Comparison of laparoscopic versus open simple nephrectomy in patients with xanthogranulomatous pyelonephritis: A singlecenter analysis of outcomes and predictors of surgical approaches and complications.

Background: The aim of this study was to compare the outcomes of open simple nephrectomy and laparoscopic simple nephrectomy in patients with xanthogranulomatous pyelonephritis (XGP) in a single-institutional retrospective study and to identify predictive factors of surgical approaches and complications. Materials and methods: We retrospectively analyzed the data of 67 consecutive patients with a histopathological diagnosis of XGP who underwent either open simple nephrectomy (ON) or laparoscopic simple nephrectomy (LN) from January 2014 to April 2020. The primary endpoint was the evaluation of perioperative outcomes and complications. Secondary endpoints were to define factors influencing the surgical approach and the likelihood of postoperative complications. Results: Overall, 44 out of 67 patients (65.67%) underwent ON, while 23 (34.33%) underwent LN. Patients in the ON group experienced more postoperative pain according to the visual analogic scale (p = 0.032). Moreover, time to deambulation and time to return to full daily activities, assessed according to the 12-Item Short Form Survey physical and mental component summary scores questionnaires, were significantly shorter in the LN group (p = 0.021, p < 0.001, and p < 0.001, respectively). Of note, there were no significant differences in intraoperative and postoperative complication rates among the groups (p = 0.258 and p = 0.317, respectively). No conversion to open surgery was described. Logistic regression analysis demonstrated that urgency (p = 0.025) was the only predictor associated with a higher risk of intraoperative complications. However, no independent factors associated with postoperative complications or with the surgical approach of choice were found. Conclusions: Based on our results, laparoscopic treatment of XGP represents a feasible alternative to ON, resulting in less postoperative pain and faster recovery. In skilled hands, LN should be considered as the treatment of choice for XGP.

Impact of systemic inflammatory markers on the response to Hyperthermic IntraVEsical Chemotherapy (HIVEC) in patients with non-muscle-invasive bladder cancer after bacillus Calmette-Guérin failure.

Objectives: To evaluate the impact of pre- and post-treatment systemic inflammatory markers on the response to Hyperthermic IntraVEsical Chemotherapy (HIVEC) treatment in a cohort of patients with high-grade non-muscle-invasive bladder cancer with bacillus Calmette-Guérin (BCG) failure or intolerance who were unsuitable or unwilling to undergo early radical cystectomy. As a secondary endpoint, we assessed the influence of some demographic, clinical and pathological factors on the response to chemo-hyperthermia. Patients and methods: Between March 2017 and December 2019, 72 consecutive patients were retrospectively analysed. Patients with diseases or conditions that could interfere with systemic inflammatory status or full blood count were excluded. The HIVEC protocol consisted of six weekly intravesical treatments with 40 mg Mitomycin-C diluted in 50 mL distilled water. The drug was heated to a temperature of 43°C. Association of categorical variables with response to HIVEC was evaluated using Yates' chi-squared test and differences in continuous variable were analysed using the Mann-Whitney test. Logistic regression analysis was performed to define independent predictors of response to HIVEC. Results: Patients who failed HIVEC were more likely to have multiple tumours (P = 0.039) at transurethral resection of bladder and a recurrence rate of >1/year (P = 0.046). Lower post-HIVEC inflammatory indices [C-reactive protein (P = 0.021), erythrocyte sedimentation rate (P = 0.027)] and lower pre- (P = 0.014) and post-treatment (P = 0.004) neutrophil-to-lymphocyte ratio (NLR) values were significantly associated with the response to the HIVEC regimen (no bladder cancer recurrence or progression). In the multivariate analysis, patients with a recurrence rate of >1/year were eight-times more likely to experience failure of HIVEC (P = 0.007). Higher pre- (P = 0.023) and post-treatment NLR values (P = 0.046) were associated with a worse response to the HIVEC regimen. Conclusions: The recurrence rate and systemic inflammatory response markers could be useful tools to predict the likelihood of obtaining a response with the HIVEC regimen. These markers might help to guide patients about the behaviour of the tumour after BCG failure, predicting failure or success of a conservative treatment. Abbreviations: CHT: chemo-hyperthermia; CIS: carcinoma in situ; CRP: C-reactive protein; EAU: European Association of Urology; ESR: erythrocyte sedimentation rate; HG: high grade; HIVEC: Hyperthermic IntraVEsical Chemotherapy; ICD: immunogenic cell death; IL: interleukin; MMC: Mitomycin-C; NK: natural killer; NLR: neutrophil-to-lymphocyte ratio; NMIBC: non-muscle-invasive bladder cancer; PLR: platelet-to-lymphocyte ratio; RC: radical cystectomy; SIR: systemic inflammatory response; TURB: transurethral resection of bladder.

Laparoscopic versus open partial nephrectomy for the management of highly complex renal tumors with PADUA score ⩾10: A single center analysis.

INTRODUCTION: The aim of this study was to compare laparoscopic and open partial nephrectomy (PN) for renal tumors of high surgical complexity (PADUA score ⩾10). METHODS: We retrospectively evaluated 93 consecutive patients who underwent PN at our department from January 2015 to September 2019. 21 patients underwent open partial nephrectomy (OPN) (Group A) and 72 underwent laparoscopic partial nephrectomy (LPN) (Group B). All OPNs were performed with a retroperitoneal approach, while all LPNs were performed with a transperitoneal approach by a single surgical team. Post-operative complications were classified according to the Clavien-Dindo system. RESULTS: The two groups showed no difference in terms of patients' demographics as well as tumor characteristics in all variables. Group A was found to be similar to group B in terms of operation time (p = 0.781), conversion to radical nephrectomy (p = 0.3485), and positive surgical margins (p = 0.338) while estimated blood loss (p = 0.0205), intra-operative (p = 0.0104), and post-operative (p = 0.0081) transfusion rates, drainage time (p = 0.0012), pain score at post-operative day 1 (<0.0001) were significantly lower in Group B. The rate of enucleation and enucleoresection/polar resection was similar (p = 0.1821) among the groups. Logistic regression analysis indicated that preoperative factors were not independently associated with the surgical approach. There was a statistically significant difference in complication rate (<0.0001) between the two groups even if no significant difference in terms of grade ⩾3 post-operative complications (p = 0.3382) was detected. DISCUSSION: LPN represents a feasible and safe approach for high complex renal tumors if performed in highly experienced laparoscopic centers. This procedure offers good intraoperative outcomes and a low rate of post-operative complications.

Clinical implications of transversus abdominis plane block (TAP-block) for robot assisted laparoscopic radical prostatectomy: A single-institute analysis.

INTRODUCTION: The aim of this study was to evaluate the role of TAP block in improvement of anesthesiological management and perioperative surgical outcomes of robot-assisted laparoscopic radical prostatectomy (RALP). METHODS: We consecutive enrolled 93 patients with prostate cancer whose underwent RALP at our department from January 2019 to December 2019. Group A included 45 patients who received bilateral TAP block, and Group B included 48 patients who did not received TAP block. TAP blocks were always performed by a single anesthesia team. An elastomeric pump device was used in all patients for post-operative pain management. TAP block was performed according to Rafi's technique, with Ropivacaine 0.375% and dexamethasone 4 mg. Mean values with standard deviations (±SD) were computed and reported for all items. Statistical significance was achieved if p-value was ⩽0.05 (two-sides). RESULTS: The two groups showed no difference in the most important demographics and baseline characteristics (p > 0.05). Group A showed a significant longer time of anaesthesia. Moreover, Ketorolac doses (started dose plus continuous post-operative infusion via elastomeric pump) used in Group A were significantly lower than Group B. Despite this, Group B showed statistical significant higher value of NRS PACU and at 12, 24, 48, 72 h than Group A but not at 96 h. Rescue analgesic medication use was significantly higher in the Group B than Group A. Moreover, patency of the intestinal tract and time to ambulation was significantly lower in the Group A. DISCUSSION: The use of TAP block during a RALP is a safe procedure that can be applied more appropriately to achieve better pain control. A multimodal protocol that includes locoregional anesthesia, reduction of intra and postoperative use of strong opiates, correct placing of the patient and the use of low pneumoperitoneum pressures should be implemented in order to reach a faster and better post-operative full recovery of patients whose underwent RALP.

A rare case of spontaneous parenchymal kidney explosion in a patient with ureteral obstruction caused by a single stone.

INTRODUCTION: Spontaneous rupture of kidney may involve collecting system or parenchyma. Parenchymal rupture usually occurs in patients with renal cell carcinoma, angiomyolipoma, renal cysts, arteriovenous malformation or vascular diseases such as periarteritis nodosa. Collecting system rupture is usually a rare complication of obstructive urolithiasis. We describe the unusual cases of spontaneous kidney rupture in patients with acute urinary obstruction. CASE PRESENTATION: The case report describes the left parenchymal kidney explosion related to ipsilateral ureteral obstruction caused by a single ureteral stone. The patient reached our emergency department with acute left flank pain and massive haematuria. At the moment of admission, the patient was in stage III hypovolemic shock and had a lower haematocrit (haemoglobin = 4.9 g/dL). Despite blood transfusions, emergency surgical exploration, extrafascial nephrectomy and intensive support care, the patient died twelve hours after surgery. CONCLUSIONS: Parenchymal renal rupture can be a life-threatening emergency. Despite its rarity, in the differential diagnosis of acute abdomen, parenchymal renal rupture should always be considered in patients with abdominal pain and an anamnesis or history of urinary stones, pointing out the need of early diagnosis also in benign urological conditions.

Four dilation techniques in percutaneous nephrolithotomy: a single-institute comparative analysis.

BACKGROUND: The aim of this study was to compare four renal access techniques in percutaneous nephrolithotomy (PCNL). METHODS: A total of 437 patients who underwent PCNL at our center from January 2015 to December 2019 were included in the analysis. Telescopic metallic coaxial dilation (TMD) was used in 146 patients, single step balloon dilation (BD) in 98 patients, one-shot dilation with 30F Amplatz (OS 30F) in 106 patients, and one-shot dilation with 16F Amplatz (OS 16F) in 87 patients. Primary endpoints were perioperative outcomes and complications of the procedures. RESULTS: Similar baseline characteristics were observed in the four groups. Fluoroscopy time was significantly shorter in OS 30F and OS 16F groups (P<0.0001). The drop in hemoglobin level was not significantly different between TMD and BD groups, but it was significantly lower in OS 16F group versus the OS 30F group and lower in OS 30F group versus the BD Group (P<0.0001). Despite this, the rate of blood transfusion was similar across groups (P=0.837). Moreover, a smaller tract was associated with reduced postoperative morbidity including time to nephrostomy removal (P=0.001), hospital stay (P<0.0001), VAS scale (P<0.0001). There were no significant differences in postoperative complications (P=0.683), and Clavien-Dindo grade ≥3 complication rates (P=0.486) among the groups. Stone-free rates and number of auxiliary procedures required to achieve stone-free status were also similar among all groups (P=0.964 and 0.988, respectively). Multinomial logistic regression analysis showed that BMI (P=0.002), stone size (P=0.002) and previous PCNL (P=0.038) were predictive factors associated with the choice of OS 16 approach. CONCLUSIONS: Different dilation methods are equally effective and safe to use in a PCNL procedure for kidney stone treatment, allowing similar stone free rates and risk of complications. The OS dilation techniques seem to allow a shorter X-ray exposure time, which might be beneficial for both patients and operators. The use of a 16 F dilator can reduce the postoperative morbidity. Risk of sepsis should be always kept in mind.

Preliminary evidence of the impact of social distancing on psychological status and functional outcomes of patients who underwent robot-assisted radical prostatectomy.

INTRODUCTION: Social distancing is considered the best strategy to prevent the spread of COVID-19 (COronaVIrus Disease 19). We aimed to analyse the effect of 'social distancing' on the emotional state, post-operative pain and functional outcomes of patients undergoing robot-assisted radical prostatectomy (RARP). MATERIAL AND METHODS: We retrospectively reviewed data of male patients who underwent RARP within the study period (from March to April 2019 [Group A = 27 patients] and from March to April 2020 [Group B = 29 patients]). Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) results were collected on the first day of hospitalization. Post-operative pain was assessed using the numerical rating scale (NRS) and visual analogic scale (VAS) after surgery in the post-anesthesia care unit (PACU) and at 24 hours. Functional outcomes were evaluated at the one-month follow-up. Demographic, pathological and peri-operative data were collected for all patients. RESULTS: There were no significant differences in demographics and pathological characteristics amongst the groups. We observed that patients in Group A had a statistically lower value on the PHQ-9 and GAD-7 questionnaires than patients of Group B. Moreover, Group A showed statistically significant better post-operative pain control in PACU and at 24 hours. At one-month follow-up, patients in Group B required more diapers for incontinence than Group A, showing poor early continence. Patients in Group A showed interest in sexual rehabilitation after 1.11 ±.320 months while patients in Group B after 2.59 ±.712 months (p <.001). Moreover, 17 out of 29 patients (58.62%) in Group B were referred to an andrologist, compared to 100% of patients from Group A (p = 0.0006). CONCLUSIONS: Social distancing during the COVID-19 pandemic is associated with a poor pre-operative emotional state, as well as influencing post-operative pain, early urinary continence and desire for sexual rehabilitation.

Outcomes and complications of Hyperthermic IntraVesical Chemotherapy using mitomycin C or epirubicin for patients with non-muscle invasive bladder cancer after bacillus Calmette-Guérin treatment failure.

INTRODUCTION: Chemohyperthermia is a feasible option in BCG (bacillus Calmette-Guérin) failure patients who desire bladder preservation. We aimed to assess outcomes and complications of chemohyperthermia using mitomycin C (MMC) or epirubicin (EPI). MATERIAL AND METHODS: From March 2017 to February 2020, 103 BCG failure or intolerance patients with high-risk NMIBC (non-muscle invasive bladder cancer) underwent a hyperthermic intravesical chemotherapy (HIVEC) regimen. Five patients did not complete at least 5 instillations and were excluded from analysis. MMC was used in 72 out of 98 patients (Group A) while EPI was used in 26 patients (Group B). Response to HIVEC, predictive factors for treatment outcome and the disease-free survival (DFS) were defined as primary endpoints. The complications of chemohyperthermia were assessed as a secondary endpoint. RESULTS: No significant differences were found in recurrence and progression after induction course between Groups A and B. Kaplan-Meier disease-free survival was 22.61 months in Group A and 21.93 in Group B. The log-rank test showed no statistically significant difference between the two curves (p = .627). In the multivariate analysis, patients with tumor size ≥3 cm (p = .029), recurrence rate >1/year (p = .034), concomitant carcinoma in situ (CIS) during transurethral resection of bladder (TURB) (p = .039) and BCG-unresponsive status (p = .048) were associated with a worse response to chemohyperthermia. The use of MMC or EPI did not influence the response to treatment (p = .157). A slightly significant higher rate of overall complications (p = .0488) was observed in Group B. A significantly higher rate of Grade 3 frequency/urgency (p = .0064) contributed to this difference. The use of EPI was the only independent factor associated with severe urinary frequency/urgency (p = .017). No patients experienced Grade 4/5 adverse events. CONCLUSIONS: HIVEC can be considered a feasible option in BCG failure/intolerant NMIBC patients, avoiding or postponing radical cystectomy in some particular subclasses of patients.

The role of Protopine associated with Nuciferine in controlling adverse events during hyperthermic intravesical chemotherapy instillations. A nutraceutical approach to control adverse event during intravesical instillations.

OBJECTIVES: The aim of this study was to analyse the role of two alkaloid, Protopine and Nuciferine, in the prevention and the treatment of the low and mild grade adverse events related to the use of HIVEC® (Hyperthermic IntraVEsical Chemotherapy) instillations. MATERIALS AND METHODS: From September 2017 to September 2019, 100 patients were prospectively randomized into two groups: Group A = Protopine and Nuciferine syrup, 10 ml, once a day, for 8 weeks; Group B = placebo (flavoured coloured water), 10 ml, once a day, for 8 weeks. The primary endpoint was the evaluation of the efficacy of the therapy with Protopine and Nuciferine in controlling of the irritative symptoms. The secondary endpoint was the evaluation of the influences of the treatment on the uroflowmetric parameters. RESULTS: The patients of Group A showed a better International Prostatic Symptoms Score (IPSS) score, a better control of urgency symptoms (PPIUS) and tolerate well the pain (VAS score). The treatment doesn't modify Uroflow-Qmax and seems to improve the Uroflow-Voided Volume (ml) without influencing the Uroflow-Post Void Residual volume (PVR). Moreover, the treatment with Protopine and Nuciferine has been proven to be effective in the treatment of overactive bladder (OAB) symptoms. Patients' evaluation of the two different treatments assessed with Patient Global Impression of Improvement questionnaire (PGI-I), demonstrated improvements in the Group A, while the Group B showed a lower satisfaction. CONCLUSIONS: Protopine and Nuciferine can be interesting nutraceutical compounds useful to control irritative and pain related symptoms of intravesical chemo/immunotherapy.

The Use of a Combination of Vaccinium Macracarpon, Lycium barbarum L. and Probiotics (Bifiprost®) for the Prevention of Chronic Bacterial Prostatitis: A Double-Blind Randomized Study.

INTRODUCTION: To evaluate the efficacy of Bifiprost® + Serenoa Repens 320 mg versus Serenoa Repens 320 mg alone for the prevention of chronic bacterial prostatitis (CBP) due to enterobacteriaceae. METHODS: Between September 2016 and September 2018, 120 patients with CBP at the National Institutes of Health (NIH type II) with recurrent infections due to enterobacteriaceae (Escherichia Coli and Enterococcus faecalis) were enrolled and randomized into 2 groups each to receive Bifiprost® + Serenoa Repens 320 mg (Group A) or Serenoa Repens 320 mg alone (Group B) daily for 24 weeks (after receiving a proper antibiotic treatment with subsequent culture negativization). The primary endpoint was the reduction in the episodes of prostatitis. The secondary endpoint evaluated was the score of the NIH-Chronic Prostatitis Symptom Index (NIH-CPSI). Evaluation was performed at baseline and at 12, 24, and 36 weeks. RESULTS: The patients of the Group A experienced a significantly larger reduction in the prostatitis episodes than the Group B at 24 and 36 weeks, but they did not experience a significantly larger reduction at 12 weeks. After 12 weeks of treatment, the mean NIH-CPSI score was reduced in both groups compared with baselines, but no significant differences were seen between the Group A and Group B. On the contrary, we observed a significant difference in the mean NIH-CPSI score between the 2 groups at 24 and 36 weeks. CONCLUSION: The association of Bifiprost® and Serenoa Repens 320 mg improves the prevention of the episodes of CBP due to enterobacteriaceae and ameliorates prostatitis-related symptoms after 6 months of therapy. The long-term impact on the entero-urinary route was also seen 3 months after the end of the treatment.

A very large leiomyoma of the urethra: A case report.

INTRODUCTION: Leiomyomas are benign mesenchymal tumours of smooth muscle origin. They are the most common uterine masses in women of reproductive age group and may be related to the hormonal status. Urethral leiomyomas are very rare. According to the literature, the mean diameter of the urethral leiomyomas is 3.7 cm. CASE REPORT: We report a case of a very large leiomyoma of the urethra. A 40-year-old women woman was admitted to our department for a giant vaginal mass. She complained of haematuria, dysuria, recurrent urinary tract infections and dyspareunia. The physical evaluation demonstrated a 6 × 5.5 cm neoformation involving the distal tract of the urethra. The patient underwent an ultrasonography and then a magnetic resonance that suggested the diagnosis of leiomyoma. The neoformation was excised through a suburethral incision. CONCLUSIONS: The patient was discharged after 3 days and no intraoperative and postoperative complications occurred. The Foley catheter was removed after a week. The patient was continent to urine, and at 6 months follow-up, the patient was symptom free and no recurrences occurred.

Emergent Embolization of a Very Late Detected Pseudoaneurysm at a Lower Pole Subsegmental Artery of the Kidney after Clampless Laparoscopic Partial Nephrectomy.

Renal artery pseudoaneurysm is a rare but life-threatening condition. Its incidence is higher after minimally invasive partial nephrectomy (PN) than after the open approach. We reported a case of a renal artery pseudoaneurysm occurred about four months after a clampless laparoscopic PN. A 49-year-old female underwent a clampless laparoscopic PN for a right renal tumor with high surgical complexity. The patient experienced an intraoperative blood loss from renal bed and the surgeons performed a deep medullary absorbable suture. Three months after surgery the patient underwent a renal ultrasonography with good results. The patient came to our emergency department 115 days after surgery with a hypovolemic shock stage 3. Her CT scan showed a pseudoaneurysm of a lower pole vessel of the right kidney. She underwent a superselective embolization of the segmental renal artery. The surgical complexity of the tumor, the anatomical relationships with the renal sinus and the deep medullary suture could be responsible for the development of the pseudoaneurysm. The authors presented an unusual case of a very late detected pseudoaneurysm of a renal vessel, suggesting that all very complex renal tumors removed with a minimally invasive technique should be followed up closely at least during the first six-months in order to early detect this major complication.

Laparoscopic management of recurrent ureteropelvic junction obstruction following pyeloplasty: a single surgical team experience with 38 cases

ABSTRACT Purpose To describe and analyze our experience with Anderson-Hynes transperitoneal laparoscopic pyeloplasty (LP) in the treatment of recurrent ureteropelvic junction obstruction (UPJO). Materials and methods 38 consecutive patients who underwent transperitoneal laparoscopic redo-pyeloplasty between January 2007 and January 2015 at our department were included in the analysis. 36 patients were previously treated with dismembered pyeloplasty and 2 patients underwent a retrograde endopyelotomy. All patients were symptomatic and all patients had a T1/2>20 minutes at pre-operative DTPA (diethylene-triamine-pentaacetate) renal scan. All data were collected in a prospectively maintained database and retrospectively analyzed. Intraoperative and postoperative complications have been reported according to the Satava and the Clavien-Dindo system. Treatment success was evaluated by a 12 month-postoperative renal scan. Total success was defined as T1/2≤10 minutes while relative success was defined as T1/2between 10 to 20 minutes. Post-operative hydronephrosis and flank pain were also evaluated. Results Mean operating time was 103.16±30 minutes. The mean blood loss was 122.37±73.25mL. The mean postoperative hospital stay was 4.47±0.86 days. No intraoperative complications occurred. 6 out of 38 patients (15.8%) experienced postoperative complications. The success rate was 97.4% for flank pain and 97.4% for hydronephrosis. Post-operative renal scan showed radiological failure in one out of 38 (2.6%) patients, relative success in 2 out of 38 (5.3%) patients and total success in 35 out of 38 (92.1%) of patients. Conclusion Laparoscopic redo-pyeloplasty is a feasible procedure for the treatment of recurrent ureteropelvic junction obstruction (UPJO), with a low rate of post-operative complications and a high success rate in high laparoscopic volume centers.

Laparoscopic management of recurrent ureteropelvic junction obstruction following pyeloplasty: a single surgical team experience with 38 cases.

PURPOSE: To describe and analyze our experience with Anderson-Hynes transperitoneal laparoscopic pyeloplasty (LP) in the treatment of recurrent ureteropelvic junction obstruction (UPJO). MATERIALS AND METHODS: 38 consecutive patients who underwent transperitoneal laparoscopic redo-pyeloplasty between January 2007 and January 2015 at our department were included in the analysis. 36 patients were previously treated with dismembered pyeloplasty and 2 patients underwent a retrograde endopyelotomy. All patients were symptomatic and all patients had a T1/2>20 minutes at pre-operative DTPA (diethylene-triamine-pentaacetate) renal scan. All data were collected in a prospectively maintained database and retrospectively analyzed. Intraoperative and postoperative complications have been reported according to the Satava and the Clavien-Dindo system. Treatment success was evaluated by a 12 month-postoperative renal scan. Total success was defined as T1/2≤10 minutes while relative success was defined as T1/2between 10 to 20 minutes. Post-operative hydronephrosis and flank pain were also evaluated. RESULTS: Mean operating time was 103.16±30 minutes. The mean blood loss was 122.37±73.25mL. The mean postoperative hospital stay was 4.47±0.86 days. No intraoperative complications occurred. 6 out of 38 patients (15.8%) experienced postoperative complications. The success rate was 97.4% for flank pain and 97.4% for hydronephrosis. Post-operative renal scan showed radiological failure in one out of 38 (2.6%) patients, relative success in 2 out of 38 (5.3%) patients and total success in 35 out of 38 (92.1%) of patients. CONCLUSION: Laparoscopic redo-pyeloplasty is a feasible procedure for the treatment of recurrent ureteropelvic junction obstruction (UPJO), with a low rate of post-operative complications and a high success rate in high laparoscopic volume centers.

Perioperative and renal functional outcomes of laparoscopic partial nephrectomy (LPN) for renal tumours of high surgical complexity: a single-institute comparison between clampless and clamped procedures.

PURPOSE: In recent times there has been a trend in mininvasive renal tumour surgery. Very limited evidence can be found in literature of the outcomes of laparoscopic partial nephrectomy (LPN) for highly complex renal tumours. The aim of the present study was to assess the feasibility and safety of LPN for renal tumours of high surgical complexity in our single-institutional experience, comparing perioperative and functional data between clampless and clamped procedures. MATERIALS AND METHODS: We enrolled 68 patient who underwent a clampless LPN (Group A) and 41 patients who underwent a clamped LPN (Group B) for a renal tumour with a R.E.N.A.L. NS ≥ 10. Intraoperative and post-operative complications have been classified and reported according to international criteria. Kidney function was evaluated by measuring serum creatinine concentration and eGFR. RESULTS: Group A was found to be similar to Group B in all variables measured except for WIT (P = 0) and blood loss (P = 0.0188). In group A the mean creatinine levels were not significantly increased at the third post-operative (P = 0.0555) day and at the 6-month follow-up (P = 0.3047). Otherwise, in the group B the creatinine levels were significantly increased after surgery (P = 0.0263), but decreased over time, showing no significant differences at 6 month follow-up (P = 0.7985) compared to preoperative values. The same trend was seen for eGFR. Optimal Trifecta outcomes were achieved in both groups. CONCLUSIONS: Clampless LPN represents a feasible and safe procedure, even for tumours with high surgical complexity, in highly experienced laparoscopic centers. When compared to clamped LPN, it results in better preservation of immediate post-operative renal function.

Spondylodiscitis: a rare complication following percutaneous nephrostomy.

Spondylodiscitis is an inflammation of the intervertebral disc and the adjacent vertebral bodies. The spondylodiscitis can not only be a complication of medical interventions such as an operation near spinal column but also urogenital and vascular interventions and intravenous catheter use. A 71-year-old man was admitted to our emergency department with fever and severe abdominal pain. Antibiotic therapy had been performed with intravenous administration of 2 g of ceftriaxone and the patient underwent the placement of a percutaneous nephrostomy according to Seldinger technique. After 1 week, the patient experienced a severe pain at the lumbar tract of the vertebral column associated with a moderate abdominal pain and septic fever. A magnetic resonance imaging (MRI) of the lumbar spine showed widespread impregnation of the upper portion of L3 and the lower portion of L2 compressing the spinal roots as well as the ileopsoas muscle such as a spondylodiscitis. Liquor culture showed an increase of liquor immunoglobulin G, total liquor protein and was positive for Extended-spectrum beta-lactamases (ESBL) - producing Escherichia coli. After the antibiotic therapy, the spondylodiscitis resolves without important sequelae. In the present case report, we describe a very rare complication of percutaneous nephrostomy tube placement, despite of the prophylactic antibiotic therapy according to the most recent guidelines. Predisposing factors to spondylodiscitis include the very young and elderly, the immunosuppressed, diabetic individuals and a general debilitating disease such as renal failure. This case suggests the importance of remembering spondylodiscitis when septic fever and back pain occurs following the placement of a percutaneous nephrostomy in a septic patient.

Rare complication after a transrectal ultrasound guided prostate biopsy: a giant retroperitoneal hematoma.

Common complications related to transrectal ultrasound (TRUS) guided prostatic needle biopsy are hematuria, hematospermia, and hematochezia. To the best of our knowledge, we report the second case of a very large hematoma extending from the pelvis into the retroperitoneal space in literature.A 66-year-old man with a serum prostate-specific antigen (PSA) of 5.4 ng/ml was admitted to our department for a TRUS-guided prostatic needle biopsy. Laboratory values on the day before biopsy, including coagulation studies, were all normal. The patients did not take any anticoagulant drugs. No immediate complications were encountered. Nevertheless, 7 hours after the biopsy, the patient reached our emergency department with severe diffuse abdominal pain, hypotension, tachycardia, and confusional state. He underwent an ultrasonography and then a computed tomography (CT) scan that showed "a blood collection in the pelvis that extending to the lower pole of left kidney associated with a focus of active contrast extravasation, indicating active ongoing prostate bleeding." Consequently, he underwent a diagnostic angiography that showed no more contrast extravasation, without the need of embolization. Management of hematoma has been conservative and hematoma was completely reabsorbed 4 months later.

Emergency embolization of actively bleeding small renal angiomyolipoma with a fast growth in four months.

Angiomyolipoma (AML) is the most common benign tumour of the kidney and is composed of smooth muscle cells, blood vessels and fat elements. AMLs are usually casually discovered when the kidneys are imaged for other reasons. Their first presentation is often a spontaneous retroperitoneal haemorrhage or bleeding into the urinary collection system, which can be life-threatening. The bleeding tendency is related to the irregular, aneurysmal, tortuous blood vessels that compose the tumor. The greatest risks for bleeding are tumour size and grade of the vascular component of the tumour. Moreover, the risk of bleeding is proportional to the size of the lesion (it is higher in AMLs with a diameter more than 4 cm). Shock due to a grave haemorrhage from AML rupture is called Wunderlich syndrome that is clinically characterized by the Lenk's triad: acute flank pain, a flank mass and hypovolemic shock.Other symptoms and signs may be present: haematuria, palpable mass, flank pain, urinary tract infections, renal failure or hypertension. Small AMLs usually require no therapy, although follow-up is recommended in order to follow its growth. Larger or symptomatic lesions can be electively embolized and/or resected with a partial nephrectomy. AMLs that present with retroperitoneal haemorrhage frequently require emergency embolization. We describe a case of an actively bleeding small renal AML, with a rapid growth, without any evidence for big aneurysmal vessels, who underwent an emergency embolization at our hospital.