A prospective randomized comparison among SWL, PCNL and RIRS for lower calyceal stones less than 2 cm: a multicenter experience : A better understanding on the treatment options for lower pole stones.

PURPOSE: To prospectively evaluate the efficacy and safety of RIRS, SWL and PCNL for lower calyceal stones sized 1-2 cm. MATERIALS AND METHODS: Patients with a single lower calyceal stone with an evidence of a CT diameter between 1 and 2 cm were enrolled in this multicenter, randomized, unblinded, clinical trial study. Patients were randomized into three groups: group A: SWL (194 pts); group B: RIRS (207 pts); group C: PCNL (181 pts). Patients were evaluated with KUB radiography (US for uric acid stones) at day 10 and a CT scan after 3 months. The CONSORT 2010 statement was adhered to where possible. The collected data were analyzed. RESULTS: The mean stone size was 13.78 mm in group A, 14.82 mm in group B and 15.23 mm in group C (p = 0.34). Group C compared to group B showed longer operative time [72.3 vs. 55.8 min (p = 0.082)], fluoroscopic time [175.6 vs. 31.8 min (p = 0.004)] and hospital stay [3.7 vs. 1.3 days (p = 0.039)]. The overall stone-free rate (SFR) was 61.8% for group A, 82.1% for group B and 87.3% for group C. The re-treatment rate was significantly higher in group A compared to the other two groups, 61.3% (p < 0.05). The auxiliary procedure rate was comparable for groups A and B and lower for group C (p < 0.05). The complication rate was 6.7, 14.5 and 19.3% for groups A, B and C, respectively. CONCLUSIONS: RIRS and PCNL were more effective than SWL to obtain a better SFR and less auxiliary and re-treatment rate in single lower calyceal stone with a CT diameter between 1 and 2 cm. RIRS compared to PCNL offers the best outcome in terms of procedure length, radiation exposure and hospital stay. ISRCTN 55546280.

Is retrograde intrarenal surgery a viable treatment option for renal stones in patients with solitary kidney?

PURPOSE: To evaluate the effectiveness and safety of retrograde intrarenal surgery (RIRS) for stones up to 2 cm in diameter in patients with solitary kidney. METHODS: From January 2008 to January 2013, we prospectively enrolled all consecutive patients with solitary kidney and renal stones. Plain abdominal computed tomography scan was performed preoperatively and 1 month after the procedure to assess the stone-free rates (SFR). Serum creatinine levels were detected preoperatively, at day 1 postoperatively, at 1 month postoperatively, and then every 6 months postoperatively. RESULTS: During the study period, we prospectively enrolled a total of 29 patients. The mean age was 55.7 ± 12.3 years; the mean stone size was 1.3 ± 0.4 cm. The primary SFR was 72.4 %; the secondary SFR was 93.1 %. The mean number of procedures per patient was 1.24. The mean serum creatinine levels were 1.5 ± 0.6, 1.6 ± 0.7, 1.6 ± 0.6, and 1.7 ± 0.7 mg/dl preoperatively, at 1 day after RIRS, at 1 month after RIRS, and at 1 year after RIRS, respectively, without detection of any statistical difference (p = 0.76). Median follow-up time was 35.7 ± 19.3 (12-72) months, but that was available for only 18 patients. The mean serum creatinine level at the last follow-up was 1.7 ± 0.9 mg/dl. No major complications were recorded. Grade I complications occurred in eight patients (27.4 %). CONCLUSIONS: RIRS is safe and effective in the treatment of renal stones in patients with solitary kidney, without worsening renal function.

Recurrent transient global amnesia after intracavernous Caverject injection in erectile dysfunction after robotic prostatectomy.

Treatment of erectile dysfunction after radical prostatectomy includes intracavernous Caverject injections. We present the case of recurrent transient global amnesia in a man performing self-administration of Caverject after robotic radical prostatectomy. The correlation between the intracavernous injection and the neurological phenomenon was repeated and evident, yet the specific aetiology of transient global amnesia remains uncertain.

Surgical correction of Peyronie's disease via tunica albuginea plication: long-term follow-up.

Peyronie's disease (PD) is an acquired connective tissue disorder of the tunica albuginea with fibrosis and inflammation that lead to palpable plaques formation, penile curvature, and pain during erection. Patients report negative effects on main domains such as physical appearance and self-image, sexual function, and performance. The aim of this study was to evaluate plication of the albuginea outcomes after a long-term follow-up period. Between 1998 and 2006, a total of 204 patients with PD underwent surgical correction with albuginea plication technique. We obtained complete long-term follow-up data in 187 cases. The follow-up data included evaluation of curvature correction, penile shortening, sexual function, complications, and patient satisfaction. After a mean follow-up of 141 months, the most common postoperative complications were: loss of length (150 patients had a minimal penile shortening ≤1.5 cm, 37 patient between 1.5, and 3 cm, none >3 cm), recurrent or residual penile curvature (15 patients, without impairing sexual intercourse), erectile dysfunction (15 patients had IIEF-5 < 10 at 5 years of follow-up vs. 28 patients at 10 years), change in penile sensation (37 patients experienced paresthesia of the glans 1 year after surgery, 28 at 5 years, and 15 at 10 years); painful or palpable suture knots (in 20 cases) spontaneously healed in 3 months. Overall, 77% of the patients and partners were completely satisfied, 14% partially satisfied, and 9% unsatisfied. Plication procedure is safe and simple to be performed compared with the classical Nesbit's procedure. It has a shorter surgical time, lower costs, and could be successfully performed by less experienced surgeons too. It has a minimal risk of de novo erectile dysfunction, injury to the dorsal neurovascular bundle. Results are good in terms of patient satisfaction according to anatomical outcome and functional correction.

Does site of specimen extraction affect incisional hernia rate after robot assisted laparoscopic radical prostatectomy?

BACKGROUND: Robot assisted laparoscopic radical prostatectomy (RALP) spread in the last decade as a minimally invasive alternative to open radical prostatectomy for men with localized prostate cancer. It is associated with excellent surgical, functional and oncological results with less postoperative pain and shorter convalescence. Anyway, the development of an incisional hernia (IH), may negate known benefits as it can lead not only to bothersome symptoms but also to severe complications, such as bowel obstruction, strangulation and perforation. Port-site or extraction site hernias, whose incidence rate is underdiagnosed, have become more commonly after minimally invasive surgery; but IH rate after robot-assisted radical prostatectomy has not been well characterized. This study aimed to evaluate the impact of extraction-site location (vertical supra-umbilical incision versus an off-midline incision) on incisional hernia rates in robotic prostatectomy. MATERIALS AND METHODS: We included in the study 800 patients undergone RALP, 400 with a supra-umbilical incision for specimen extraction and 400 with off-midline incision. All were followed up for at least 3 years. The main study end point was IH occurrence at the extraction site (midline versus off-midline). RESULTS: IH rate for the entire series was 4.75%, in particular 5% for the midline group and 4.5% for the off-midline group. The hernias were diagnosed at a mean of 20.2 and 18.2 months after surgery, respectively in the two groups. There was no statistically significant differences in baseline characteristics; anyway larger prostate weight, wound infection and history of prior cholecystectomy were associated with higher proportion of IH. CONCLUSION: Extraction site hernias are a rare but a potentially serious complication following RALP. In our series, the midline extraction doesn't result in a significantly higher IH rate in comparison with the off-midline extraction site.

Thulium laser enucleation (ThuLEP) versus transurethral resection of the prostate in saline (TURis): A randomized prospective trial to compare intra and early postoperative outcomes. / Enucleación con láser de tulio (ThuLEP) frente a resección transuretral de la próstata en solución salina (TURis): un ensayo prospectivo aleatorizado para comparar resultados intra y postoperatorios tempranos.

OBJECTIVE: To compare clinical intra and early postoperative outcomes between thulium laser transurethral enucleation of the prostate (ThuLEP) and transurethral bipolar resection of the prostate (TURis) for treating benign prostatic hyperplasia (BPH) in a prospective randomized trial. METHODS: The study randomized 208 consecutive patients with BPH to ThuLEP (n=102) or TURis (n=106). For all patients were evaluated preoperatively with regards to blood loss, catheterization time, irrigation volume, hospital stay and operative time. At 3 months after surgery they were also evaluated by International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and postvoid residual urine volume (PVR). RESULTS: The patients in each study arm each showed no significant difference in preoperative parameters. Compared with TURIS, ThuLEP had same operative time (53.69±31.44 vs 61.66±18.70minutes, P=.123) but resulted in less hemoglobin decrease (0.45 vs 2.83g/dL, P=.005). ThuLEP also needed less catheterization time (1.3 vs 4.8 days, P=.011), irrigation volume (29.4 vs 69.2 L, P=.002), and hospital stay (1.7 vs 5.2 days, P=.016). During the 3 months of follow-up, the procedures did not demonstrate a significant difference in Qmax, IPSS, PVR, and QOLS. CONCLUSION: ThuLEP and TURis both relieve lower urinary tract symptoms equally, with high efficacy and safety. ThuLEP was statistically superior to TURis in blood loss, catheterization time, irrigation volume, and hospital stay. However, procedures did not differ significantly in Qmax, IPSS, PVR, and QOLS through 3 months of follow-up.

Unusual pleural effusion from vulvar squamous cell carcinoma: report of a case and review of the literature.

Vulvar tumors are not very common and account for about 4% of all cancers affecting the female genital organs. Frequently, malignant neoplasia of this site have squamous phenotype and the rare cases of metastasization are reported in the locoregional lymph nodes and in the surrounding organs. We report a case of metastasization of a vulvar squamous cell carcinoma in an unusual place such as the parietal pleura, in a relapsing patient that was submitted to a surgical vulvectomy the previous year.

Resonance(®) metallic stent in patients with ureterocutaneostomies.

PURPOSE: To evaluate the effectiveness and the safety of Resonance(®) stents in patients with ureterocutaneostomies (UCS). MATERIALS AND METHODS: We retrospectively enrolled all patients with UCS who presented with impaired ureteral drainage with traditional polymeric ureteral prosthesis. Preoperative and follow-up (1, 3, 6, 12 months) workup, after Resonance(®) placement, included: medical history, physical examination, serum laboratory tests, urinalysis, urine culture and urinary tract imaging by ultrasound, administration of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 (QLQ-C30) and an evaluation of patients' satisfaction rate. In addition, the number of emergency department patient admissions and hospitalizations occurred 1 year before and after the stent Resonance(®) placement was noted. RESULTS: Twenty-five renal units in 14 patients with UCS were included. Statistically significant improvements in creatinine serum levels, patients' satisfaction rate, hydronephrosis and number of urinary tract infections (UTI) were found at 1-, 3-, 6-, and 12-month follow-up compared to baseline. Statistically significant differences in EORTC QLQ-C30 were detected only in Emotional, Social and Global QoL domains before and after Resonance(®) placement (p < 0.0001). At inclusion, a total of 39 referrals to ED were recorded; at 1-year follow-up, only five cases of ED presentations have been recorded (p < 0.01). At the same endpoints, the number of hospitalizations was 18 and 2, respectively (p < 0.05). Failure rate was 8.3%. CONCLUSION: At 1-year follow-up, Resonance(®) stents are effective and safe in patients with UCS refractory to polymeric ureteral prosthesis, reporting evidence for significant improvements in hydronephrosis rate, renal function, UTI, and patients' satisfaction rate and QoL.

Adaptation and validation of an Italian version of the Prostate Cancer Specific Quality of Life Instrument (PROSQOLI).

OBJECTIVE: The Prostate Cancer Specific Quality of Life Instrument (PROSQOLI) is a measure of health-related quality of life (HRQoL) in advanced hormone-resistant prostate cancer. In this study, we aimed at performing a cross-cultural adaptation and validation of the Italian version of the PROSQOLI. PATIENTS AND METHODS: The original version of the PROSQOLI underwent several turnarounds of translations. A total of 472 patients treated with radical prostatectomy, radiotherapy or medical therapy were enrolled for the validation of the questionnaire. The PROSQOLI was administered together with the SF-12. Reliability indexes were calculated by using Cronbach alpha. To evaluate the validity of the construct, relationships between PROSQOLI and SF12 were assessed. The ANOVA test was used to evaluate the differences between groups of patients who had received different treatments. RESULTS: The reliability coefficient was 0.91. Item-to-total correlation indices were in most cases >0.70. The correlation between the scores of the PROSQOLI and those of the SF-12 questionnaire was high (r=0.8139, p<0.0001). The ANOVA test showed significant differences between groups (p<0.01) based on age, recurrence risk and treatment. CONCLUSIONS: The adaptation process showed that the PROSQOLI Italian version has high reliability and presents both convergent and discriminant validity. This version of the tool can be used to assess HRQoL in Italian men who underwent radical treatment for advanced prostate cancer.

[Transluminal percutaneous angioplasty of stenosis of arteriovenous fistulas; 24-month follow-up]. / Angioplastica percutanea transluminare delle stenosi di fistole artero-venose. Follow-up di 24 mesi.

Stenosis is a common cause of the functional loss of vascular shunts used in chronic hemodialysis and percutaneous transluminal angioplasty represents the elective method to correct these anomalies. A total of 42 percutaneous transluminal angioplasties were performed, with a prospective study and follow-up lasting an average of 18 months, in 32 patients with insufficient blood flow of arteriovenous fistula. In over 90% of cases the procedure restored adequate hemodynamic conditions that remained unchanged during follow-up. The authors therefore conclude that percutaneous transluminal angioplasty is an efficacious, easily performed and low-cost method that does not present major complications.

[Cavernosography]. / La cavernosografia.

Dynamic cavernosography remains today an important step in diagnosis of veno-occlusive impotence, as support to cavernosometry: cavernosometry facilitate the diagnosis and the evaluation of venous-defect, but a contemporary show-timed cavernosography takes many informations about the site of venous-escape; these date allow to perform a correct selective vein ligation or percutaneous procedures, recently introduced in the clinical practice as an alternative or in association with vein ligation. Static cavernous-spongiosography, instead, has many indications in neoplasms and severe malformations.

[Laser-assisted endoscopic resection: a new surgical technique for the treatment of benign prostatic hypertrophy. Preliminary results of a study involving 100 patients]. / Resezione endoscopica laser assistita: nuova tecnica chirurgica per il trattamento dell'ipertofia prostatica benigna. Risultati preliminari di uno studio riguardante 100 pazienti.

This study was designed to assess the efficiency of 2 kind of laser prostatectomy devices in the treatment of Benign Prostatic Hyperplasia: a non contact technique versus a contact technique versus a contact one. From January 1994 to September 1994, 100 patients were included in a randomized comparison of 2 laser prostatectomy devices with right angle firing laser fibers: a non contact technique with Urolase fiber (Bard) (50 patients) versus a contact technique with Fibertom fiber (Dornier) (50 patients). The Urolase fiber was used at 60 Watts power setting for 60 seconds and administered to each lobe at 2, 4, 8 and 10 o'clock positions. The Fibertom fiber was used by dragging or the so called "painting" technique at 3 and 6 months with 3 parameters: Madsen symptom scores, peak urinary flow rates and post-void residual urine volumes. Operative morbidity rate was 9%. No difference in morbidity between both fibers. No blood transfusion was required in any case. Statistical analysis of the aforementioned parameters shows a p-value of < 0.001 for all parameters. Comparing the 2 different fibers, there was no statistical difference in outcome for any of these parameters. From this study we conclude that the preliminary results achieved, using the Urolase and the Fibertom fiber, are equivocal and interesting. However, a long term follow-up is necessary to evaluate the definitive efficiency of laser prostatectomy and to determine the optimal procedure.

[Section of the spermatic vein]. / Sezione della vena spermatica.

Surgical treatment of varicocele can be carried out using different techniques. The laparoscopic approach [1-2] represent a new trend that we used to ligate and dissect the spermatic vein in 10 patients, 8 with monolateral left varicocele and 2 with bilateral varicocele. The average time for laparoscopic surgery has been 45 minutes for monolateral varicocele and 65 minutes in the bilateral one. The absence of important complications during and after the operation has allowed to dismiss all patients 48 hours after the surgical treatment. The preferential direction of laparoscopic approach to varicocele is represented by the bilateral form.

Variation in nocturnal urinary excretion of melatonin in a group of patients older than 55 years suffering from urogenital tract disorders.

Melatonin (MLT) is directly or indirectly related to cell growth (both of normal and neoplastic cells), to the immune system stimulation and to the endocrine system modulation. This controlled study was carried out to evaluate urinary excretion of MLT in patients suffering from urogenital tract disorders. Eighty-one patients affected by urogenital disorders were divided in two groups (neoplastic and non-neoplastic) and urinary excretion of MLT was evaluated. Mean diurnal (from 8 a.m. to p.m.) urinary excretion of MLT was 4.97 + 6.08 pg/12 h in non-oncologic patients and 4.82 + 6.21 pg/12 h in oncologic patients (p = 0.50). Mean nocturnal (from 8 p.m. at 8 a.m.) urinary excretion of MLT was 11.97 + 9.34 pg/12 h in non-oncologic patients while in oncologic patients it was 7.86 + 8.95 pg/12 h. Statistically significant variation in nocturnal urinary excretion of melatonin was observed in oncologic patients (p = 0.022) versus non oncologic patients.

[100 orthotopic neobladders in men after cystectomy: a 5-year experience]. / 100 neovesciche ortotopiche nel maschio cistectomizzato: esperienza di 5 anni.

Urethral bladder substitution is traditionally suggested to good prognosis cystectomized patients. In our series this diversion was chosen for all but the salvage cystectomized men. Between the 1st of February 1991 and the 30th of April 1996, one hundred consecutive men underwent lower urinary tract reconstruction after radical cystoprostatectomy for bladder cancer. An orthotopic ileal neobladder was constructed (in 84 cases according to Kock's technique and in 16 to Studer's technique). Total early complication rate was 29% (29/100), including one perioperative death due to sepsis (mortality rate 1%). 13 patients required surgery (6 retroperitoneal hematomas, 2 wound dehiscences, 1 urinary fistula, 1 lymphocele, 1 rectal-neobladder fistula, 1 rectal-cutaneous fistula, 1 necrosis of the terminal ureter). The late complication rate was 19% (19/100); in 8 cases reparative surgery was required (1 mechanical ileus, 2 bladder neck stenoses, 3 stenoses of the ureteral anastomosis, 2 laparoceles). Four patients were lost at the follow-up; out of the 96 remaining patients only 85 were evaluable for continence: continence during the day was achieved in a period between there to six months in 78 patients (91.7%); night continence was achieved with planned awakenings in 60 patients (70.5%). Eight patients recovered potency, another 7 had successful intercourses after PGE1 intracavernous injection. Renal function based on creatinine value was mildly impaired in 5/78 evaluable patients (6.4%) (peak creatinine 2.8 mg%). In 29 patients tumour progression was observed (29%): 9 pelvic and 20 metastatic. Among the latter 2 urethral recurrences were observed (2%). Twenty-four patients died for metastatic cancer, one for primitive lung cancer, one patient for postoperative septic shock. Adjuvant chemotherapy was administered in 11 patients without complication with an indwelling catheter in the neobladder to avoid drug reabsorption. Four patients showed complete response (2 are alive after a mean of 12 months), 6 were non responders and 1 had a partial response. In our series the ileal neobladder is a feasible method of urinary diversion when urethral cancer involvement is ruled out. Early and late complications are proportionally decreasing with experience and overall continence is satisfactory. The fate of the neobladder depends on both the technique and patient's compliance. Only educated patients can cope successfully with neobladder diversion without major complications. All the patients operated for non salvage cystectomy deserve to be diverted with a continent urethral bladder substitution.

[Recovery of urinary incontinence after retropubic radical prostatectomy. Results in 100 patients]. / Ripresa della continenza urinaria dopo prostatectomia radicale retropubica. Risultati in 100 pazienti.

AIM OF THE STUDY: To shorten the time to recovery of full urinary continence after radical retropubic prostatectomy and to increase the postoperative continence rate. MATERIALS AND METHODS: One hundred and five consecutive patients were submitted to radical retropubic prostatectomy for prostate cancer, with curative intent, focusing our attention on three steps of the operation. First, to achieve a complete control of bleeding from the dorsal vein complex and to perform a minimal touch dissection of the urethral stump; second, to perform a conservative dissection of the bladder neck, and, third, to implement a vascular type, watertight, vesico urethral anastomosis. Continence was assessed 24 hours after catheter removal and at monthly follow up visits until full recovery and graded as dry if no dropping was visible and the patient was able to interrupt the urinary stream during micturition; stress incontinence, if any dropping was observed during abdominal strain between micturitions; and wet, if uncontrollable dropping occurred, and the number of pads needed per day recorded. RESULTS: At a median follow-up time of 18 months, range 6 to 30, a total of 87 of 100 evaluable patients (87%) resulted as dry; 10 patients (10%) resulted as having a variable degree of stress incontinence needing one to three pads per day, and 3 patients (3%) resulted as wet. In 41 of the 87 dry patients (47.1%) continence was achieved within the first day from catheter removal, and in a median time of 4 weeks, range 2 to 16 in the remaining 46 patients (52.9%). CONCLUSIONS: The results of total continence rate of the present study seem to compare to the recent literature except for the time to full recovery which is shorter; it is difficult to identify the contribution of each single surgical step.

[Laparoscopic nephrectomy]. / Nefrectomia laparoscopica.

Laparoscopic nephrectomy is a new procedure in which the entire kidney is removed introducing it in an Endopouch and, after morcellation pulled out through a 12 mm port. After an initial experimental experience, in our Institute we have performed one laparoscopic nephrectomy for left pyelonephritic kidney and ureteral reflux. The operation required the positioning of 5 trocars and 4 hours for its execution. The discharge of the patient was possible four days after.

[Laparoscopic lymphadenectomy]. / Linfoadenectomia laparoscopica.

7 patients, suffering by prostatic adenocarcinoma in clinical stage B, were undergone to laparoscopic pelvic lymphadenectomy, to obtain a complete staging. The average time of execution of the operation was 180 minutes. The absence of important complications during and after surgical time, within low surgical trauma, has allowed the dismission of patients 48 hours after the operation. The low morbility demonstrated for this technique has allowed the dissection of a number of lymph node to consent an adequate staging.

[Renal cysts resection]. / Resezione di cisti renale.

Six patients with inferior and middle polar renal cysts of 8-15 centimeters of diameter, underwent the resection of the cyst by laparoscopic technique. The operation required an average time of execution of two hours and the positioning of four trochars to consent an adequate access. The absence of important complications during and after the operation has allowed a quick dismission of the patients. The laparoscopic treatment of renal cysts represent a valid choice to traditional surgery and percutaneous needle aspiration.