Improving Patient Outcomes in Abdominal Surgery.

Post-operative acute kidney injury (PO-AKI) is a frequent complication described in 15% of non-cardiac surgeries, 30% of cardiac surgeries, and 52% of patients requiring intensive post-operative care [...].

Perioperative Intravenous Amino Acid Infusion in Major Urologic Surgery.

Post-operative acute kidney injury (PO-AKI) is a serious complication that may occur after major abdominal surgery. The administration of intravenous perioperative amino acids (AAs) has been proven to increase kidney function and has some beneficial effects to prevent PO-AKI. The aim of this study was to establish if the perioperative infusion of AAs may reduce the incidence of PO-AKI in patients undergoing major urological minimally invasive surgery. From a total of 331 patients, the first 169 received perioperative crystalloid fluids and the following 162 received perioperative AA infusions. PO-AKIs were much higher in the crystalloid group compared to the AA group (34 vs. 17, p = 0.022) due to a lower incidence of KDIGO I and II in the AA group (14 vs. 30 p = 0.016). The AA group patients who developed a PO-AKI presented more risk factors compared to those who did not (2 (2-4) vs. 1 (1-2), p = 0.031) with a cut-off of 3 risk factors in the ROC curve (p = 0.007, sensitivity 47%, specificity 83%). The hospital length of stay was higher in the crystalloid group (p < 0.05) with a consequent saving in hospital costs. Perioperative AA infusion may help reduce the incidence of PO-AKI after major urological minimally invasive surgery.

Application of a protocol for enhanced recovery after radical cystectomy: a before-and-after cohort study.

PURPOSE: Radical cystectomy with urinary diversion is a major urological surgery burdened both by a high rate of short- and long-term complications and by a high emotional and psychological impact. Post-operative recovery is extremely important and the application of ERAS protocols can facilitate the return to functional autonomy. The aim of the present study was to verify the efficacy of our ERAS programme on outcomes of recovery after surgery of patients undergoing radical cystectomy with various urinary diversions. METHODS: This is a before-after study comparing the historical group (n. 77) of radical cystectomies following a peri-operative standard of care with the prospective observational group (n. 83) following our ERAS programme. Recovery after surgery outcomes evaluated were length of stay, re-admission rate at 30-90/days and post-operative complications. RESULTS: Patients treated following the ERAS protocol presented less intra-operative blood loss (p < 0.001) and less intra-operative fluid infusions (p < 0.001). Time of first flatus was shorter in the ERAS group, though no difference was found in timing of nasogastric tube removal and defecation. Removal of drainage was done significantly earlier in the ERAS group. The median length of stay decreased from 12 to 9 days (p = 0.003) with a significant reduction also in re-admission rates at 30 and long-term complications at 90 days from surgery. CONCLUSION: The application of an opioid-free ERAS protocol to patients undergoing open radical cystectomy was associated, as compared with prior traditional care, with significant reductions of recovery time and length of stay, number of total in-hospital complications, in particular functional ileus and re-admissions by 30 and 90 days after surgery.

Low Intra-Abdominal Pressure with Complete Neuromuscular Blockage Reduces Post-Operative Complications in Major Laparoscopic Urologic Surgery: A before-after Study.

Most urological interventions are now performed with minimally invasive surgery techniques such as laparoscopic surgery. Combining ERAS protocols with minimally invasive surgery techniques may be the best option to reduce hospital length-of-stay and post-operative complications. We designed this study to test the hypothesis that using low intra-abdominal pressures (IAP) during laparoscopy may reduce post-operative complications, especially those related to reduced intra-operative splanchnic perfusion or increased splanchnic congestion. We applied a complete neuromuscular blockade (NMB) to maintain an optimal space and surgical view. We compared 115 patients treated with standard IAP and moderate NMB with 148 patients treated with low IAP and complete NMB undergoing major urologic surgery. Low IAP in combination with complete NMB was associated with fewer total post-operative complications than standard IAP with moderate NMB (22.3% vs. 41.2%, p < 0.001), with a reduction in all medical post-operative complications (17 vs. 34, p < 0.001). The post-operative complications mostly reduced were acute kidney injury (15.5% vs. 30.4%, p = 0.004), anemia (6.8% vs. 16.5%, p = 0.049) and reoperation (2% vs. 7.8%, p = 0.035). The intra-operative management of laparoscopic interventions for major urologic surgeries with low IAP and complete NMB is feasible without hindering surgical conditions and might reduce most medical post-operative complications.

Two-stage functional and aesthetic reconstructive surgery in melanoma in situ of the glans penis and urethra.

Melanoma in situ including glans penis and fossa navicularis is unique and represents a challenging dilemma since surgery should not be very aggressive. We present a case of melanoma in situ treated with a two-stage penile and urethral reconstructive surgery, with emphasis on functional and aesthetic results. At the first-stage surgery an anatomic glansectomy was perfomed, and combined preputial and full-thickness skin grafts were used to prepare the urethral plate and restore the aesthetic aspect of the corpora cavernosa. After 6 months, the distal urethra was repaired including the configuration of an orthotopic meatus and a neo-glans.

Management of Prostate Cancer with Systemic Therapy: A Prostate Cancer Unit Perspective.

The scenario of systemic therapy for prostate cancer is rapidly evolving, with new drugs and new treatment options. To update the background knowledge of shared uro-oncologic practice, we reviewed current statements and landmarks in systemic therapy. A number of new agents are under investigation in non-metastatic and metastatic disease. Similarly, new target imaging technologies are under development to improve the detection rate of true non-metastatic and true metastatic patient. Five new drugs have shown to be effective on progression-free and overall survival in metastatìc prostate cancer. However, the optimal sequencing of these treatments requires further investigation. The tolerability and side effects of the new drugs are also crucial issues to be discussed, as well as their activity against the disease. The uro-oncologic team has to stay updated about new medical therapies in order to be confident in debating with other professionals involved in prostate cancer decision making. Different points of view and nuances should be shared during multidisciplinary group discussions to achieve a balanced decision in disease management.

Non-secreting adrenal myelolipoma in a middle-aged male patient manifesting with sudden onset of severe lower back pain.

Adrenal myelolipoma (AML) is a rare benign tumor, usually non-functioning and asymptomatic until it reaches large size. AML is mostly detected incidentally by imaging and is composed of adipose tissue and hematopoietic elements. Only symptomatic tumor needs surgical excision. We report the case of a large non-functioning adrenal tumor discovered by means of combined imaging techniques in a middle-aged male patient who complained the sudden onset of severe lower back pain; successful laparoscopic removal was performed, and AML was diagnosed at histopathology.

Non-invasive removal of self-locking entrapped nephrostomy tubes.

INTRODUCTION: The removal of an encrusted nephrostomy tube can be a challenging maneuver. Urological literature is very bare in detailing techniques for removal of entrapped percutaneous catheters. We present a simple, safe and non-invasive technique of nephrostomy removal using a vascular introducer sheath, useful to manage complicated situations such as nephrostomies blocked for severe encrustations or disabled in their self-locking system. SURGICAL TECHNIQUE: The nephrostomy tube is cut and the stump is passed with a suture needle. The suture is passed through the inner vascular introducer sheath tip, and the introducer is then removed. The introducer sheath is advanced over the nephrostomy until joining the pigtail segment, under fluoroscopy guidance. Thus the suture is pulled out with strenght to contrast the opposite stiffness of the encrusted coil, until the nephrostomy has safely come out. COMMENT: The sheath exchange technique is quick, involves less manipulation through the perirenal fascia and kidney, and is suitable for different conditions of entrapped nephrostomies.

Functional and oncological outcomes of 3D clampless sutureless laparoscopic partial nephrectomy for renal tumors with low nephrometry score.

BACKGROUND: Renal cell carcinoma still represents 2-3% of all tumors but its mortality is decreased in the last decades due to the early detection of small masses and to the innovative surgical techniques. The aim of our study was to evaluate safety and feasibility of clampless and sutureless laparoscopic partial nephrectomy (CSLPN) in terms of intra- and postoperative functional results, complication rate and oncological outcome. METHODS: We evaluated patients undergoing CSLPN between July 2013 and December 2019. Inclusion criteria were single, organ confined tumor with size ≤4 cm, intraparenchymal depth ≤1.5 cm, renal nephrometry score between 4 and 6 and no close contact with the collecting system. RESULTS: Overall, 62 patients underwent CSLPN. Mean operative time was 105 minutes, mean intraoperative blood loss was 165 mL. Mean drain time and hospital stay were respectively 2.5 and 4.2 days. Mean 24 hours hemoglobin (Hb) decrease was 2.5 g/dL. No significative variations are described in pre- and postoperative renal function. Twelve patients had postoperative complications. At a median follow-up of 38.5 months all the patients are alive and disease free. CONCLUSIONS: Different techniques have been proposed to reduce warm ischemia time (WIT). In our experience we found many benefits in an off-clamp procedure: it gives an ischemia-related advantage, reduces the overall operating time, eliminates the risks associated with the isolation of hilar vessels. In conclusion CSLPN is a safe and effective procedure for selected renal masses; it does not increase complication rate and offers excellent functional and oncological outcomes.

[Flexible cystoscope for the treatment of urinary stones in intestinal reservoirs.] / Cistoscopia flexible para el tratamiento de las litiasis urinarias en reservorios intestinales.

OBJECTIVE: Stones are common mid- and long-term complications in urinary diversions built with bowel. However the reservoir intestinal loops can lead to difficult endoscopic approach. METHODS: We report two challenging cases with unfavourable anatomy successfully treated by gently handling a flexible cystoscope in a low pressure system. RESULTS: One patient with stones in a continent pouch was cleaned up with a grasping basket through the efferent umbilical limb. Another patient with an orthotopic ileal neobladder not accessible by rigid cystoscope due to high pelvic floor was treated with holmiun laser lithotripsy. CONCLUSIONS: Urologists should consider the versatility of flexible cystoscope to obviate the need for percutaneous lithotripsy or open lithotomy.

OBJETIVO: La aparición de litiasis es una complicación común a medio y largo plazo en las derivaciones urinarias construidas con intestino. Sin embargo, las asas intestinales de los reservorios pueden tener un acceso endoscópico difícil. METODOS: Presentamos dos casos difíciles con anatomía desfavorable tratados con éxito utilizando cuidadosamente un cistoscopio flexible en un sistema de baja presión. RESULTADOS: Un paciente con litiasis en una neovejiga continente quedó libre de litiasis utilizando una cestilla a través del asa eferente umbilical. Otro paciente con una neovejiga ileal ortotópica no accesible por cistoscopio rígido debido a un suelo pélvico elevado, fue tratado con litotricia con láser de Holmio. CONCLUSIONES: Los urólogos deben considerar la versatilidad de la cistoscopia flexible para obviar la necesidad de litotricia percutánea o litotomía abierta.

Flexible cystoscope for the treatment of urinary stones in intestinal reservoirs / Cistoscopia flexible para el tratamiento de las litiasis urinarias en reservorios intestinales

Objective: Stones are common mid- and long-term complications in urinary diversions built with bowel. However the reservoir intestinal loops can lead to difficult endoscopic approach. Methods: We report two challenging cases with unfavourable anatomy successfully treated by gently handling a flexible cystoscope in a low pressure system. Results: One patient with stones in a continent pouch was cleaned up with a grasping basket through the efferent umbilical limb. Another patient with an orthotopic ileal neobladder not accessible by rigid cystoscope due to high pelvic floor was treated with holmiun laser lithotripsy. Conclusions: Urologists should consider the versatility of flexible cystoscope to obviate the need for percutaneous lithotripsy or open lithotomy

Objetivo: La aparición de litiasis es una complicación común a medio y largo plazo en las derivaciones urinarias construidas con intestino. Sin embargo, las asas intestinales de los reservorios pueden tener un acceso endoscópico difícil. Métodos: Presentamos dos casos difíciles con anatomía desfavorable tratados con éxito utilizando cuidadosamente un cistoscopio flexible en un sistema de baja presión. Resultados: Un paciente con litiasis en una neovejiga continente quedó libre de litiasis utilizando una cestilla a través del asa eferente umbilical. Otro paciente con una neovejiga ileal ortotópica no accesible por cistoscopio rígido debido a un suelo pélvico elevado, fue tratado con litotricia con láser de Holmio. Conclusiones: Los urólogos deben considerar la versatilidad de la cistoscopia flexible para obviar la necesidad de litotricia percutánea o litotomía abierta