Is spinal anesthesia a safe alternative for retrograde intrarenal surgery for stone disease in daily practice?

OBJECTIVES: Retrograde intrarenal surgery (RIRS) is commonly performed under general anesthesia (GA) because renal mobility during breathing may affect lithotripsy. However, spinal anesthesia (SA) is adopted in clinical practice due to clinical conditions that contraindicate GA. We aimed to compare results of RIRS for stones performed under GA compared to SA regarding stone-free rate (SFR) status and postoperative complications in a consecutive single-center series. METHODS: We retrospectively reviewed all patients who underwent RIRS for stones between 2017 and 2020. INCLUSION CRITERIA: age ≥ 18 years, renal stone burden deemed suitable for RIRS with a stone diameter ≤ 20 mm. EXCLUSION CRITERIA: stones >20 mm, urinary tract infection, bilateral surgery, second-look procedures, unmodifiable bleeding diathesis, <5mm asymptomatic lower calyx stones. SFR was defined as no residual fragment >3 mm at 6-12 weeks follow-up. The choice of anesthesia was a shared decision between anesthesiologists and patient preference. RESULTS: 230 patients were included in the analysis. Mean age was 57.50±13.73 years. 33% of stones were located in the pelvis. 28.7% of patients had multiple stones. Mean cumulative stone diameter was 16.60±6.54 mm. 63% of patients underwent RIRS under SA. There were no significant differences between the two groups in terms of preoperative characteristics, except for comor-bidity, significantly higher in the GA group. Mean time of operating room occupation was longer in the GA group (81.58±35.37 minutes) than in the SA group (72.85±25.91 minutes,p=0.033). Length of stay was shorter in the SA group (mean 2.2±1.66 days vs 3.46±5.88 in GA,p=0.019). Logistic regression showed that multiple stones in the collecting system were associated with residual fragments (HR 0.386, 95%CI 0.151-0.991,p=0.04). There were no statistically significant differences in overall and high-grade complications, and in SFR between SA (75.9%) and GA groups (70.6%,p=0.317). CONCLUSION: SA does not affect SFR and postoperative complications in patients who underwent RIRS in daily practice.

Is spinal anesthesia a safe alternative for retrograde intrarenal surgery for stone disease in daily practice?

Objectives: Retrograde intrarenal surgery (RIRS) is commonly performed under general anesthesia (GA) because renal mobilityduring breathing may affect lithotripsy. However, spinal anesthesia (SA) is adopted in clinical practice due to clinical conditionsthat contraindicate GA. We aimed to compare results of RIRS for stones performed under GA compared to SA regarding stonefree rate (SFR) status and postoperative complications in a consecutive single-center series.Methods: We retrospectively reviewed all patients who underwent RIRS for stones between 2017 and 2020. Inclusion criteria:age ≥ 18 years, renal stone burden deemed suitable for RIRS with a stone diameter ≤ 20 mm. Exclusion criteria: stones >20mm, urinary tract infection, bilateral surgery, second-look procedures, unmodifiable bleeding diathesis, <5mm asymptomaticlower calyx stones. SFR was defined as no residual fragment >3 mm at 6-12 weeks follow-up. The choice of anesthesia was ashared decision between anesthesiologists and patient preference.Results: 230 patients were included in the analysis. Mean age was 57.50±13.73 years. 33% of stones were located in the pelvis.28.7% of patients had multiple stones. Mean cumulative stone diameter was 16.60±6.54 mm. 63% of patients underwent RIRSunder SA. There were no significant differences between the two groups in terms of preoperative characteristics, except for comorbidity, significantly higher in the GA group. Mean time of operating room occupation was longer in the GA group (81.58±35.37minutes) than in the SA group (72.85±25.91 minutes,p=0.033). Length of stay was shorter in the SA group (mean 2.2±1.66 days vs3.46±5.88 in GA,p=0.019). Logistic regression showed that multiple stones in the collecting system were associated with residualfragments (HR 0.386, 95%CI 0.151-0.991,p=0.04). There were no statistically significant differences in overall and high-gradecomplications, and in SFR between SA (75.9%) and GA groups (70.6%,p=0.317)...(AU)

Unusual clinical scenarios in Urology and Andrology.

This collection includes some unusual cases and how they were diagnosed and treated. Case 1: A case of a patient with primary hyperthyroidism presenting with a submucosal ureteral stone after endoscopic lithotripsy was described. After multiple endoscopic treatment, the stone was successfully removed by open ureterolithotomy recovering ureteral patency and normal renal function. Case 2: A case of burned-out testicular cancer with atypical lymphatic spread (stage II A) was presented. After right orchiectomy and complete remission of tumor markers, due to atypical metastases location and uncertain histology, the patient was treated with systemic therapy based on bleomycin, etoposide and cisplatin (PEB). At re-staging after chemotherapy computed tomography showed reduction of all node metastases and an observation protocol was proposed. Case 3: A patient was readmitted to hospital after 12 days from an uneventful Robot-Assisted Radical Prostatectomy (RARP) for prostate cancer due to lower abdominal pain plus abdominal distension, nausea and constipation not responsive to medical therapy. Computed Tomography showed colon and small bowel dilatation without any evidence of anatomical or mechanical obstruction. Laparoscopic abdominal exploration confirmed bowel distension without evidence of obstructing lesions. Ogilvie's Syndrome or acute colonic pseudo-obstruction (ACPO) was diagnosed. The patient fully recovered and was discharged six days after the procedure. Case 4: A case of recurrent Acute Idiopathic Scrotal Edema (AISE) was diagnosed on clinical signs together with the decisive help of pathognomonic ultrasound findings as the "fountain sign". Case 5: Small bilateral testicular nodules were diagnosed in a 30-years old patient undergoing scrotal ultrasound in follow up of acute lymphoblastic leukemia. Ultrasound guided testis sparing surgery was performed demonstrating Leydig cell tumors.

Combined treatment of ureteropelvic junction obstruction and renal calculi with robot-assisted laparoscopic pyeloplasty and laser lithotripsy in children: Case report and non-systematic review of the literature.

OBJECTIVE(S): The incidence of urinary tract stone disease is steadily increasing in both adult and paediatric populations. This condition develops due to different factors: dietary or metabolic alterations, infection, and congenital anatomic malformations. Standard indications and treatments for children are analogous to the ones indicated for adults. Extracorporeal shock wave lithotripsy, ureterorenoscopy and percutaneous nephrolithotomy (PCNL) should be preferred to more invasive techniques. Moreover, the introduction of laparoscopic and robot-assisted laparoscopic approaches have improved surgical outcomes, lowering the bleeding risk with higher stone-free rates, even in complicated cases. Despite these well-known improvements, there are few reports regarding laparoscopic robot-assisted management for urinary tract stone disease in paediatric patients under the age of 10, especially with concomitant treatment of ureteropelvic junction obstruction and multiple calyceal stones. PATIENT AND METHOD(S): A 4-year-old child was referred for recurrent right abdominal flank pain, macroscopic haematuria and a previous history of urinary tract infections. A computed tomography of the abdomen showed right ureteropelvic junction obstruction associated with multiple unilateral stones located in the renal pelvis and in the interpolar renal calyces. Due to its complexity, we held a multidisciplinary meeting with paediatric surgeons and nephrologists to determine optimal treatment. As a result, a combined robot-assisted laparoscopic pyeloplasty (LP) and renal calculi holmium laser lithotripsy using a digital flexible ureteroscope through an abdominal robotic trocar was performed. No post-surgical complications were recorded, and the patient was discharged within 48 h following surgery. At subsequent regular follow-up examinations over a period of 24 months, no signs of recurrence were detected for both ureteropelvic junction obstruction and stone disease. RESULT(S): Robot-assisted LP with concomitant laser lithotripsy is a reasonable treatment option for designated young paediatric patients with challenging ureteropelvic junction obstruction complicated by urolithiasis, especially in cases where stones are not amenable with standard procedures.

Uretero-iliac artery fistula: a challenge diagnosis for a life-threatening condition: monocentric experience and review of the literature.

INTRODUCTION: Uretero-iliac artery fistulae (UIAF) are the consequence of chronic inflammatory events that create a fibrous and poorly vascularized uretero-vascular adhesion. They often occur in patients with a history of surgery, pelvic radiotherapy, and chronic ureteral stenting. The presentation is usually massive gross hematuria with acute anemia unto to hemorrhagic shock, representing a life-threatening condition. High mortality rate is reported (7-23%). MATERIALS AND METHODS: We present four cases in three patients, treated in our Institution from 2013 to 2018, and reviewed the published literature. UIAF was defined as the ratified presence of an abnormal communication between the ureter and any artery. In all patients, the UIAF was initially evaluated by contrast-enhanced computed tomography (CT) angiography. The management strategy was defined individually based on the specific risk profile of each patient. RESULTS: In all cases, ureteral-iliac artery fistula occurred in female patients with previous surgery or radiation and with presence of indwelling ureteral stent. In every case the hematuria was massive and life-threatening. Diagnosis was delayed because of the poor diagnostic accuracy of CT scan, leading to over-treatment. Angiography resulted the best diagnostic tool. The endovascular treatment proved good outcomes in terms of early complications, with no case of mortality. CONCLUSIONS: In case of gross hematuria during ureteral stent change in female patients with history of previous pelvic surgery and radiation, UIAF must be suspected and immediately treated, since it represents a urological emergency. Angiography can be useful to confirm the diagnosis and endovascular treatment with vascular endoprosthesis is the best therapeutic option.

Safety and efficacy of percutaneous nephrolithotomy in the Galdakao - Modified Supine Valdivia position: A prospective analysis.

OBJECTIVE: Aim of the present study was to evaluate the safety and efficacy of Percutaneous Nephrolithotomy (PCNL) in the Galdakao- Modified Supine Valdivia (GMSV) position in order to predict operative time, stone-free rate and onset of complications taking into account comorbidity, stone-related parameters and anatomic upper urinary tract abnormalities. MATERIAL AND METHODS: A prospective evaluation of patients who underwent to PCNL in GMSV position for renal stones > 2 cm, from January 2009 to February 2015 was performed. According to the technique, upper urinary tract abnormalities, stone chemical and morphological characteristics, and patients' history were matched with operative outcome, in terms of stone-free, intervention time and incidence of perioperative complications. RESULTS: Seventy-two cases were collected; mean operative time was 105 minutes (DS 41): staghorn stones and the presence of comorbidity resulted statistically significant variables. The complication-rate resulted in line with data showed in literature: hyperpyrexia and hemorrhage were the more frequently complications found. The overall stone-free was reached in 48 patients (67%), and it was influenced by patients' anatomic abnormalities. CONCLUSIONS: In the treatment of renal stones, PCNL may be a safe and effective choice; nevertheless, patients' anatomic abnormalities or staghorn-stones may influence the outcomes. Thus, a prospective study with a larger population is needed to verify our outcomes.

Pseudoaneurysm with arteriovenous fistula of the prostate after pelvic trauma: Ultrasound imaging.

Pseudoaneurysm (PA) associated with an arteriovenous fistula (AVF) of the internal pudendal artery branches are very uncommon. We report a case of post-traumatic PA with AVF connected to Santorini plexus. Diagnosis was made with trans-rectal ultrasound (TRUS) after recurrent hematuria. TRUS reported a 1.7 × 1.4 × 1.5 cm anechoic area, on anterior prostate apex close to Santorini plexus. The use of color Doppler in this area revealed high flow velocity that was indicative for AVF. The feeding artery was a distal branch of the left pudenda artery. After selective embolization was observed complete occlusion of the feeding branches and disappearance of PA with AVF. Prostate PA with concomitant symptomatic AVF detected with TRUS has not yet described in literature after pelvic trauma and represents complex diagnostic challenges. This case report suggests that the use of TURS and color Doppler can provide an important diagnostic and follow-up to address the clinical suspicion of occult vascular injuries using a noninvasive approach.

Improvement of lower urinary tract symptoms and sexual activity after open simple prostatectomy: prospective analysis of 50 cases.

OBJECTIVES: To evaluate the improvement of Lower Urinary Tract Symptoms (LUTS) and Erectile Function (EF) evaluated before and after Open Simple Prostatectomy, focusing on which patients this procedure allows better outcomes in term of sexual activity. MATERIAL AND METHODS: 50 men with large size benign prostatic hyperplasia (BHP) greater than 80 gr were prospectively evaluated before and 6 months after Open Simple Prostatectomy (Freyer procedure) between October 2012 to September 2013. Patients had a pre-operative transrectal ultrasound (TRUS) for volume evaluation and filled pre and post operative questionnaires for International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF-5) score. RESULTS: Mean patients age was 71 years (D.S. 3,5), mean prostate volume results 103 ml (D.S. 23,7); regarding LUTS and EF, mean improvement of IPSS score was 15,3 (D.S. 4) and mean increase of IIEF-5 score was 3,4 (D.S.3). This study highlights a correlation between patients' age and increase of IIEF-5 score; no correlation with prostate size was found. CONCLUSION: According to the EAU Guidelines 2014, large size BPH (over 80-100 mL) with LUTS refractory to medical management continue to have open prostatectomy as the treatment of choice. In our experience we found not only an reduction of LUTS after the procedure but also an improvement of erectile function; this improvement was related with patient's age.

[The use of haemostatic agents in Urology]. / Uso degli emostatici in Urologia.

Intra- and post-operative bleedings are frequent complications of all surgical procedures and can represent a severe risk for patients. Beginning from the second half of the 20th century, with an important spur from the development of laparoscopy, great efforts were made in the field of surgical research, aiming at improving hemostatic techniques. The development of mechanical and thermic hemostatic devices, in addition to the improvement of new suturing materials, already improved the possibility of bleeding control; yet a very important contribution in this field has been represented by the introduction in the surgical setting of chemical/biological agents capable of empowering locally blood hemostatic capacity. Currently, there are more chemical hemostatic agents surgeons can make use of in order to minimize bleedings: we reviewed the most important classes, considered their advantages, disadvantages and risks, and tried to look forward to those that will offer, in our view, the best options - for surgeons and patients - for an efficient and safe prevention and control of surgical bleedings, either in open or minimally invasive surgery.

Biopsy of the anterior prostate gland: technique with end-fire transrectal ultrasound.

OBJECTIVES: Transperineal approach is considered the best method to biopsy the anterior tissue of the prostate gland that is generally neglected by transrectal approach. We describe a technique of anterior prostate biopsy obtained with transrectal approach using an end-fire probe. MATERIALS AND METHODS: We correlated the images of the video of the diagnostic biopsy, the histology of the biopsy and of the surgical specimen after radical prostatectomy. A 68 years old may previously underwent two biopsies: first biopsy and re-biopsy were performed using the transrectal approach with 12 and 16 cores respectively, including the tranisizion zone (2 per side). Initial histology revealed high grade PIN only. We performed a saturation biopsy (28 samples) under local anesthesia, as outpatient, using endfire ultrasound probe, including anterior zone and fibromuscolar stroma (2 per side). Images of the procedure was stored electronically. Each biopsy core was pre-embedded and inked at one side in order to identify the rectal end (pericapsular side). Surgical specimen of radical nerve sparing prostatectomy was analyzed according to the Stanford protocol (3 mm). All biopsies and surgical specimens were reviewed by the same uro-pathologist. RESULTS: Cancer was detected only by anterior biopsy (left side, 1 core, 3 mm of total cancer extension, Gleason score 3 + 3, placed into the not inked core side). Histology of the surgical specimen confirmed the location of the disease with 0.3 cc tumor volume. Technically, to improve biopsy of the anterior zone the tip of the needle should obtain all the tissue up to the Santorini venous plexus. Postoperative recovery was uneventful after both procedures. CONCLUSION: We showed that end-fire probe makes possible, effective and safe the biopsy of the anterior prostate, which may contain cancer in particular when previous biopsies are negative. The anterior biopsy technique herein described is easy and reliable. Based on our experience, end-fire probe should be used in re-biopsy or saturation biopsy if transrectal approach is preferred. Confirmatory randomized clinical trial should be done in the future.