test the effect of BCE on cancer-specific (CSM) and other-cause mortality (OCM). DESIGN, SETTING, AND PARTICIPANTS: We relied on Surveillance, Epidemiology, and End Results database (2004-2014) for UTUC of the renal pelvis patients (T1-T3, N0, M0) treated with NU with or without BCE. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Cumulative incidence plots relying on competing-risks methodology illustrated 5-yr CSM and OCM rates. Multivariable competing-risks regression (MCRR) models tested the effect of BCE versus no BCE at NU. RESULTS AND LIMITATIONS: Of 4266 assessable patients, 2913 (68.3%) underwent NU with BCE. Between 2004 and 2014, rates of BCE at NU increased from 63.0% to 74.5% (European Association for Palliative Care: 2%; p<0.001). At 60 mo, CSM rates were 19.7% versus 23.5% (p=0.005) in NU with BCE versus NU without BCE patients, respectively. In MCRR models, no difference in CSM was recorded according to BCE at NU (hazard ratio [HR]: 0.88, confidence interval [CI]: 0.75-1.03, p=0.1). Finally, OCM was unaffected by BCE at NU (HR: 0.94, CI: 0.77-1.15, p=0.5). This study is retrospective. CONCLUSIONS: According to guideline recommendation, the rates of NU with BCE increased over time. However, BCE status does not appear to affect CSM or OCM. Thus, our study was unable to examine the rates of urothelial cancer recurrence or metastatic progression according to BCE status. PATIENT SUMMARY: Rates of bladder cuff excision (BCE) at nephroureterectomy (NU) are increasing. This observation confirms improved adherence to guidelines over time. However, BCE status does not appear to affect survival after NU for upper tract urothelial carcinoma.

Survival Effect of Chemotherapy in Metastatic Upper Urinary Tract Urothelial Carcinoma.

BACKGROUND: Few data examined the potential survival benefit of chemotherapy (CHT) in the setting of metastatic upper urinary tract urothelial carcinoma (mUTUC). We hypothesized that a survival benefit might be associated with the use of CHT in nonsurgically treated primary mUTUC and tested this hypothesis within a large population-based cohort. PATIENTS AND METHODS: Within the Surveillance, Epidemiology, and End Results database (2004-2014), we identified 539 patients with nonsurgically treated primary mUTUC. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier plots, as well as multivariable Cox regression models relying on IPTW and landmark analyses, were used to test the effect of CHT versus no CHT on overall mortality and cancer-specific mortality. RESULTS: Of 539 patients with metastatic UTUC, 277 (51.4%) underwent CHT. In nonadjusted and IPTW-adjusted Kaplan-Meier plots, CHT was associated with better overall survival (9 vs. 2 months; P < .001 in both analyses). In multivariable Cox regression models, CHT administration independently predicted lower overall mortality before IPTW (hazard ratio [HR], 0.31; 95% confidence interval [CI], 0.25-0.39; P < .001), as well as after IPTW adjustment (HR, 0.31; 95% CI, 0.25-0.38; P < .001). Similar results were recorded in landmark analyses (HR, 0.52; 95% CI, 0.38-0.70; P < .001). Finally, virtually the same results were obtained for cancer-specific mortality. CONCLUSIONS: Our analyses suggest a survival benefit after CHT in the setting of nonsurgically treated primary mUTUC.

Rates of lymph node invasion and their impact on cancer specific mortality in upper urinary tract urothelial carcinoma.

PURPOSE: To analyze lymph node invasion (LNI) rates according to tumor characteristics and to test the impact of LNI and its extent on cancer specific mortality (CSM) in surgically-treated non metastatic urothelial upper urinary tract carcinoma (UTUC) patients. MATERIALS AND METHODS: Within the SEER database (2004-2014), we identified 2098 patients with histologically confirmed non-metastatic urothelial carcinoma of renal pelvis or ureter who underwent NU with LND. LNI rates stratified according to tumor location and stage were described. Kaplan-Meier plots illustrated CSM rates according to LNI and its extent. Multivariable Cox regression models (MCRMs) tested the effect of LNI and its extent on CSM. RESULTS: Of 2098 UTUC patients, who underwent nephroureterectomy with lymph node dissection, 646 (33%) had LNI. The median number of removed lymph nodes was 3 [Interquartile range (IQR): 1-7]. The median number of positive lymph nodes in patients, who harbored LNI was 1 (IQR:1-3). LNI rates according to tumor location were, respectively, 23.6% for ureteral and 36.5% for renal pelvis tumors. LNI rates according to tumor stage were 9.6, 18.0, 38.7 and 63.9%, for respectively, T1, T2, T3 and T4 UTUC. In MCRMs, LNI achieved independent predictor status for higher CSM (HR 3.00; p < 0.001). Finally, in MCRMs, number of positive lymph nodes defined as the 75th percentile (n ≥ 3) achieved independent predictor status for higher CSM (HR 1.37; p = 0.04). CONCLUSIONS: LNI in non-metastatic UTUC patients is the most important determinant of CSM. Number of positive lymph node is independently associated with higher CSM. In consequence, lymph node dissection can provide extensive prognostic information.

A contemporary analysis of radiotherapy effect in surgically treated retroperitoneal sarcoma.

BACKGROUND AND PURPOSE: Contemporary data regarding the benefit of radiotherapy in surgically treated retroperitoneal sarcoma are scarce. The aim of the study was to evaluate the effect of radiotherapy on cancer specific mortality in surgically treated patients according to tumor size, histological subtype and grade. MATERIAL AND METHODS: Within Surveillance, Epidemiology, and End Results database (2004-2014), we identified 1226 patients with non-metastatic retroperitoneal sarcoma. Univariable and multivariable logistic regression models tested for predictors of radiotherapy delivery. Univariable and multivariable Cox regression models tested the effect of radiotherapy on cancer specific mortality in the overall population. Subgroup analyses explored the result of tumor grade and tumor size on radiotherapy effect. All analyses were repeated after adjustment according to inverse probability of treatment. Additionally, all analyses were subjected to 1000 bootstrap resamples for internal validation. RESULTS: Radiotherapy was delivered in 372 patients (30.3%). In univariable and multivariable logistic regression models high grade (OR: 1.46, CI:1.12-1.90; p = 0.006), and leiomyosarcoma histologic subtype (OR: 2.14, CI: 1.55-2.95; p < 0.001) predicted radiotherapy delivery. In the overall population multivariable Cox regression models showed lower cancer specific mortality (HR: 0.73, CI: 0.55-0.96; p = 0.025) with radiotherapy. In subgroup analyses multivariable Cox regression models showed radiotherapy benefit predominantly in high grade, large tumor size retroperitoneal sarcomas (HR 0.51: C.I.: 0.30-0.86; p = 0.02). CONCLUSIONS: In this retrospective report, delivery of radiotherapy was associated with lower cancer specific mortality in high grade, large tumor size retroperitoneal sarcoma patients. Our findings are predominantly representative of liposarcomas and leiomyosarcomas that accounted for 90% of study population. Further study is needed to evaluate the role of radiotherapy in retroperitoneal sarcoma patients.

Surgically Treated Retroperitoneal Sarcoma: A Population-based Competing Risks Analysis.

BACKGROUND: Data regarding the relationship between non-disease-specific (NDSM) and disease-specific mortality (DSM) in patients with surgically treated nonmetastatic retroperitoneal sarcoma (nmRPS) are lacking. OBJECTIVE: To examine the rates of NDSM and DSM among patients with surgically treated nmRPS. DESIGN, SETTING AND PARTICIPANTS: We used the Surveillance, Epidemiology and End Results (SEER) database (2004-2014) to obtain data for patients with surgically treated nonmetastatic RPS. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES: The 5-yr DSM and NDSM rates were generated via competing risks regression (CRR) methodologies. Multivariable CRR models were used to test the effects of age, histologic subtype, grade, size, and radiotherapy (RT) status on NDSM and DSM. RESULTS AND LIMITATIONS: Overall, 231 (26.8%) and 57 patients (6.7%) died from DSM and NDSM, respectively. Following stratification according to age, histologic subtype, grade, size, and RT status, the proportion of patients who succumbed to NDSM was higher for patients with age above the median, liposarcoma histologic subtype, low grade, and tumor size ≥17cm. DSM rates were also higher among patients with age above the median, leiomyosarcoma histologic subtype, high grade, and tumor size ≥17cm. Multivariable CRR models revealed that age above the median was associated with higher NDSM (hazard ratio [HR]1.7, 95% confidence interval [CI] 1.1-2.7; p=0.019). Conversely, leiomyosarcoma (HR 1.9, 95% CI 1.4-2.6; p<0.0001), sarcoma not otherwise specified (HR 2.4, 95% CI 1.5-3.8; p<0.0001) and other RPS (HR 2, 95% CI 1.2-3.4; p=0.01) histologic subtypes, high grade (HR 3, 95% CI 2.3-4; p<0.0001), and tumor size above the median (HR 1.4, 95% CI 1.1-3.8; p=0.012) were associated with higher DSM. This is a retrospective study and misclassification bias may be present because of the reliability of the distinction between DSM and NDSM. CONCLUSIONS: The impact of NDSM in surgically treated nmRPS is not trivial, particularly among patients with favorable characteristics such as liposarcoma histologic subtype and low-grade tumors. PATIENT SUMMARY: Mortality from causes not related to the specific disease is important in patients with retroperitoneal sarcoma (RPS) treated surgically. In particular, patients with good tumor characteristics, namely liposarcoma histologic subtype and low grade, most often do not die from their cancer but succumb to causes other than RPS. Unfortunately, tumor characteristics and radiotherapy administration shed relatively little light on predicting mortality from causes other than cancer in patients with surgically treated RPS. Our report compares the risk of dying from RPS with that of dying from other causes according to the type of surgically treated sarcoma.

Retrograde intrarenal surgery using ureteral access sheaths is a safe and effective treatment for renal stones in children weighing <20 kg.

INTRODUCTION: Surgical treatment of pediatric kidney stones has changed dramatically in recent years because of the miniaturization of surgical instruments and the availability of intracorporeal lithotripters. The retrograde intrarenal surgery (RIRS) technique is nowadays considered an effective and safe procedure but studies in very young children are lacking and use of a ureteral access sheath (UAS) has also been debated. OBJECTIVE: To assess safety and efficacy of RIRS using UAS in children weighing < 20 kg. MATERIALS AND METHODS: Data from 13 children weighing <20 kg who underwent RIRS for renal stones were collected. A Double-J stent was positioned 14 days before surgery. Demographics, stone location, stone number and composition, stone-free status (SFS) and complications were evaluated. Descriptive statistics were applied to describe the cohort. RESULTS: Thirteen patients, age 3.91 ± 1.8 years (mean ± SD), underwent 16 RIRS. Mean patient weight and stone burden were 14.88 ± 3.81 kg (range 10-20 kg) and 15.5 ± 3.8 mm (median 16 mm), respectively. A UAS was used in 15 out of 16 (93.8%) procedures. SFS was achieved in 81.3% of cases after the first procedure and 100% after auxiliary procedures. Postoperative urinary tract infections with fever (Clavien II) were observed in two (12.5%) patients. Hydrocalyx (Clavien IIIb) was noted in one (6.3%) patient. Patients with stones located in the lower polar calices (p = 0.024) and with mixed composition (p = 0.036) had a greater prevalence of complications than those with calculi of other compositions located in other sites. After a mean follow-up of 22.4 months no cases of ureteral strictures or vesicoureteral reflux were observed (Table). DISCUSSION: The current findings support previous evidence showing safety and efficacy of RIRS with use of the UAS in pre-stented very young children. In our experience RIRS seems to be an effective and safe option with a stone-free rate of 81.3% and only 1 severe complication (Clavien-Dindo grade IIIb) and no long-term complications. This study is, to date, the first to examine the safety and efficacy of RIRS using UAS for the treatment of intrarenal stones in a selected cohort of pre-school patients weighing <20 kg. CONCLUSIONS: RIRS using UAS is an effective and safe procedure for treating kidney stones in pre-school patients weighing <20 kg without complications at both short and long term follow up. Stones of mixed composition located in the lower polar calices are associated with a greater risk of postoperative complications.

Life-threatening complications after ureteroscopy for urinary stones: survey and systematic literature review.

INTRODUCTION: Retrograde ureteroscopy (URS) has become a common procedure for the management of urinary stones. Although its efficacy and safety are well known, the literature about major complications is still poor. This study highlighted some cases of life-threatening complications after semi-rigid ureteroscopy (s-URS) or flexible ureteroscopy (f-URS). EVIDENCE ACQUISITION: Experienced endourologists (more than 75 cases/year in the last 3 years) we enrolled, and a survey was performed asking to review their series and report the cases encumbered by major complications (Clavien-Dindo IIIb-IV grade). A literature search was also conducted in the Medline (PubMed) and Cochrane Libraries databases in July, 2016 to identify all studies reporting the presence of major complications in patients underwent URS procedures. A PubMed search was performed using the following key words in combination: "kidney injury," "ureteroscopy," "nephrectomy," "life-threatening," "urinary stones," "complications." EVIDENCE SYNTHESIS: Eleven urologists reported on 12 major complications (4 after s-URS, 8 after f-URS). Eight patients developed a kidney injury, 1 an arteriovenous fistula, 2 a ureter avulsion and 1 acute sepsis. Six patients underwent open nephrectomy, two surgical repair, one open pyeloplasty, one coil artery embolization and two superselective artery embolization. CONCLUSIONS: Guidelines and clinical practice give useful recommendations about intraoperative safety and prevention of life-threatening events. The careful postoperative observation and the surgical active treatment of this complications play a key role in reducing morbidity, kidney loss and mortality. This study encourages a strict and active care of patients, supports a routine reporting of complications, and highlights the need for systematic use of standardized classification systems.

Robotic prostatectomy: an update on functional and oncologic outcomes.

Since the first procedure performed in 2000, robotic-assisted radical prostatectomy (RARP) has been rapidly gaining increasing acceptance from both urologists and patients. Today, RARP is the dominant treatment option for localised prostate cancer (PCa) in the United States, despite the absence of any prospective randomised trial comparing RARP with other procedures. Robotic systems have been introduced in an attempt to reduce the difficulty involved in performing complex laparoscopic procedures and the related steep learning curve. The recognised advantages of this kind of minimally invasive surgery are three-dimensional (3D) vision, ten-fold magnification, Endowrist technology with seven degrees of freedom, and tremor filtration. In this article, we examine this technique and report its functional (in terms of urinary continence and potency) and oncologic results. We also evaluate the potential advantages of RARP in comparison with open and laparoscopic procedures.

[Ralp and Rocco stitch: original technique]. / Ralp e Rocco stitch: tecnica originale.

Incontinence and impotence are the two chief drawbacks of radical prostatectomy (RP). Incontinence is the most relevant for most of the patients, even if there is high variability in terms of prevalence and definition of continence. Incontinence seems the result of several factors, the most important being the surgical injury of some structures and the biomechanical instability associated with vesicourethral anastomosis. In the posterior urethra, which guarantees the continence mechanism, two functionally independent regions can be recognized: the proximal and the distal. The proximal region can be identified with the bladder neck, while the distal region is the rhabdosphincter urethrae. Concerning the distal functional region, two kinds of strategy can be applied: the preservation of puboprostatic ligaments and urethral attachments, or the reconstruction of the urethral rhabdosphincter, which can be anterior, posterior or total. We describe our technique of choice for posterior reconstruction, first described by Rocco and then modified by Patel et al.

Emphysematous pyelonephritis in decompensated diabetes: a case report and review of the literature.

Emphysematous pyelonephritis is a rare and severe renal parenchyma necrotizing infection visible just in diabetic patients which results in gas presence--probably produced through the glucose fermentation process--in the collecting system, renal parenchyma and perirenal tissue. We present a case of a not known diabetic female patient with emphysematous pyelonephritis of the left kidney and emphysematous pyelitis of the controlateral kidney.

Epidemiology of renal colic in a district general hospital.

BACKGROUND/AIMS: To assess the incidence of renal colic and the results of emergency management. METHODS: During a 12 month period data of patients with symptoms of renal colic were collected. RESULTS: A total of 495 visits were registered. The M/F was 2.19. Mean age was higher in males (45.5+/-13.0 vs 42.5+/-15.5 years, P=0.025). Three patients were hospitalised for immediate urinary diversion due to anuria or sepsis. Fifty-three patients recovered without performing any pharmacological treatment. Analgesic treatment (mainly NSAID) was offered to 439 patients. After a 6 hour period 36 patients were admitted to the hospital owing to persistent pain. Pain was reduced in 403 patients (91.8%) who were offered outpatient renal ultrasound within 48 hours. Twenty-five patients (6.2%) required deferred hospitalisation. Follow up with renal ultrasound was obtained in 213. CONCLUSION: Renal colics accounted for 0.9% of ambulatory care visits to our emergency departments with an annual rate of 0.158 visits per 100 in the general population. NSAIDs were efficacious in the management of colic. Diagnostic work up was able to demonstrate the presence of a stone in 56% of the subjects presenting with renal colic whereas alternative diagnoses were demonstrated in 12%.

Early continence recovery after open radical prostatectomy with restoration of the posterior aspect of the rhabdosphincter.

OBJECTIVES: We believe early incontinence after radical retropubic prostatectomy (RRP) is mainly due to the shortening of the sphincter's anatomic and functional length as a result of caudal retraction of the urethral sphincteric complex and disruption of the posterior median fibrous raphe. We illustrate a technique of anatomic and functional reconstruction of the rhabdosphincter (RS) aimed at achieving early continence recovery after RRP. Our modification to the Walsh RRP avoids caudal retraction of the urethrosphincteric complex and reconstructs the posterior fibrous raphe. METHODS: Prior to completion of the vesicourethral anastomosis, the posterior fibrous tissues of the sphincter are joined to the residual Denonvilliers fascia on the posterior bladder wall 1-2 cm cephalad and dorsally to the new bladder neck. The study end point was assessment of early and long-term continence rate. Modified RRP (group 1: 250 patients) was compared with unmodified RRP (historical group 2: 50 patients). A crude comparison of treatment effect was assessed by using Pearson chi-square. Multiple logistic regression was used to assess treatment efficacy at discharge, 1, 3, and 12 mo, while taking into account age, pathologic stage, and Gleason score. Continence was defined as 0-1 pad per day. RESULTS: Patients in group 1 achieved significantly better continence at discharge (62.4% vs. 14.0%), 1 mo (74.0% vs. 30%), and 3 mo of follow-up (85.2% vs. 46%); long-term recovery was similar in the two treatment groups (94% vs. 90%). CONCLUSIONS: The technical modification that we proposed achieved a substantial and significant reduction in time to continence with no adverse effects.

Case report: Cystoscopic use of cyanoacrylate glue for bleeding during transurethral resection of bladder tumors.

An 81-year-old woman with a history of nephroureterectomy and bladder cuff excision for grade 3 stage pT3N0M0 transitional-cell neoplasia presented with three bladder neoplasms. She also had symptomatic varicose veins in the lower extremities and received low-molecular-weight heparin. During transurethral resection of the tumors, deep ablation of the base of one lesion resulted in significant arterial bleeding that could not be controlled with normal endoscopic techniques. On the basis of previous positive experience, we endoscopically injected 3 mL of cyanoacrylate glue (Glubran 2) deeply (5 mm) into the tissue surrounding the bleeding site, making four injections with a device used for collagen injections. The area was irrigated with mannitol and sorbitol, and within a few seconds, there was complete remission of bleeding. We waited a further 90 seconds with the bladder distended to allow the substance to lose its adhesive properties so as to avoid having the bladder walls stick together. The catheter was removed on the third day, with resumption of micturition and clear urine. This appears to be the first case of cystoscopic use of cyanoacrylate glue to control bleeding.

[Pathology and physiopathology of urethral stenosis]. / Anatomia patologica e fisiopatologia delle stenosi uretrali.

The research of new techniques for surgical repair of urethral stenosis, has developed interest and knowledge toward tissue handling and transfer in urology. Successful surgical repair of "long" stenosis is possible nowadays, using graft or flap tissue transfer. The knowledge of methral anatomy and of histopathology urethral anatomy, histopathology and physiopathology of the mechanism involved in process of urethral narrowing, is necessary for the diagnosis and the surgical indication of this pathology. To review physiopatological and anatomopathological aspects of urethral stenosis is the aim of the authors.