Surgery-related complications of robot-assisted radical cystectomy with intracorporeal urinary diversion.

OBJECTIVES: To assess the surgery-related complications at robot-assisted radical cystectomy with total intracorporeal urinary diversion during our learning curve in treating 45 patients with bladder cancer. METHODS: A total of 45 patients were pooled in 3 consecutive groups of 15 cases each to evaluate the complications according to the Clavien classification. As a surrogate for our learning curve, the following parameters were assessed: operative time, blood loss, urinary diversion type, lymph node yield, surgical margin status, and length of hospital stay. RESULTS: Early surgery-related complications were noted in 40% of the patients and late complications in 30%. The early Clavien grade III complications remained significant (27%) and did not decline with time. Overall, fewer complications were observed between the groups over time, with a significant decrease in late versus early complications (P = .005 and P = .058). The mean operative times declined from the first group to the second and third groups (P = .005) and the hospital stays shortened (P = .006). No significant difference was observed between groups regarding the lymph node yield at cystectomy (P = .108), with a mean of 22.5 nodes (range 10-52) removed. More patients received an orthotopic bladder substitute (Studer) in each of the latter 2 groups than in the first. CONCLUSIONS: Although robot-assisted radical cystectomy with total intracorporeal urinary diversion is a complex procedure, we observed decreased surgery-related complications and improved outcomes over time in the present series. Our results need to be confirmed by others before robot-assisted radical cystectomy with totally intracorporeal urinary diversion can be accepted as a treatment option for patients with bladder cancer.

Endourologic management of malignant ureteral obstruction: indications, results, and quality-of-life issues.

Obstruction of the upper urinary tract is a problem commonly faced by practicing urologists. The constant evolution in endourology has effectively facilitated minimally invasive management of upper-tract obstruction. In a case in which malignancy is the cause of obstruction, however, the situation significantly changes. Questions arise regarding the need for relieving the obstruction, the means to accomplish this, and the benefits and drawbacks of each technique regarding both their efficacy and their impact on the patients well-being and the crucial issue of quality of life in the face of malignancy.

Hormonal regulation of spermatogenesis and spermiogenesis.

Normal testicular function is dependent upon hormones acting through endocrine and paracrine pathways both in vivo and in vitro. Sertoli cells provide factors necessary for the successful progression of spermatogonia into spermatozoa. Sertoli cells have receptors for follicle stimulating hormone (FSH) and testosterone which are the main hormonal regulators of spermatogenesis. Hormones such as testosterone, FSH and luteinizing hormone (LH) are known to influence the germ cell fate. Their removal induces germ cell apoptosis. Proteins of the Bcl-2 family provide one signaling pathway which appears to be essential for male germ cell homeostasis. In addition to paracrine signals, germ cells also depend upon signals derived from Sertoli by direct membrane contact. Somatostatin is a regulatory peptide playing a role in the regulation of the proliferation of the male gametes. Activin A, follistatin and FSH play a role in germ cell maturation during the period when gonocytes resume mitosis to form the spermatogonial stem cells and differentiating germ cell populations. In vitro cultures systems have provided evidence that spermatogonia in advance stage of differentiation have specific regulatory mechanisms that control their fate. This review article provides an overview of the literature concerning the hormonal pathways regulating spermatogenesis.