[VESICO-VAGINAL FISTULAS (VVF)].

INTRODUCTION: Vesico-vaginal fistula, is a known complication that can occur following damage to the bladder wall during pelvic surgery or prolonged birth. Prompt and accurate diagnosis and timely repair are essential for a quick solution to the problem, and a reduction in medico-legal claims. Successful treatment requires an accurate assessment of the size and the location of the fistula, determination of timing and the surgical technique. There is an approach that advocates postponing the surgery for several months until "tissue healing" subsides and some advocate immediate repair. In our department, the surgery is performed early, immediately upon diagnosis without delay. The aim of the work is to define the clinical manifestation of fistula after surgery, to analyze the factors, and to summarize the experience of an early intervention. METHODS: We reviewed the records of consecutive patients undergoing repair of urogenital fistulas at our institution. Patients with only vesico-vaginal fistulas were included. We recorded demographic characteristics, as well as surgical data, and postoperative complications were also collected. The follow-up period was at least 3 months. RESULTS: A total of 67 women with urogenital fistulas were identified, of whom 37 were only with vesico-vaginal fistulas. Iatrogenic injury, during hysterectomy was the main cause in 70.3%; 2 women were treated conservatively. A repair in the vaginal approach was performed in 31 women, and in 4 women the repair was performed in the abdominal approach, of them, two underwent urethral re-implantation simultaneously. Complications included sepsis in one case, and vaginal cuff dehiscence in another. The success rate of the repair was 92%. Recurrence occurred in 3 patients, of whom 2 had a history of previous radiation. CONCLUSIONS: A vesico-vaginal fistula can be successfully repaired by early repair, without delay, thus saving the patient considerable distress and discomfort.

Pain Control after Laparoscopic Radical Prostatectomy: Comparison between Unilateral Transversus Abdominis Plane Block and Wound Infiltration.

BACKGROUND AND OBJECTIVES: To determine the efficacy of unilateral transversus abdominis plane (TAP) block versus wound local infiltration for postoperative pain following laparoscopic radical prostatectomy (LRP). METHODS: Data of consecutive patients who underwent extraperitoneal LRP and received either wound infiltration or unilateral TAP block for analgesia were retrospectively analyzed. The patients were divided into 2 groups based on the technique used. We compared pain intensity scores and on-demand analgesic use both during the hospital stay and post-discharge between the 2 groups. RESULTS: A total of 48 patients were included, 27 received unilateral TAP blocks (group 1) and 21 were managed with wound infiltration (group 2). The unilateral TAP block group showed lower median pain scores on postoperative days (POD) 1 with pain scores being 0.2 (0-4) and 0.8 (0-4), respectively (p < 0.05). On POD2, the median pain intensity was 0.9 (0-5) and 1.6 (0-6) in groups 1 and 2, respectively (p < 0.05). The median number of on-demand analgesic doses during the POD1 was 0.2 (0-2) and 0.4 (0-2) in groups 1 and 2, respectively (p = 0.19). On POD2, the patients received 0.5 (0-2) and 1.1 (0-3) on-demand doses in groups 1 and 2, respectively (p < 0.05). CONCLUSION: Unilateral TAP block might improve pain control more pronounced after LRP than wound infiltration.

Laparoscopic partial nephrectomy for tumors 7cm and above. Perioperative outcomes.

PURPOSE: To assess and report the outcomes of laparoscopic partial nephrectomy )LPN) for T2 renal masses. MATERIALS AND METHODS: Retrospective review of patients undergoing LPN for clinically localized renal masses ≥7cm between the years 2005-2016. Descriptive analyses were generated for demographics, lesion characteristics, perioperative variables (operative time, warm ischemia time (WIT), estimated blood loss (EBL), intra-operative and post-operative complications (IOC and POC) and pathologic variables (pathology, subtype and Fuhrman grade). RESULTS: A total of 27 patients underwent LPN for a T2 renal mass at our institution between 2005 and early 2016 of which 19 were males. The mean age was 66 (52-72). All procedures were transperitoneal with 16 on the right and 11 on the left. Median operative time was 200 minutes (IQR 181-236) and median WIT 19 minutes (IQR 16-23). EBL was 125mL (IQR 75-175). One case was converted to laparoscopic radical nephrectomy due to suspected tumor thrombus in the renal vein. Surgical margins were positive in one renal tumor in a patient with multiple tumors. There was a total of 2 IOC (7.4%) and 3 POC (11%) classified as Clavien grade 3. CONCLUSIONS: To our knowledge, this series is the first to describe the outcomes of LPN for cT2 renal masses. In our series, LPN for larger renal masses appears feasible with favorable perioperative outcomes. Additional data are needed to further explore the benefits of minimally invasive surgical approaches to larger renal masses.

Escherichia coli isolates from patients with bacteremic urinary tract infection are genetically distinct from those derived from sepsis following prostate transrectal biopsy.

BACKGROUND: Transrectal ultrasound-guided (TRUS) prostate biopsy is a very common procedure that is generally considered relatively safe. However, severe sepsis can occur after TRUS prostate biopsies, with Escherichia coli being the predominant causative agent. A common perception is that the bacteria that cause post-TRUS prostate biopsy infections originate in the urinary tract, but this view has not been adequately tested. Yet other authors believe on the basis of indirect evidence that the pathogens are introduced into the bloodstream by the biopsy needle after passage through the rectal mucosa. METHODS: We compared E. coli isolates from male patients with bacteremic urinary tract infection (B-UTI) to isolates of patients with post prostate biopsy sepsis (PPBS), in terms of their sequence types, determined by multi-locus sequence typing (MLST) and their virulence markers. RESULTS: B-UTI isolates were much richer in virulence genes than were PPBS isolates, supporting the hypothesis that E. coli causing PPBS derive directly from the rectum. Sequence type 131 (ST131) strains and related strain from the ST131 were common (>30%) among the E. coli isolates from PPBS patients as well as from B-UTI patients and all these strains expressed extended spectrum beta-lactamases. CONCLUSIONS: Our finding supports the hypothesis that E. coli causing PPBS derive directly from the rectum, bypassing the urinary tract, and therefore do not require many of the virulence capabilities necessary for an E. coli strain that must persist in the urinary tract. In light of the increasing prevalence of highly resistant E. coli strains, a new approach for prevention of PPBS is urgently required.

The Value of Rectal Cultures in Treatment of Sepsis Following Post-Transrectal Ultrasound-Guided Prostate Biopsy.

BACKGROUND: Cases with sepsis after transrectal ultrasound-guided prostate biopsy (TRUSPB) were documented, with special focus on cultures and susceptibility of isolates. We also evaluated the contribution of concomitant rectal cultures to the treatment of selective cases. MATERIALS AND METHODS: Patients with sepsis after TRUSPB were followed prospectively. Manifestations and risk factors for antimicrobial resistance were documented. Results of urine and blood cultures and antimicrobial susceptibility were recorded for all participating patients. In 40 patients, rectal swab cultures were obtained concomitantly. RESULTS: Ninety-five patients were consecutively studied. Sepsis symptoms started showing up within 48 h after biopsy in 93% of patients. At least one of the cultures was positive in 72 patients. E. coli grew in 70 cases; isolates were highly resistant: 67% displayed multidrug-resistance. Rectal cultures grew E. coli in 38 cases. In patients with positive E. coli in rectum and in at least one additional culture (blood and/or urine), the antibiogram was identical in all cases but one. Eight cases had negative cultures. CONCLUSION: The prevalence of antimicrobial resistance among E. coli isolates from patients with TRUSPB sepsis was alarming. Susceptibilities of rectal E. coli isolates used for deescalation of initial empiric treatment in culture-negative TRUSPB sepsis can contribute to the reduction of broad-spectrum antibiotics exposure.

The value of testicular ultrasound in the prediction of the type and size of testicular tumors.

OBJECTIVES: Ultrasound (US) is often used for the work-up of testicular pathology. The findings may implicate on its management. However, there is only scant data on the correlation between US findings and testicular tumor type and size. Herein, we report on a multicenter study, analyzing these correlations. METHODS: The study included patients who underwent orchiectomy between 2000 and 2010. Their charts were reviewed for US echogeneity, lesion size, pathological dimensions, histology, and the presence of calcifications, fibrosis, necrosis and/or intraepithelial neoplasia. The incidence of these parameters in benign versus malignant lesions and seminomatous germ cell tumors (SGCT) versus nonseminomatous germ cell tumors (NSGCT) was statistically compared. RESULTS: Eighty five patients fulfilled the inclusion criteria, 71 malignant (43 SGCT, 28 NSGCT) and 14 benign. Sonographic lesions were at least 20% smaller than the pathologically determined dimensions in 21 (25%) patients. The ability of US in estimating the size of malignant tumors was 71%, compared to 100% of benign tumors (p=0.03), with no significant difference between SGCT and NSGCT. Necrosis was more frequent in malignant tumors (p=0.03); hypoechogeneity and fibrosis were more frequent in SGCT than in NSGCT (p=0.002 and 0.04 respectively). CONCLUSIONS: Testis US of malignant lesions underestimates the size in 25% of the cases, a fact that may impact on the decision of testicular sparing surgery. The ultrasonic lesions were eventually proven to be benign in 16% of the cases. Therefore it is advised to apply frozen sections in borderline cases. Hypoechogeneity is more frequent in SGCT than NSGCT.

Oncological safety of simultaneous transurethral resection of high-grade urothelial carcinoma of the bladder and benign prostatic hyperplasia.

Objectives: To examine the oncological safety of simultaneous resection of bladder tumor and prostate in the presence of non-muscle invasive high-grade urothelial carcinoma of the bladder (UCB). Materials and Methods: Between 2007 and 2019, 170 men with high-grade UCB who had a follow-up of at least 12 months were included in the study, including 123 with transurethral resection of bladder tumor (TURBT) only and 47 with simultaneous TURBT and transurethral resection of the prostate (TURP). We recorded and compared patients' clinicopathological parameters, recurrence, and progression rates during the follow-up period, as well as time to UCB recurrence in the bladder and the prostatic urethra/fossa. Results: Baseline demographic and pathological characteristics were comparable between the groups. At a median follow-up of 31 months in both groups, there were no significant differences in recurrence rates in the bladder and the prostatic urethra/fossa in either group (34.1% and 7.3% vs. 36.2 and 6.4%, p=0.402, p=0.363). No statistically significant differences were found between the two groups in terms of follow-up time, elapsed time to recurrence, or and progression in the bladder or prostatic urethra/fossa. Conclusions: Simultaneous TURBT and TURP in the presence of high-grade UCB appears to be oncologically safe in selected patients.

Sexually transmitted Escherichia coli urethritis and orchiepididymitis.

We describe herein a case of uropathogenic Escherichia coli urethritis and orchiepididymitis in a heterosexual man, which he had acquired sexually from his girlfriend. The identity of the genital isolates from both partners was confirmed by pulsed-field gel electrophoresis.

Laparoscopic partial nephrectomy: beyond the straightforward T1a.

UNLABELLED: What's known on the subject? and What does the study add? Complex tumour features (e.g. size, hilar location, multifocality) are generally considered contraindicative for LPN and only a handful of studies reporting encouraging outcomes with more complex tumours. Herein we suggest that in experience hands the benefits of minimally-invasive surgery may be safely extended to patients with more complex renal masses. OBJECTIVE: To report on our experience in extending the indications for LPN beyond the single, T1a renal mass assessing the perioperative outcomes in a comparative fashion. PATIENTS AND METHODS: Retrospective review of consecutive patients undergoing LPN for a renal mass in an academic centre between 2005-2010. 150 patients were divided into two groups based on tumours characteristics: straightforward T1a (group 1: single, <4 cm, n = 84) and complex (group 2: multiple and/or hilar and/or ≥4 cm, n = 66). Comparison of demographic, clinical, radiographic and perioperative outcomes (operative times, blood loss, warm ischemia times, intra- and postoperative complications). RESULTS: In group 2, 19 tumours were hilar, 15 were multifocal and 44 measured ≥4 cm; 2 of these criteria were present in 7, and all three in 3 cases. Warm ischemia times and blood loss were comparable (medians of 21 vs 20 min, and 100 vs 100 mL). Operative times were longer in group 2 (190 vs 140min, P < 0.001). Complications occurred in 11.9% and 12.1% of patients in group 1 and 2, with Clavien grade 3 events in 8.3 and 10.9%, respectively (P = 1.00 and P = 0.547). There were 4 conversions to laparoscopic radical nephrectomy (1 in group 1, 3 in group 2). CONCLUSION: With adequate laparoscopic expertise, the indications for LPN can be safely extended beyond the single, small, peripheral T1a renal mass. In this series, more complex masses were effectively treated with LPN combining the advantages of minimally-invasive surgery to those of nephron-sparing approach.

Uretero-vesico-cervical fistula following a caesarean section: a unique case report.

A unique combined fistula involving simultaneously the bladder, ureter, and cervix following cesarean section is described. Evaluation, management, and review of the literature regarding this rare and challenging case are reported. This unique case report emphasizes the potential complexity of iatrogenic genitourinary fistulae, suggesting that these might have unexpected morphology and present with multiple fistulous components. It has been demonstrated that concomitant ureteral involvement is estimated to complicate at least 10 % of vesico-vaginal fistulae. Thus, increased awareness of the possibility of complex iatrogenic fistulae and precise evaluation of the upper urinary tract are necessary to accurately define the extent of all fistulous tracts during the initial evaluation. This in turn may enable tailored management of these challenging cases. Moreover, in the case of surgical treatment, an accurate initial definition of fistula morphology may enable a single-stage reconstructive procedure sparing additional interventions and avoiding any potential complications.

Simplified hemostatic technique during laparoscopic partial nephrectomy.

INTRODUCTION: Laparoscopic partial nephrectomy (LPN) has gained popularity in recent years, although it remains a challenging procedure. Herein we describe our technique of renal defect closure using sutures as the sole means of hemostasis during LPN. SURGICAL TECHNIQUE: The kidney is approached transperitoneally in a standard fashion. After the renal artery is clamped and the tumor has been excised, the defect is closed in two separate knot-free suture layers. The deep layer suture is continuous and involves deep parenchyma including the collecting system, if opened. The superficial layer suture approximates the margins of the defect using absorbable clips on one parenchymal edge only. No bolsters, glues or other additional hemostatic agents are used. RESULTS: At present this technique was applied in 34 patients. Tumor size ranged from 17-85 mm. Median warm ischemia time was 23 min (range 12-45) and estimated blood loss 55 mL (30-1000). There were no intraoperative complications or conversions to open surgery. No urine leaks or postoperative bleedings were observed. CONCLUSIONS: This simplified technique appears reliable and quick, and therefore may be attractive for many urologic surgeons. Furthermore, the avoidance of routine use of additional hemostatic maneuvers may provide an economical advantage to this approach with no compromise of the surgical outcome.

Minimally invasive meshless and minimal dissection ligament fixation system for apical organ prolapse procedures: A 4-year prospective follow up study.

OBJECTIVE: EnPlace™ (formerly named NeuGuide™) is a minimally invasive meshless anchoring system for pelvic organ prolapse (POP) repair designed to provide centro-apical pelvic floor support. We present a 4-year prospective follow up evaluation of this repair system. METHODS: This was a single-center longitudinal prospective study of women with advanced POP who underwent pelvic floor apical repair using EnPlace™ with at least 4 years of follow-up. The primary outcome was surgical success defined as anatomical success, no symptoms of vaginal bulging and no need for re-treatment. A standardized validated questionnaire to assess symptom burden was used. RESULTS: Fifteen women were enrolled in the study. Two patients were lost to follow-up. The median follow-up was 51 months (range 42-57) with a surgical success rate of 92.3%. One patient (7.7%) reported symptoms of vaginal vault prolapse and underwent a repeated prolapse surgery. Using the UDI-6 questionnaire, an improvement in all domains was seen. CONCLUSION: The 4-year prospective follow up suggests that apical repair using the EnPlace™ device may be considered safe and effective for sacrospinous ligament fixation with a sustainable long-term success. This procedure is a minimally invasive meshless addition to pelvic surgeon's armamentarium.

Laparoscopic partial nephrectomy for multiple tumours: feasibility and analysis of peri-operative outcomes.

OBJECTIVE: • To describe our experience with laparoscopic partial nephrectomy (LPN) for multiple kidney tumours and compare the outcomes with LPN performed for single masses. PATIENTS AND METHODS: • Retrospective analysis of medical records of patients undergoing LPN at our institution between 2005 and 2009 was performed. • The cohort was divided in two groups based on tumour focality: group 1, LPN for a single tumour (n= 99) and group 2, LPN for multiple ipsilateral tumours (n= 12). • The groups were compared with regards to demographic and peri-operative variables. RESULTS: • Demographic variables were not different between the groups. Median dominant tumour size was 3.1 cm (interquartile range [IQR] 2.4-4.0) and 4.0 cm (2.3-5.9) in groups 1 and 2, respectively. • Median secondary tumour size in group 2 was 1.0 cm (1.0-1.8). • Operative times were longer in group 2 compared with group 1 (220 vs 160 min, P= 0.009). • Warm ischaemia times (WIT) (23 vs 22 min) and estimated blood loss (EBL) (100 vs 85 mL) were similar. CONCLUSIONS: • LPN is a viable option for the treatment of multiple ipsilateral renal tumours. • Peri-operative outcomes are similar to standard LPN with the exception of longer operative time. • In experienced hands, the advantages of minimally invasive surgery may be extended to select patients with ipsilateral multifocal renal tumours.

Perioperative metabolic alkalemia is more frequent than metabolic acidemia in major elective abdominal surgery.

OBJECTIVE: To investigate the incidence, type and etiology of perioperative metabolic disturbances associated with major abdominal surgery. We hypothesized that metabolic alkalemia is more frequent than metabolic acidemia. METHODS: This was a prospective, observational study, performed in a university-affiliated hospital. 98 consecutive patients undergoing major abdominal surgery were included in the study. Patients were observed by serial vital signs and laboratory measurements during the preoperative, intraoperative, PACU and the first three postoperative day periods. Central venous pressure, systolic pressure variation, fluid input, urine output, temper- ature, electrolytes, and acid-base variables were recorded. The primary endpoint of the study was the incidence of metabolic alkalemia or acidemia. Metabolic alkalemia was defined as pH >7.45 and BE >+3. Metabolic acidemia was defined as pH <7.35 and BE <-3. Continuous variables were described as mean ± standard deviation. Distributions of continuous variables was assessed for normalty using the Kolmogorov-Smirnov test (cut off at P = 0.01). The frequency of metabolic acidemia or alkalemia was compared across time points using Cochran's Q test and between time points using the binomial distribution. RESULTS: Metabolic acidemia occurred only intraoperatively and in the PACU. Subjects with metabolic acidemia were older, (74 ± 9 yr. vs. 66 ± 12, P = 0.01). Intraoperative body temperature was inversely associated with PACU lactate (P = 0.035). Blood loss >500 mL was more frequent in acidemic patients (42% vs. 19%, P = 0.033). More patients with hyperphosphatemia had acidemia than subjects without hyperphosphatemia (39% vs. 17%, P = 0.019). Metabolic alkalemia occurred more frequently than metabolic acidemia (49% vs. 23%, P < 0.0001) and was correlated with hypochloremia. The incidence of metabolic alkalemia decreased from baseline to intraoperative and PACU periods (13% vs. 3%, P = 0.003) and increased from the PACU to the three postoperative days (3% vs. 45%, P = 0.007). CONCLUSIONS: Metabolic alkalemia occurred more frequently than metabolic acidemia and occurred mainly preoperatively and postoperatively, while acidemia occurred mainly during surgery and in the PACU.

A novel reconstructive option for long upper ureter obliteration.

INTRODUCTION: Injuries of the upper (lumbar) portion of the ureter are rare; however, their reconstruction may pose considerable challenges. We describe a novel technique of surgical reconstruction in case of a long upper ureteral obliteration that may be a viable treatment option in select patients. MATERIALS AND METHODS: Reconstruction of a iatrogenic 5 cm injury to the upper ureter, consisting of 2 cm obliteration and 1.5 cm stenotic segments on its sides, unsuitable for an end-to-end reanastomosis, was performed using a novel technique of augmented pelvic flap anastomotic ureteroplasty. The injured ureteral segment was excised, the ureteral stump was spatulated on the medial aspect and the lateral tissue defect was replaced by a flap from the posterior surface of the renal pelvis. RESULTS: The procedure was successfully performed avoiding more aggressive and morbid management choices. To date, patient's renal function is stable and there is no clinical or radiographic evidence of obstruction. CONCLUSIONS: The described augmented anastomotic ureteroplasty using a pelvic flap is a useful surgical solution for select patients with long upper ureteral obliteration that cannot be managed by a direct reanastomosis. This technique may represent a valid addition to the urologic surgical armamentarium.

Patients treated for uric acid stones reoccur more often and within a shorter interval compared to patients treated for calcium stones.

INTRODUCTION: We aimed to investigate the association between stone composition and recurrence rate in a well-characterized group of patients. METHODS: From our prospectively assembled database of 1328 patients undergoing ureteroscopy and percutaneous nephrolithotomy (PCNL) between 2010 and 2015, we identified 457 patients who met the inclusion criteria: a minimum of two years' followup, stone-free status following surgery, normal anatomy, and Fourier transform infrared (FT-IR) stone analysis results. Stone recurrence was identified by kidney-ureter-bladder (KUB) or an ultrasound (US). All symptomatic events were recorded. Kaplan-Meier and Cox proportional hazard regression methods were used to assess the differences in recurrence rates and associated risk factors. RESULTS: Calcium oxalate (CaOx), uric acid (UA), and struvite stones were found in 298 (65.2%), 99 (21.7%), and 28 (6.1%) patients, respectively. During a median followup of 38 months (interquartile range [IQR] 31-48), stone recurred in 111 (24%) patients. One-year stone-free rates (SFRs) stratified by composition were: CaOx 98%, UA 91.9%, calcium phosphate 90%, struvite 88%, and, cystine 83%; the two-year SFRs were 92.6%, 82.7%, 80%, 73%, and 75%, respectively. On multivariate Cox regression analysis, UA composition, the absence of medical preventive therapy, and preoperative stone burden were associated with a shorter time to recurrence. Secondary intervention for recurrent, symptomatic stones was required in 11 (11.1%) and 22 (7.4%) of patients with UA and CaOx stones, respectively (p=0.02). CONCLUSIONS: UA stone-formers are more likely to have a recurrence and to undergo surgical intervention in comparison to CaOx stone-formers, regardless of medical preventive treatment. These differences are more prominent during the first year of followup and should be incorporated into the patient's followup protocol.

Value of separate tumor base biopsy in transurethral resection of bladder tumors.

INTRODUCTION: The aim of our study was to evaluate whether a biopsy from the tumor base after transurethral resection of bladder tumor (TURBT) has an impact on subsequent management of patients with bladder tumors. While tumor base biopsy at the completion of TURBT is a common practice, there is no definition of its role within the major international professional guidelines. MATERIAL AND METHODS: We retrospectively reviewed the records of consecutive patients undergoing TURBT between 2015 and 2019 at our institution. We recorded demographic and tumor characteristics of initial TURBT, tumor base biopsy and restaging TURBT pathology outcomes. The pathologic outcomes were correlated to assess the additional value of a separate tumor base biopsy. RESULTS: A total of 532 patients underwent TURBT. A separate tumor base biopsy after completion of TURBT was performed in 154 patients. The mean patient's age was 72.8 ±11.7 years (range 48-94) and 119 (77.2%) were men. In 40 patients (25.9%) muscle was absent in the pathological specimen of the tumor resection. Muscle was present in all but 6 (3.9%) tumor base biopsies. Of the 33 patients who underwent repeated transurethral resection for pT1 tumors, 2 had residual low-grade pTa, 1 had residual high-grade pT1, and 3 patients were upstaged to pT2. CONCLUSIONS: Although tumor base biopsy at the completion of TURBT is a common practice, our analysis fails to demonstrate any tangible benefit in the staging of bladder tumors. In our experience tumor base biopsy did not change the management in patients with superficial or muscle invasive disease.

Transobturator tape procedure with and without concomitant vaginal surgery.

PURPOSE: We evaluated results and complications of the transobturator tape procedure for female stress urinary incontinence and assessed the effect of concomitant vaginal surgery on the outcome. MATERIALS AND METHODS: We prospectively studied consecutive women who underwent the transobturator tape procedure without (group 1) or with (group 2) concomitant vaginal surgery at our institution from 2003 to 2006. Followup was at least 12 months. Preoperative evaluations included medical history, Urogenital Distress Inventory-6, physical examination, urinalysis and culture, and urodynamics. The procedure was performed as an out-in technique. Therapeutic success was defined as complete continence not requiring pad protection. All other outcomes were classified as failures. RESULTS: A total of 96 patients with a mean age of 63 years (range 37 to 89) who fulfilled study entry criteria comprised the study cohort. Group 1 included 35 patients and group 2 included 61 with 1 or more concomitant vaginal surgeries, including hysterectomy in 28, anterior colporrhaphy in 61, posterior colporrhaphy in 11, and excision of a vaginal granuloma with suture thread and excision of the eroded part of the tape in 1 each. There were no intraoperative complications. One patient per group had transient leg pain. Seven group 2 patients had voiding dysfunction, of whom 3 underwent tape release for a presumed obstructed urethra. Postoperatively 29 women (82.86%) in group 1 and 52 (85.2%) in group 2 were continent throughout the 36.1-month followup (range 12 to 54). CONCLUSIONS: Transobturator tape is safe and effective for stress urinary incontinence. Voiding dysfunction is more prevalent after concomitant vaginal surgery but that surgery does not affect the transobturator tape continence outcome.

Laparoscopic removal of local renal cell carcinoma recurrence.

PURPOSE: To describe an entirely laparoscopic technique for excising a recurrence of local renal cell carcinoma (RCC). MATERIALS AND METHODS: The patient is placed in a full flank position. A 10-mm trocar is inserted using Hasson's technique with three additional ports in the upper abdomen. After lysis of adhesions, the psoas muscle, ureteral and gonadal vein remnants, inferior vena cava or aorta, and renal vessel stumps are dissected and isolated. The specimen, including the mass, the adrenal gland, and the ipsilateral pararenal and paracaval or para-aortic tissue within Gerota's fascia remnants, are excised en bloc and removed inside an Endocatch-II bag. RESULTS: To date we have used this technique for excising RCC recurrences in three patients. Pathologic examination showed clear cell type RCC Fuhrman grade 2 in the specimens of two patients and chromophobe type in one. No patient has had further recurrence after 50, 38 and 12 months of follow-up. CONCLUSIONS: An entirely laparoscopic surgical approach for excising local RCC recurrence has not, to our knowledge, been previously described. This method can be effectively applied while adhering to oncologic principles, with minimal blood loss and low morbidity.