Oncological safety of simultaneous transurethral resection of high-grade urothelial carcinoma of the bladder and benign prostatic hyperplasia.

Objectives: To examine the oncological safety of simultaneous resection of bladder tumor and prostate in the presence of non-muscle invasive high-grade urothelial carcinoma of the bladder (UCB). Materials and Methods: Between 2007 and 2019, 170 men with high-grade UCB who had a follow-up of at least 12 months were included in the study, including 123 with transurethral resection of bladder tumor (TURBT) only and 47 with simultaneous TURBT and transurethral resection of the prostate (TURP). We recorded and compared patients' clinicopathological parameters, recurrence, and progression rates during the follow-up period, as well as time to UCB recurrence in the bladder and the prostatic urethra/fossa. Results: Baseline demographic and pathological characteristics were comparable between the groups. At a median follow-up of 31 months in both groups, there were no significant differences in recurrence rates in the bladder and the prostatic urethra/fossa in either group (34.1% and 7.3% vs. 36.2 and 6.4%, p=0.402, p=0.363). No statistically significant differences were found between the two groups in terms of follow-up time, elapsed time to recurrence, or and progression in the bladder or prostatic urethra/fossa. Conclusions: Simultaneous TURBT and TURP in the presence of high-grade UCB appears to be oncologically safe in selected patients.

[VESICO-VAGINAL FISTULAS (VVF)].

INTRODUCTION: Vesico-vaginal fistula, is a known complication that can occur following damage to the bladder wall during pelvic surgery or prolonged birth. Prompt and accurate diagnosis and timely repair are essential for a quick solution to the problem, and a reduction in medico-legal claims. Successful treatment requires an accurate assessment of the size and the location of the fistula, determination of timing and the surgical technique. There is an approach that advocates postponing the surgery for several months until "tissue healing" subsides and some advocate immediate repair. In our department, the surgery is performed early, immediately upon diagnosis without delay. The aim of the work is to define the clinical manifestation of fistula after surgery, to analyze the factors, and to summarize the experience of an early intervention. METHODS: We reviewed the records of consecutive patients undergoing repair of urogenital fistulas at our institution. Patients with only vesico-vaginal fistulas were included. We recorded demographic characteristics, as well as surgical data, and postoperative complications were also collected. The follow-up period was at least 3 months. RESULTS: A total of 67 women with urogenital fistulas were identified, of whom 37 were only with vesico-vaginal fistulas. Iatrogenic injury, during hysterectomy was the main cause in 70.3%; 2 women were treated conservatively. A repair in the vaginal approach was performed in 31 women, and in 4 women the repair was performed in the abdominal approach, of them, two underwent urethral re-implantation simultaneously. Complications included sepsis in one case, and vaginal cuff dehiscence in another. The success rate of the repair was 92%. Recurrence occurred in 3 patients, of whom 2 had a history of previous radiation. CONCLUSIONS: A vesico-vaginal fistula can be successfully repaired by early repair, without delay, thus saving the patient considerable distress and discomfort.

Patients treated for uric acid stones reoccur more often and within a shorter interval compared to patients treated for calcium stones.

INTRODUCTION: We aimed to investigate the association between stone composition and recurrence rate in a well-characterized group of patients. METHODS: From our prospectively assembled database of 1328 patients undergoing ureteroscopy and percutaneous nephrolithotomy (PCNL) between 2010 and 2015, we identified 457 patients who met the inclusion criteria: a minimum of two years' followup, stone-free status following surgery, normal anatomy, and Fourier transform infrared (FT-IR) stone analysis results. Stone recurrence was identified by kidney-ureter-bladder (KUB) or an ultrasound (US). All symptomatic events were recorded. Kaplan-Meier and Cox proportional hazard regression methods were used to assess the differences in recurrence rates and associated risk factors. RESULTS: Calcium oxalate (CaOx), uric acid (UA), and struvite stones were found in 298 (65.2%), 99 (21.7%), and 28 (6.1%) patients, respectively. During a median followup of 38 months (interquartile range [IQR] 31-48), stone recurred in 111 (24%) patients. One-year stone-free rates (SFRs) stratified by composition were: CaOx 98%, UA 91.9%, calcium phosphate 90%, struvite 88%, and, cystine 83%; the two-year SFRs were 92.6%, 82.7%, 80%, 73%, and 75%, respectively. On multivariate Cox regression analysis, UA composition, the absence of medical preventive therapy, and preoperative stone burden were associated with a shorter time to recurrence. Secondary intervention for recurrent, symptomatic stones was required in 11 (11.1%) and 22 (7.4%) of patients with UA and CaOx stones, respectively (p=0.02). CONCLUSIONS: UA stone-formers are more likely to have a recurrence and to undergo surgical intervention in comparison to CaOx stone-formers, regardless of medical preventive treatment. These differences are more prominent during the first year of followup and should be incorporated into the patient's followup protocol.

Ectopic Intravesical Ejaculatory Ducts: Case Report of Bulking Agent Injection for Treatment of Recurrent Epididymitis in a Patient With Anorectal Malformation.

As far as we know this is the first report on bulking agent injection into intravesical ectopic ejaculatory orifices reported in the English literature. During a follow-up period of 23 months, the child was free of episodes of epididymo-orchitis. Deflux injection in this rare anomaly of intravesical refluxing ducts had prevented irreversible damage to the testes from recurrent EO. Thus, it may be a better option than vasectomy when antibiotic treatment fails.

Pain Control after Laparoscopic Radical Prostatectomy: Comparison between Unilateral Transversus Abdominis Plane Block and Wound Infiltration.

BACKGROUND AND OBJECTIVES: To determine the efficacy of unilateral transversus abdominis plane (TAP) block versus wound local infiltration for postoperative pain following laparoscopic radical prostatectomy (LRP). METHODS: Data of consecutive patients who underwent extraperitoneal LRP and received either wound infiltration or unilateral TAP block for analgesia were retrospectively analyzed. The patients were divided into 2 groups based on the technique used. We compared pain intensity scores and on-demand analgesic use both during the hospital stay and post-discharge between the 2 groups. RESULTS: A total of 48 patients were included, 27 received unilateral TAP blocks (group 1) and 21 were managed with wound infiltration (group 2). The unilateral TAP block group showed lower median pain scores on postoperative days (POD) 1 with pain scores being 0.2 (0-4) and 0.8 (0-4), respectively (p < 0.05). On POD2, the median pain intensity was 0.9 (0-5) and 1.6 (0-6) in groups 1 and 2, respectively (p < 0.05). The median number of on-demand analgesic doses during the POD1 was 0.2 (0-2) and 0.4 (0-2) in groups 1 and 2, respectively (p = 0.19). On POD2, the patients received 0.5 (0-2) and 1.1 (0-3) on-demand doses in groups 1 and 2, respectively (p < 0.05). CONCLUSION: Unilateral TAP block might improve pain control more pronounced after LRP than wound infiltration.

Implementation of supine percutaneous nephrolithotomy: a novel position for an old operation.

INTRODUCTION: Supine percutaneous nephrolithotomy (PCNL) has become increasingly widespread during the last 2 decades. The aim of this study was to analyze the transition from prone to mainly supine PCNL in 2 endourologic centers. MATERIAL AND METHODS: We retrospectively analyzed data on 214 consecutive supine PCNLs divided into the first (2011-2013) and last (2014-2016) 3 years of this study. The first 27 cases were also included in a randomized controlled trial (RCT) by comparison with 24 prone PCNLs. We compared the clinical outcome and implementation rate. The surgical team was surveyed for their overall impression of performing supine PCNLs. RESULTS: The RCT revealed a trend toward shorter operative time (138 vs. 150 minutes), anesthesia time (174 vs. 192 minutes) and hospitalization (2.2 vs. 2.6 days) in the supine PCNL group, without statistical significance and similar stone free rates (SFR) as for the prone PCNL group. Implementation of the supine PCNL reached 96% in 3 years. There was a decrease in operative time (110 vs. 154 minutes; P <0.0001), hospital stay (1.5 vs. 2.1 days; P <0.01), blood transfusion (5% vs. 14%; P <0.05) and rate of ancillary procedures (5% vs. 16%; P <0.05) in the last 3 years of the study. SFR remained stable. Both the surgeons and anesthesiologists expressed their unanimous preference for the supine position over the prone position. CONCLUSIONS: Supine PCNLs are easy to implement without a significant learning curve for an experienced endourologist. They can be employed in complex cases and improve surgeon's ergonomics and anesthesiologist's access to the patient.

Effects of Sacral Neuromodulation on Urinary and Fecal Incontinence.

BACKGROUND: Fecal incontinence is defined as involuntary passage of stool through the anus. It may vary from soiling to complete evacuation. This involuntary loss of feces, flatus or urge incontinence adversely affects quality of life. Urinary urge incontinence is characterized by symptoms of frequency, urgency and urge incontinence (either alone or in combination). Urgency frequency syndrome is defined as symptoms of frequency and urgency without incontinence episodes. OBJECTIVES: To evaluate the efficacy of sacral neuromodulation on these pathologies. METHODS: Following a detailed investigation, 51 patients with either urinary or fecal incontinence, or both, who did not respond to medical and behavioral treatment were offered the temporary implant. Of the 51 patients 40 showed improvement and advanced for a permanent device. RESULTS: After a mean follow-up of 5 years (range 1-8), there was a significant reduction in the number of incontinence episodes (P < 0.0001), and the number of pads used also declined significantly (P < 0.0001). A marked improvement in quality of life was reported by 71.4% of the women and 58.3% of the men. CONCLUSIONS: Sacral neuromodulation as shown in this study appears to be a promising treatment for urinary and fecal incontinence and can dramatically improve patients' quality of life.

Simplified hemostatic technique during laparoscopic partial nephrectomy.

INTRODUCTION: Laparoscopic partial nephrectomy (LPN) has gained popularity in recent years, although it remains a challenging procedure. Herein we describe our technique of renal defect closure using sutures as the sole means of hemostasis during LPN. SURGICAL TECHNIQUE: The kidney is approached transperitoneally in a standard fashion. After the renal artery is clamped and the tumor has been excised, the defect is closed in two separate knot-free suture layers. The deep layer suture is continuous and involves deep parenchyma including the collecting system, if opened. The superficial layer suture approximates the margins of the defect using absorbable clips on one parenchymal edge only. No bolsters, glues or other additional hemostatic agents are used. RESULTS: At present this technique was applied in 34 patients. Tumor size ranged from 17-85 mm. Median warm ischemia time was 23 min (range 12-45) and estimated blood loss 55 mL (30-1000). There were no intraoperative complications or conversions to open surgery. No urine leaks or postoperative bleedings were observed. CONCLUSIONS: This simplified technique appears reliable and quick, and therefore may be attractive for many urologic surgeons. Furthermore, the avoidance of routine use of additional hemostatic maneuvers may provide an economical advantage to this approach with no compromise of the surgical outcome.

Simplified hemostatic technique during laparoscopic partial nephrectomy

INTRODUCTION: Laparoscopic partial nephrectomy (LPN) has gained popularity in recent years, although it remains a challenging procedure. Herein we describe our technique of renal defect closure using sutures as the sole means of hemostasis during LPN. SURGICAL TECHNIQUE: The kidney is approached transperitoneally in a standard fashion. After the renal artery is clamped and the tumor has been excised, the defect is closed in two separate knot-free suture layers. The deep layer suture is continuous and involves deep parenchyma including the collecting system, if opened. The superficial layer suture approximates the margins of the defect using absorbable clips on one parenchymal edge only. No bolsters, glues or other additional hemostatic agents are used. RESULTS: At present this technique was applied in 34 patients. Tumor size ranged from 17-85 mm. Median warm ischemia time was 23 min (range 12-45) and estimated blood loss 55 mL (30-1000). There were no intraoperative complications or conversions to open surgery. No urine leaks or postoperative bleedings were observed. CONCLUSIONS: This simplified technique appears reliable and quick, and therefore may be attractive for many urologic surgeons. Furthermore, the avoidance of routine use of additional hemostatic maneuvers may provide an economical advantage to this approach with no compromise of the surgical outcome.

Combined thermo-chemotherapy for recurrent bladder cancer after bacillus Calmette-Guerin.

PURPOSE: Despite an initial adequate response many patients with nonmuscle invasive urothelial cell carcinoma of the bladder eventually have recurrence after intravesical bacillus Calmette-Guerin treatments. We evaluated the efficacy of combined bladder wall hyperthermia and intravesical mitomycin C instillation (thermo-chemotherapy) in cases of recurrence after bacillus Calmette-Guerin. MATERIALS AND METHODS: A total of 111 patients with recurrent papillary nonmuscle invasive urothelial cell carcinoma of the bladder after previous bacillus Calmette-Guerin treatment underwent complete bladder tumor resection and were referred for prophylactic adjuvant treatment with thermo-chemotherapy. Treatment was received on an outpatient basis weekly for 6 weeks, followed by 6 maintenance sessions at 4 to 6-week intervals. Each treatment included 2, 30-minute cycles of 20 mg mitomycin C and bladder wall hyperthermia to 42C +/- 2C. Cystoscopy and urine cytology were performed after the completion of induction treatment and every 3 months thereafter. RESULTS: The Kaplan-Meier estimated disease-free survival rate was 85% and 56% after 1 and 2 years, respectively. No maintenance treatment was associated with decreased efficacy, that is the recurrence rate was 61% at 2 years vs 39% in those with maintenance treatments (p = 0.01). The progression rate was 3%. CONCLUSIONS: Thermo-chemotherapy may be effective for papillary nonmuscle invasive urothelial cell carcinoma of the bladder that recurs after BCG treatment without increasing the risk of tumor progression. Maintenance therapy is important and improves the outcome.

Transperitoneal laparoscopic radical nephrectomy is an effective procedure for large (more than 7 cm) renal masses.

PURPOSE: We aimed to evaluate our experience with the transperitoneal radical nephrectomy (TLRN) in patients with large (more than 7 cm) renal mass to determine if this procedure can be recommended as a reference standard for treating large renal masses. PATIENTS AND METHODS: Of 213 patients who underwent TLRN in both institutions we have reviewed medical files of 35 who had large than 7 cm renal masses. Operative time, blood loss, conversion rate, pathologic tumor type, and oncologic outcome were evaluated. RESULTS: The mean tumor size was 10.1 cm (range: 7 to 19 cm). Mean blood loss during surgery was 388 mL (range: 150 to 600 mL). In 2 patients with 16 cm renal masses the operation was converted to hand-assisted technique as planned upon the surgery after ligation and transsection of the vascular pedicel to facilitate kidney dissection from surrounding tissue. In 1 patient the operation was converted to the open technique. Twenty-two (62.8%) patients had renal cell carcinoma and the remaining 13(37.5%) patients had other types of the renal tumors. Mean hospital stay was 4.36 days (range: 3 to 7 d). Median follow-up after the surgery was 29 months (range: 8 to 60 mo). Three patients who underwent cytoreduction nephrectomy died whereas receiving immunotherapy 3, 8, and 11 months, respectively, after surgery. One patient developed a local tumor recurrence and 2 developed remote metastasizes. CONCLUSIONS: Our data show that TLRN is an effective procedure for the removal larger than 7 cm renal tumors. In those patients with exceptionally big tumors planned conversion to the hand-assisted technique after laparoscopic ligation of the renal vessels enabling easier renal dissection whereas preserving the advantages of minimally invasive procedure.

Transient neurological symptoms after isobaric subarachnoid anesthesia with 2% lidocaine: the impact of needle type.

BACKGROUND: The reported incidence of transient neurological symptoms (TNS) after subarachnoid lidocaine administration is as high as 40%. We designed this clinical trial to determine the incidence of TNS with two different pencil-point spinal needles: one-orifice (Atraucan) and two-orifice (Eldor) spinal needles. METHODS: Ninety-nine ASA physical status I or II patients undergoing surgical procedures of the urinary bladder or prostate were prospectively allocated to receive spinal anesthesia with 40 mg, 2% isobaric lidocaine plus fentanyl injected through either a 26-gauge Atraucan (n = 52) or a 26-gauge Eldor (n = 47) spinal needle. During the first three postoperative days, patients were observed for postoperative complications, including TNS. The primary end-point for this trial was the percentage of TNS in both double- and single-orifice spinal needle procedures. RESULTS: The incidence of TNS was higher when spinal anesthesia was done through the Atraucan needle (28.8% vs 8.5%, P = 0.006). Fifty percent of the patients in the double-orifice group versus 100% of the single-orifice group developed TNS after surgery in the lithotomy position (P = 0.014). The relative risk for developing TNS with the Eldor needle was 0.29 (95% CI: 0.07-0.75) compared with the Atraucan needle. CONCLUSIONS: The use of a double-orifice spinal needle was associated with a lower incidence of TNS, which may have been due to the needle design.

Rhabdomyolysis: another complication after prolonged surgery.

We present the case of a young patient who underwent a prolonged urological procedure in the lateral decubitus position. The patient's postoperative course was complicated by rhabdomyolysis manifested by elevated levels of serum creatine phosphokinase and the presence of myoglobin in urine and blood. To prevent renal failure, we managed the patient in the intensive care unit with generous volumes of intravenous fluids, forced diuresis, and urine alkalization. Subsequently, the patient had an uneventful recovery. The linkage between surgical positioning, prolonged surgery time, and rhabdomyolysis is discussed.

The 471delAAAG mutation and C353T polymorphism in the RNASEL gene in sporadic and inherited cancer in Israel.

The rate of RNASEL 471delAAAG mutation was previously reported to be less than 7% in Ashkenazi prostate cancer patients. It seems plausible that the same mutation may also be involved in breast/ovarian cancer predisposition in Jewish individuals. To evaluate the role of this mutation in cancer predisposition, a total of 1011 individuals including 294 Jewish men with prostate cancer, 61 Ashkenazi women with ovarian cancer and 50 unaffected women, matched for age and ethnicity, were genotyped for sequence anomalies in a single RNASEL gene amplicon using DGGE and sequencing. Additionally, 209 Ashkenazi BRCA1/2 mutation carriers, 205 high-risk non-carriers matched for cancer type and age at diagnosis, and 192 healthy Ashkenazi women were screened, using DHPLC and restriction methods. The 471delAAAG mutation was detected in a single male with prostate cancer (1/294, 0.3%), in two ovarian cancer patients (2/141, 1.4%) and in one of 242 healthy controls (0.41%). An abnormal DHPLC profile identical to the one produced by the 471delAAAG mutation was noted in 23 additional women. The rate of this polymorphism was significantly elevated in high-risk non-carrier women (16/205; 7.8%) than in BRCA1/2 carriers (2/209; 1.0%) and controls (5/192; 2.6%) (chi = 11.670; P < 0.001). Sequence analysis disclosed a silent polymorphism in Valine at codon 118: c.353 C- > T.The 471delAAAG mutation occurs rarely in Israeli prostate and breast/ovarian cancer patients. A silent polymorphism in the RNASEL gene occurs more prevalently in high-risk Ashkenazi breast/ovarian cancer patients without a BRCA1/2 mutation.

Gene expression in the bladder carcinoma rat model.

We investigated gene expression in N-butyl-N-(4-hydroxybutyl)nitrosamine (BBN)-induced rat bladder carcinoma in order to test its applicability as a model for the study of novel therapeutic modalities, particularly gene therapy. We administered BBN in the drinking water to Wistar rats for up to 30 wk and induced papillary transitional cell carcinoma (TCC), which is similar to the most prevalent type of human bladder cancer. Tumor evolution was similar to that found in previous studies. However, we described the morphological stages according to modern human bladder carcinoma terminology. Our main goal was to examine the expression levels of the H19 gene, of the insulin-like growth factor 2 (Igf2) transcripts expressed from promoters P2 and P3 and of the telomerase subunits that we had previously investigated as tools for targeted gene therapy of bladder cancer. We detected at 30 wk of BBN exposure significant upregulation of these sequences in the rat bladder tumors, similar to our previous findings in human bladder cancer. To reinforce the similarity of this model to the corresponding human disease, we searched for additional tumor-specific genes documented as having altered expression in human bladder carcinoma, using cDNA expression arrays (Clontech). We suggest that BBN-induced rat bladder cancer has morphological, biological, and molecular parallels to human bladder cancer and is an attractive model for studying novel alternatives of therapeutic intervention.

Aggressive resection of retroperitoneal sarcoma is superior to simple excision: an animal study using a novel model for retroperitoneal sarcoma.

BACKGROUND AND OBJECTIVES: Retroperitoneal sarcomas constitute a difficult management problem. The need for, and extent of, aggressive surgery continues to be debated. The aim of our study was to compare the impact of radical en bloc resection of retroperitoneal sarcoma with complete resection of the tumor alone in a rat model. METHODS: Under laparoscopic guidance, a fibrosarcoma cell line suspension was injected into the left paranephric space of a rat, resulting in the development of a macroscopic retroperitoneal tumor. Ten days after inoculation, 50 rats were randomized into three groups: (1) local resection, (2) radical resection, and (3) follow-up only. Groups 1 and 2 were further randomized for sacrifice 1 month after surgery or were followed up for 2 months. RESULTS: Local recurrence: 46% of group 1, while none in group 2 developed local recurrence during the same follow-up period (P = 0.02). Survival: 33% of group 1 were alive after 2 months, as compared with 54.5% of group 2. (P = 0.04). All rats in the control group died within <25 days. CONCLUSIONS: Our results suggest that aggressive en bloc resection of retroperitoneal sarcomas with adjacent viscera, even when macroscopically uninvolved with disease, has an advantage over complete local resection alone.