Fibrin glue therapy for severe hemorrhagic cystitis after allogeneic hematopoietic stem cell transplantation.

Hemorrhagic cystitis (HC) occurring after allogeneic transplantation significantly affects quality of life and, in some cases, becomes intractable, increasing the risk of death. To date, its therapy is not established. We used the hemostatic agent fibrin glue (FG) to treat 35 patients with refractory post-transplantation HC. Of 322 adult patients undergoing an allogeneic transplantation for hematological malignancy, 35 developed grade ≥ 2 HC refractory to conventional therapy and were treated with FG, diffusely sprayed on bleeding mucosa by an endoscopic applicator. The cumulative incidence of pain discontinuation and complete remission, defined as regression of all symptoms and absence of hematuria, was 100% at 7 days and 83% ± 7%, respectively, at 50 days from FG application. The 6-month probability of overall survival for all 35 patients and for the 29 in complete remission was 49% ± 8% and 59% ± 9%, respectively. In the matched-pair analysis, the 5-year probability of overall survival for the 35 patients with HC and treated with FG was not statistically different from that of the comparative cohort of 35 patients who did not develop HC (32% ± 9% versus 37% ± 11%, P = not significant). FG therapy is a feasible, effective, repeatable, and affordable procedure for treating grade ≥2 HC after allogeneic transplantation.

Zoledronic acid induces a significant decrease of circulating endothelial cells and circulating endothelial precursor cells in the early prostate cancer neoadjuvant setting.

PURPOSE: Published data demonstrated that zoledronic acid (ZOL) exhibits antiangiogenetic effects. A promising tool for monitoring antiangiogenic therapies is the measurement of circulating endothelial cells (CECs) and circulating endothelial precursor cells (CEPs) in the peripheral blood of patients. Our aim was to investigate the effects of ZOL on levels of CECs and CEPs in localized prostate cancer. METHODS: Ten consecutive patients with a histologic diagnosis of low-risk prostate adenocarcinoma were enrolled and received an intravenous infusion of ZOL at baseline (T0), 28 days (T28) and 56 days (T56). Blood samples were collected at the following times: T0 (before the first infusion of ZOL), T3 (72 h after the first dose), T28, T56 (both just before the ZOL infusion) and T84 (28 days after the last infusion of ZOL) and CEC/CEP levels were directly quantified by flow cytometry at all these time points. RESULTS: Our analyses highlighted a significant reduction of mean percentage of CECs and CEPs after initiation of ZOL treatment [p = 0.014 (at day 3) and p = 0.012 (at day 84), respectively]. CONCLUSION: These preliminary results demonstrate that ZOL could exert an antiangiogenic effect in early prostate cancer through CEP and CEC modulation.

York Mason procedure to repair iatrogenic rectourinary fistula: our experience.

BACKGROUND: Rectourinary fistula (RUF) is an uncommon but devastating condition in men. It usually occurs as a complication of prostatic cancer treatment, whether this is by radiation therapy or surgery. It can also occur in patients with benign pathology of the prostate, inflammatory bowel disease, or Fournier's gangrene, and following pelvic trauma. RUF represents a challenge for the surgeon because spontaneous closure is a rare event. Several techniques have been described for surgical repair of fistula. The goal of the present study was to demonstrate that the York Mason posterior, transrectal correction of an iatrogenic RUF is a reliable approach that offers good postoperative outcomes. METHODS: We retrospectively reviewed the medical records of 39 patients who underwent York Mason repair from 1998 to 2012 at the University of Southern California (USC) and Campus Bio-Medico University of Rome (UCBM). The most frequent common causes of RUF were itemized, and statistical analysis was performed to determine correlations between the fistula's etiology and surgical outcome. Patients were then divided into two different cohorts: those who had undergone only one previous procedure (group 1) and those who had undergone two or more surgeries (group 2). We performed a statistical analysis between the two groups and calculated the percentage of fistula repair by means of the posterior trans-sphincteric approach with the York Mason technique in each groups We evaluated the presence of comorbidities (diabetes and infection) and their influence on the surgical outcome. Finally, we reported patient outcomes during follow-up. RESULTS: In the present series, the RUF was iatrogenic in every case. The onset of the fistula followed prostate cancer treatment, most commonly after laparoscopic procedures. The success rate of fistula repair was found to be independent of the fistula's etiology. Diabetes and infections did not influence the surgical outcome. Overall, more than 50 % of patients treated with the York Mason posterior, transanal, transrectal approach remained free of fistula during follow-up. Almost 90 % of those who were previously operated only once remained free of fistula. CONCLUSIONS: The posterior trans-sphincteric approach of the York Mason technique is effective in treating RUF.

Fibrin glue for refractory hemorrhagic cystitis after unrelated marrow, cord blood, and haploidentical hematopoietic stem cell transplantation.

BACKGROUND: Patients undergoing hematopoietic stem cell transplant (HSCT) are particularly exposed to the risk of developing hemorrhagic cystitis (HC), which is characterized by symptoms ranging from macroscopic hematuria to renal failure. Although HC significantly affects the quality of life and in a few cases becomes intractable leading to patient death, its therapeutic management has not been established. Fibrin glue (FG), a hemostatic agent derived from human plasma, has been largely employed in different surgical settings including urologic procedures. STUDY DESIGN AND METHODS: In this pilot study we used FG to treat refractory HC. During cystoscopy, bladder distension was maintained at a constant pressure of 12 mmHg by a carbon dioxide insufflator. An endoscopic applicator allowed spraying FG on the bleeding and raw surfaces of bladder mucosa. RESULTS: Five of 221 patients undergoing an HSCT developed a very severe, refractory HC and have been treated with endoscopic FG. The treatment was successful in 3 patients; the response was partial in 1 patient and transient in the last one, whose clinical course was severely complicated by acute graft-versus-host disease and multiple organ failure. CONCLUSIONS: FG therapy is a feasible procedure and this pilot study suggests that it may be an effective treatment for refractory HC. Its application could be considered also in Grade 1 or 2 HC to prevent progression of damaged mucosa. The use of FG for HC should be prospectively investigated in terms of therapeutic efficacy, transfusion support, length of hospitalization, quality of life, and costs.

Collagen changes in the ureteropelvic junction after failed antegrade endopyelotomy.

PURPOSE: We evaluated the collagen content and differentiation of the ureteropelvic junction (UPJ) of patients who underwent Anderson-Hynes dismembered pyeloplasty after failure of antegrade endopyelotomy. MATERIALS AND METHODS: A total of 12 UPJ obstructions were examined more than 12 months after endopyelotomy with both histochemical staining to analyze total collagen content and immunohistochemical staining to analyze collagen types I and III. The specimens were compared with 12 primary UPJ obstructions and 6 normal UPJs. Statistical analysis was performed using Fisher's test and Wilcoxon matched-pairs signed-rank test. RESULTS: Immunohistochemical staining revealed that collagen type I was located in the interfascicular space and collagen type III in the intrafascicular space in all UPJs. We found more collagen in obstructed than in normal UPJs. Collagen type III was more abundant in secondary than in primary UPJ obstructions (P < 0.01). In obstruction after endopyelotomy, the staining intensity of collagen type III was greater than the intensity of collagen type I (P < 0.01). CONCLUSION: Our results suggest that the success of antegrade endopyelotomy was impaired by an inflammatory process. This condition determined a shift of collagen differentiation toward type III, which is more fibrous than type I.

Robotic "Side Hole" Technique Placement of Ureteral Stent for Ureteral Lesion.

A 67-year-old patient underwent robotic-assisted laparoscopic radical prostatectomy and experienced right ureteral lesion. The laceration was recognized intraoperatively and immediately repaired over the ureteral double J stent. The wire and the stent were first advanced distally to the bladder. Then the wire was pulled with its soft end, cranially through one of the side holes of the proximal end of the stent toward the kidney allowing exact positioning of the stent. Postoperative hospitalization was similar to a classic laparoscopic robotic-assisted prostatectomy. Robotic approach and the "side hole" technique represent an accurate and safe option in case of ureteral laceration management.

Robot-assisted laparoscopic radical prostatectomy after previous open transvesical adenomectomy.

INTRODUCTION: Robot-assisted laparoscopic radical prostatectomy (RALRP) is one of the best treatment for patients with localized prostate cancer. RALRP is currently performed in patients without previous surgical treatment for benign prostatic hyperplasia. This paper presents a successfully performed RALRP after previous open transvesical adenomectomy (TVA). CASE REPORT: A 68-year-old patient underwent nerve-sparing RALRP for prostate cancer revealed by transrectal ultrasound guided prostate biopsy, 7 years after TVA. RESULTS: Postoperatively, a regular diet was allowed on day 1. The Foley catheter was removed on day 7. At 3 months' follow-up, the patient complained of moderate stress incontinence but erectile function was responsive to Tadalafil(®). Serum prostate-specific antigen was undetectable. Quality of life was satisfactory. CONCLUSIONS: A history of previous prostatic surgery does not appear to compromise the outcome of RALRP. Nerve sparing is still indicated. Long-term follow-up is necessary to define RALRP as a gold standard also in patients with previous TVA.

Bladder cancer after radiotherapy for prostate cancer.

External beam radiotherapy (EBRT) is frequently used in the management of prostate cancer (PCa) as definitive, postoperative, or salvage local treatment. Although EBRT plays a central role in the management of PCa, complications remain a troubling by-product. Several studies have demonstrated an association between radiotherapy and elevated risk of acute and late toxicities. A secondary malignancy induced by initial therapy represents one of the most serious complications related to definitive cancer treatment. The radiation-related secondary primary malignancy risk increases with increasing survival time. Transitional cell carcinoma of the bladder is the most frequent secondary primary malignancy occurring after radiotherapy and is described as more aggressive; it may be diagnosed later because some radiation oncologists believe that the hematuria that occurs after prostate EBRT is normal. Some patients treated for localized PCa will subsequently develop invasive bladder cancer requiring surgical intervention. Patients with PCa treated with EBRT should be monitored closely for the presence of bladder cancer.

Bilateral ureteral tapering and secondary ureteroneocystostomy for late stenosis in a patient with bladder extrophy.

OBJECTIVE: To report a case of severe hydronephrosis 20 years after bladder exstrophy (BE) repair, managed by bilateral ureteral tapering and secondary ureteroneocystostomy. CASE PRESENTATION: A 21-year-old woman with a history of BE and ureteral reimplantation, presented with hematuria-dysuria syndrome and recurrent febrile urinary tract infections. After counselling, she elected to undergo bilateral ureteral tapering and second ureteroneocystostomy. CONCLUSION: Hydronephrosis secondary to ureteralvesical stricture in BE patients can be successfully managed with ureteral reimplantation associated to ureteral tapering even after a prior reimplantation.

Robotic-assisted laparoscopic approach in the treatment for Zinner's Syndrome associated with ipsilateral megaureter and incomplete double-crossed ectopic ureter.

To report a rare congenital anomaly of the genitourinary tract, renal dysplasia is associated with ipsilateral incomplete duplicated ectopic ureter and seminal vesicle cyst in an adult, successfully treated with robotic-assisted laparoscopic approach.

Robotic-assisted simple prostatectomy with clamping of bilateral hypogastric arteries.

To present a case of laparoscopic robotic-assisted simple prostatectomy with temporary clamping of the bilateral hypogastric arteries. A 74-year-old patient with large prostatic adenoma (> 80 ml) underwent robotic-assisted laparoscopic transvesical adenoma enucleation according to Sotelo's technique. The hypogastric arteries were isolated just below the ureteral cross with the iliac vessels and bilaterally occluded for 12 minutes during enucleation of the adenoma. The patient's pain was mild after surgery and he required short-term analgesics and antibiotic prophylaxis. Blood loss was 80 ml. The transient occlusion of the internal iliac arteries is a proven maneuver to reduce bleeding during pelvic surgery. We propose the temporary clamping of the bilateral internal iliac arteries as a safe and rapid surgical maneuver to reduce the intraoperative risk of bleeding, especially when performing first procedures.

Retroperitoneal urinoma spontaneously drained in the scrotum repaired with gracilis muscle flap: a case report.

Aim. To report a unique case of retroperitoneal urinoma extending to the scrotum through the spermatic cord and successfully treated with nephrostomy, drainage, and gracilis muscle flap.

Severe hydronephrosis and dysuria-hematuria syndrome after 20 years of bladder exstrophy correction: a case report.

The aim of this paper is to report a case of severe hydronephrosis and incontinence 20 years after bladder exstrophy repair, managed successfully by secondary ureteroneocystostomy and by transurethral submucosal injection of Macroplastique.

The differentiation of humane adult mesenchimal stem cells of bone marrow (hMSC) into urothelial cells on bio-engineering support (scaffold): preliminary experience of tissue engineering.

OBJECTIVES: Tissue Engineering can develop scaffolds of Poly-L-Lactic Acid (PLLA) for tissue regeneration. The purpose of the present job is to test the possibility to seed human adult mesenchymal stem cells on a scaffold supplemented with specific grow factors to differentiate them into urothelium. METHODS: The Electrospinning technique was used to realize three scaffolds. The first one was seeded with urothelial cells, of a primary culture, and Keratinocyte serum free medium (KSFM); the second one was seeded with human mesenchymal stem cells (hMSC) and a minimum essential medium (aMEM); the third one was seeded with hMSC and conditioned medium. RESULTS: Electron microscopy showed scaffolds with cellular vitality (>90%) and their cellular proliferation. Moreover, the differentiation of hMSC, seeded in conditioned medium, into urothelial cells was demonstrated through immunofluorescence assays. CONCLUSIONS: Tissue Engineering can develop PLLA scaffolds thanks to the Electrospinning technique. The scaffold is a perfect environment for cellular culture and proliferation; a protocol for the differentiation of hMSC into urothelial cells is now available. Immunofluorescence assays can demonstrate the hMSC differentiation into urothelial cells.