Stone free rate and clinical complications in patients submitted to retrograde intrarenal surgery (RIRS): Our experience in 571 consecutive cases.

INTRODUCTION: The purpose of this study is to report the stone free rate (SFR) and clinical complications in patients submitted to retrograde intrarenal surgery (RIRS). MATERIALS AND METHODS: A total of 571 procedures of upper urinary stones treated using flexible ureteroscopy and holmium laser lithotripsy from January 2014 to February 2020 have been analyzed. Overall SFR was evaluated after 3 months following the procedure by means of a non-contrast computed tomography. Success was considered as stone-free status or ≤ 0.4 cm fragments. RESULTS: The overall SFR was 92.3% in group 1 (stone size: < 1 cm), 88.3% in group 2 (stone size: > 1 ≤ 2 cm), 56.7% in group 3 (stone size: 2-3 cm) and 69.6% in group 4 (multiple stones). Post-operative complications, according to the Clavien- Dindo (CD) classification system, were recorded in 32 (5.6%) procedures. The major complications recorded were: one case of subcapsular hematoma (SRH) associated with pulmonary embolism two days after the procedure (CD Grade IIIa) treated conservatively and one case of hemorrhagic shock 2 hour with multiple renal bleedings requiring urgent nephrectomy (CD Grade IVA). CONCLUSIONS: The RIRS is an effective and safe procedure with a high SFR significantly correlated with the stone size; at the same time, RIRS could be characterized by severe clinical complications that require rapid diagnosis and prompt treatment.

Flexible ureteroscopy using a 120-w holmium laser: The low-energy/high-frequency approach. / Ureteroscopia flexible utilizando laser holmium 120 W: baja energía/alta frecuencia.

OBJECTIVES: With the spread of more powerful lasers and the advent of new technologies, endoscopic interventions for urolithiasis are continuously evolving. The aim of this study is to present our experience and technique regarding Low Energy (LE)/High Frequency (HF) lithotripsy by using a 120-W Holmium laser (Lumenis®). METHODS: We retrospectively analysed our prospectively maintained Retrograde Intra Renal Surgery (RIRS) database. Lithotripsy was performed using LE/HF settings with a Long Pulse Width (LPW) and consisted of the following steps: 1) contact Laser lithotripsy (LE/HF/LPW dusting - 0,5 J/50 Hz or 02 J/70 Hz); 2) extraction ofmain fragments; 3) non-contact Laser lithotripsy (LE/HF/Short Pulse Width Pop Dusting - 0,5 J /80Hz). Pre-operativeand peri-operative outcomes were collected. Post-operative complications were recorded according to Clavien-Dindo Grading System. Finally, all patients under went a CT scan at three months after RIRS to assess the success of procedure, defined as stone-free or presence of ≤4 mm fragments (Clinical Insignificant Residual Fragments - CIRF). RESULTS: Overall, 104 LE/HF/LPW RIRS from December 2017 to January 2019 were performed. Mean operative time was 59 (SD ±23) minutes, median post-operative stay was two days (IQR 2-3). The post-operative complication rate was 4,8%: one patient had nausea and vomiting (Clavien-Dindo I) and four patients developed urosepsis (Clavien-Dindo II). The success rate was 88,5% (71,2% stone-free and 17,3% CIRF). CONCLUSIONS: LE/HF/LPW RIRS seems to be safe and effective in terms of positive success rate, safety and standard operative time. However, randomized clinical trials are needed to compare this technique to standard RIRS.

OBJETIVOS: Con la aparición de láseres de alta potencia y las nuevas tecnologías, las intervenciones endoscópicas para las urolitiasis continúan evolucionando. El objetivo de este estudio es presentar nuestra experiencia y técnica de baja energía (BE), alta  frecuencia (AF) de litotricia utilizando el laser holmium120 W (Lumenis®). MÉTODOS: Retrospectivamente analizamos nuestra base de datos prospectiva de ureteroscopia retrograda intrarenal. La litotricia fue realizada utilizando BE/AFcon pulsos amplios y largos (LPW). La técnica consistió en los siguientes pasos: 1) Contacto litotricia laser (BE/AF/LPW polvo- 0.5J/50 Hz o 02 J/70 Hz); 2) extracción de los fragmentos principales; 3) litotricia laser sin contacto (BE/AF/pulso corto polvo- 0,5 J /80Hz). Los resultados preoperatorios y perioperatorios fueron recogidos. Las complicaciones postoperatorias fueron recogidas por el sistema Clavien-Dindo. Finalmente, todos los pacientes recibieron un TAC a los 3 meses después de la ureteroscopia retrograda para evaluar el éxito del procedimiento, que se definió como la no existencia de litiasis o de fragmentos de menos de 4 mm (fragmentos clínicamente insignificantes). RESULTADOS: 104 BE/AF/LPW ureteroscopias retrógradas se realizaron entre diciembre de 2017 y enero de 2019. El tiempo operatorio medio fue de 50 minutos( SD ± 23), la estancia media postoperatoria fue de 2 días (IQR 2-3). La tasa de complicaciones postoperatorias fue de 4,8%: un paciente tuvo nauseas y vómitos (Clavien I) y 4 pacientes desarrollaron urosepsis (Clavien II). La tasa de éxito fue de 88%, 71,2% libre de litiasis y 17,3% fragmentos clínicamente insignificantes. CONCLUSIONES: BE/AF/LPW ureteroscopia retrógrada es un procedimiento seguro y efectivo en términos de tasa de éxito, seguridad y tiempo quirúrgico. Aunque, estudios randomizados son necesarios para comparar esta técnica con la ureteroscopia retrógrada estándar.

Prostatic artery embolization in benign prostatic hyperplasia: preliminary results in 13 patients.

AIM: The aim of the paper is to report the clinical outcome after prostatic artery embolisation (PAE) in 13 consecutive patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: From May 2012 to October 2013, we performed PAE in 13 consecutive patients (mean age 75.9 years) with BPH and LUTS and refractory to medical therapy; seven patients had an indwelling bladder catheter. Clinical follow-up (mean follow-up time 244 days) was performed using the international prostate symptoms score (IPSS), quality of life (QoL), the international index of erectile function (IIEF), blood prostatic specific antigen (PSA) testing and transrectal prostatic ultrasound (US) scan with volume and weight calculation at 3, 6 and 12 months. Pre-procedural CT angiography (CTA) was done for vascular mapping. Embolisation was performed using Embosphere (300-500 micron). Technical success was defined when selective prostatic arterial embolisation was completed in at least one pelvic side. Clinical success was defined when symptoms and quality of life were improved. RESULTS: PAE was technically successful in 12/13 patients (92%). In one patient, PAE was not performed because of tortuosity and atherosclerosis of iliac arteries. PAE was completed bilaterally in 9/13 (75%) patients and unilaterally in three (27%). All patients removed the bladder catheter from 4 days to 4 weeks after PAE. We obtained a reduction in IPSS (mean, 17.1 points), an increase in IIEF (mean, 2.6 points), an improvement in Qol (mean, 2.6 points) and a volume reduction (mean, 28%) at 12 months. CONCLUSIONS: Consistent with the literature, our experience showed the feasibility, safety and efficacy of PAE in the management of patients with LUTS related to BPH. PAE may play an important role in patients in whom medical therapy has failed, who are not candidates for surgery or transurethral prostatic resection (TURP) or refuse any surgical treatment. Larger case series and comparative studies with standard TURP can confirm the validity of the technique.

Penile dermal flap in patients with Peyronie's disease: long-term results.

PURPOSE: In 1995 a penile dermal flap was described as an ideal operation for penile curvature due to Peyronie's disease. We report our experience with penile dermal flaps in patients with penile curvature due to Peyronie's disease. MATERIALS AND METHODS: Between January 2001 and May 2004, 26 potent white men with Peyronie's disease underwent corporoplasty with a penile dermal flap. They were evaluated at 3, 6 and 12 months, and yearly thereafter by determination of penile length changes and residual curvature, and the International Index of Erectile Function-5. RESULTS: At the maximum followup (mean 95 months, range 81 to 108) 22 of 26 patients (85%) were available for examination, of whom 14 (63.6%) had no residual curvature, and 2 (9.1%) and 7 (31.8%) had improved and worse erectile function, respectively. Nine patients (40.9%) had inclusion cysts at the surgical site, including 5 who underwent surgical cyst removal with no cyst recurrence. Only 9 of 22 patients (40.9%) were satisfied with the cosmetic and functional outcome. CONCLUSIONS: Despite the attractiveness of the operation to our knowledge no other experience with this technique has been reported. Our results differ from those reported, although we tried to exactly follow the original technique of dermabrading the flap with sandpaper. Based on these results we abandoned the penile dermal flap in patients with Peyronie's disease.

Urinary and sexual outcomes in long-term (5+ years) prostate cancer disease free survivors after radical prostatectomy.

BACKGROUND: After long term disease free follow up (FUp) patients reconsider quality of life (QOL) outcomes. Aim of this study is assess QoL in prostate cancer patients who are disease-free at least 5 years after radical prostatectomy (RP). METHODS: 367 patients treated with RP for clinically localized pCa, without biochemical failure (PSA or= 5 years were recruited.Urinary (UF) and Sexual Function (SF), Urinary (UB) and Sexual Bother (SB) were assessed by using UCLA-PCI questionnaire. UF, UB, SF and SB were analyzed according to: treatment timing (age at time of RP, FUp duration, age at time of FUp), tumor characteristics (preoperative PSA, TNM stage, pathological Gleason score), nerve sparing (NS) procedure, and hormonal treatment (HT).We calculated the differences between 93 NS-RP without HT (group A) and 274 non-NS-RP or NS-RP with HT (group B). We evaluated the correlation between function and bother in group A according to follow-up duration. RESULTS: Time since prostatectomy had a negative effect on SF and a positive effect SB (both p < 0.001). Elderly men at follow up experienced worse UF and SF (p = 0.02 and p < 0.001) and better SB (p < 0.001).Higher stage PCa negatively affected UB, SF, and SB (all: p

Lingual mucosal graft urethroplasty for anterior urethral reconstruction.

OBJECTIVE: Evaluate the use of lingual mucosal graft (LMG) in anterior urethral strictures. METHODS: From January 2001 to December 2006, 29 men (mean age, 48.5 yr) with anterior urethral strictures underwent graft urethroplasty with LMG. The mean length of stricture was 3.6cm. Patients with bulbar, penile, or bulbopenile strictures received one-stage dorsal free graft urethroplasties. In patients with failed hypospadias repair we performed a two-stage urethroplasty. Criteria for successful reconstruction were spontaneous voiding with no postvoid residual urine and no postoperative instrumentation of any kind. Clinical assessment included the donor site morbidity. RESULTS: Mean follow-up was 17.7 mo. One-stage bulbar and penile urethroplasties without meatal involvement had an 81.8-100% success rate. Bulbopenile urethroplasties were successful in 60% of the cases, whereas one-stage urethral reconstructions in patients with meatal involvement were successful in 66.6%. The two cases of two-stage urethral reconstruction with LMG and buccal mucosal graft after failed multiple hypospadias repairs were unsuccessful. The overall early recurrence rate was 20.7%. Patients with the graft harvested from the tongue reported only slight oral discomfort at the donor site and difficulty in talking for 1 or 2 d. CONCLUSIONS: The mucosa of the tongue, which is identical to the mucosa of the rest of the oral cavity, is a safe and effective graft material in the armamentarium for urethral reconstruction with potential minor risks of donor site complications. LMG may be used alone for short strictures (<5cm) or in combination with buccal mucosa when longer grafts are needed.

Congenital penile curvature: dermal grafting procedure to prevent penile shortening in adults.

OBJECTIVES: We report the results of a derma graft corporoplasty in a selected group of patients with congenital penile curvature (CPC) who refused a simple plication technique for the risk of penile shortening, even if minimal. METHODS: Between January 1995 and January 2004, 15 potent patients with CPC underwent corporoplasty with inguinal derma graft, with or without tunica albuginea plication. Mean age was 26.6 years (range 19-36). Six patients had a simple lateral left curvature, three had a simple lateral right curvature, four had a ventro-lateral left curvature, one patient had a ventro-lateral right curvature, and one patient had ventral curvature. In nine patients the preoperative mean IIEF-5 score was 22.55 (range 21-24). All the patients were evaluated after three, six and 12 months. RESULTS: One graft was placed in one patient (6.6%), seven (46.6%) received one graft and underwent a tunica albuginea plication, four (26.6%) received two grafts, three (20%) received two grafts and underwent tunica albuginea plication. A residual curvature after three, six and 12 months was present respectively in all (100%), seven (46.6%) and one (6.6%) patients. No patients had a decrease of penile length. The mean difference in the IIEF-5 score before and after the surgical procedure was not statistically significant. CONCLUSIONS: Surgical correction of CPC with derma grafts in potent patients restores penile straightening with no postoperative shortening and preserves normal erectile capacity. Patient satisfaction indicates that the proposed technique may be used in selected cases.

Primary malignant melanoma of the bladder.

Primary malignant melanomma of bladder is extremely rare: 18 cases are reported to date. An 82 year-old man underwent trans-urethral resection of bladder for a bleeding tumor of the posterior wall. Histological diagnosis was melanoma of the bladder. There was no history of previous or regressed cutaneous malignant melanoma. Margins of the bladder lesion contained atypical melanocytes similar to those commonly seen in the periphery of primary mucous membrane lesions. Clinical studies and radiological examinations were negative for other primary site of melanoma. The patient had a bladder recurrence that was consistent with primary tumor and died of widespread disease 9 months after diagnosis.

Intravesical gemcitabine in superficial bladder cancer: a phase II safety, efficacy and pharmacokinetic study.

BACKGROUND: We investigated the safety, efficacy and pharmacokinetics of the intravesical administration of 2000 mg gemcitabine once a week in the four weeks before transurethral resection of superficial bladder cancer (TUR), and in the four successive weeks. MATERIALS AND METHODS: Nine patients with superficial transitional cell bladder carcinoma were studied. Two thousand mg of gemcitabine dissolved in 50 ml of distilled water were administered intravesically. The dwell time was 60 min. The pharmacokinetics of gemcitabine and its metabolite, 2',2'-difluorodeoxyuridine (dFdU), were studied in plasma and urine before and after TUR. Cystoscopy was repeated 30 days after completion of the TUR treatment and subsequently at time intervals of one or two months. RESULTS: No systemic toxicity was noted, and only three patients displayed modest signs of local toxicity. One patient had recurrence 1 month after TUR, three between 3 and 6 months, and another three after 8, 11 and 18 months, respectively; two were recurrence-free after 21 and 22 months, respectively. The peak plasma concentrations of gemcitabine never exceeded 1000 ng/ml before TUR and 350 ng/ml after TUR, and declined rapidly. The plasma levels of dFdU were higher than those of gemcitabine, increased until 60 min and then declined little. Between 52% and 100% of the gemcitabine dose was present in voided urine. CONCLUSION: Intravesical gemcitabine, at the dose of 2000 mg, is well tolerated, is associated with minimal systemic absorption and has a moderate efficacy in the treatment of superficial bladder cancer.