Optimizing decision-making process of benign uretero-enteric anastomotic stricture treatment after radical cystectomy.

PURPOSE: To identify preoperative predictors of endo-urological treatment (EUT) failure while promoting a new diagnostic and therapeutic pathway for benign uretero-enteric anastomosis stricture (UES) management after radical cystectomy (RC). MATERIALS AND METHODS: We relied on a prospectively maintained database including 96 individuals (122 renal units) who developed a benign UES at our institution between 1990 and 2018. UES was classified into two different types according to morphology: FP1 (i.e., sharp or duckbill) and FP2 (i.e., flat or concave). EUT feasibility, success rate, as well as intra and postoperative complications were recorded. Uni- and multivariable logistic regression analysis (MVA) assessed for predictors of EUT failure. RESULTS: Overall, 78 (63.9%) and 32 (26.3%) cases were defined as FP1 and FP2, respectively. EUT was not feasible in 33 (27.1%) cases. After a median follow-up of 50 (IQR 5-240) months, successful treatment was reached only in 15/122 (12.3%) cases. EUT success rates raised when considering short (< 1 cm) (16.8%), FP1 morphology (16.7%) strictures, or the combination of these characteristics (22.4%). Overall, 5 (5.2%) cases had CD ≥ III complications. FP2 (OR: 1.91, 95%CI 1.21-5.31, p = 0.03) and stricture length ≥ 1 cm (OR: 9.08, 95%CI 2.09-65.71, p = 0.009) were associated with treatment failure at MVA. CONCLUSIONS: Endoscopic treatment for benign UES after RC is feasible but harbors a low success rate. Stricture length and radiological morphology of the stricture are related to endoscopic treatment failure. Surgeons should be aware of the stricture features during the preoperative decision-making process to choose the optimal candidate for endoscopic treatment.

Outcomes following surgical management of adrenocortical carcinoma: A single-center experience. / Resultados del manejo quirúrgico del carcinoma adrenocortical: experiencia de un centro hospitalario.

OBJECTIVE: Adrenocortical carcinoma (ACC) is a rare and heterogeneous disease, with challenging management and poor prognosis. Surgery withcurative intent is the preferred treatment option for localized disease, with a reported 5-year survival rate of 55% for complete resections. However, owing to the high risk of recurrence there is a need for adjuvant therapies, such as mitotane, an adrenolytic drug, or irradiation, while in advanced disease the standard of careis a combined chemotherapy scheme. The aim of this study was to report our experience in the surgical management and outcomes of ACC patients. MATERIALS AND METHODS: A retrospective observational study was performed in a cohort of ACC patients who had undergone surgical resection (open or laparoscopic approach) and were followed up at our tertiary hospital. Patients with localized or locally advanced disease were included in the analysis. All medical records, including clinical, surgical, pathologic, and follow-updata, were collected and analyzed. RESULTS: A total of 19 ACC patients were managed at our center between August 1990 and August 2013. The median age at diagnosis was 50.5 years (range 19-72), and most patients were males. Abdominal pain was the most common clinical presentation (n=9,47.4%). Abdominal contrast-enhanced computed tomography (CT) was performed in all cases. Only 3 tumors (15.8%) were functional and most were stage II at diagnosis (n=9, 47.4%). No patient presented metastasis. Of the 19 patients, 18 (94.7%) under went surgerywith curative intent, while one (5.3%) received adjuvant radiotherapy (ART). The open approach was used in 17 patients (89.5%), while the remaining 2 (10.5%) underwent laparoscopy. Postoperative complications occurred in 8 patients (42.1%); none were of grade IV or V. Median follow-up was 66 months (range 3-312). The majority of patients (n=15, 78.9%) were disease free with surgery alone. None received adjuvant mitotane therapy (AMT). Four patients (21%) experienced metachronous metastases and 3 (15.8%) local recurrence after a median time of 10.5 months (range 2-60) and 9.3 months (range 1.5-30), respectively. The 5-year overall survival rate was 47.4%. CONCLUSIONS: Our findings confirm both the unpredictable nature of ACC and the accepted primary role of surgery. The use of adjuvant therapy was less frequent in this series than is supported currently. However, a multidiscipinary approach should be the initial step in the management of this rare malignancy.

OBJETIVO: El carcinoma adrenocortical es una enfermedad heterogénea y rara que conlleva un manejo complicado y cuyo pronóstico es malo. Ante una enefermedad localizada el manejo quirúrgico es de elección, observando una tasa de supervivencia a los 5 años del 55% en resecciones completas. Sin embargo, debido a la alta tasa de recurrencias, se requiere complementar el manejo con una terapia adyuvante como es el caso del mitotane, un agente adrenolítico, o la radioterapia. En casos de enfermedad avanzada la terapia de elección incluye una pauta de quimioterapia combinada. El objetivo del presente estudio es reportar nuestra experiencia en el manejo quirúrgico y resultados obtenidos de los pacientes con diagnóstico de carcinoma adrenocortical. MATERIALES Y MÉTODOS: Se realizó un estudio observacional de una cohorte de pacientes diagnosticados de carconinoma adrenocortical que requirieron un manejo quirúrgico (abierto o laparoscópico) y que realizaron su seguimiento en nuestro hospital terciario. Se incluyó a pacientes con enfermedad localizada y localmente avanzada en el análisis. Todos los dados clínicos, quirúrgicos, patológicos y de seguimiento fueron recolectados para el análisis. RESULTADOS: Entre agosto del 1990 y agosto del 2013 un total de 19 pacientes diagnosticados de carcinoma adrenocortical fueron tratados en nuestro centro. La mediana de edad al diagnóstico fue 50,5 años (rango 19-72), siendo la mayoría hombres. El síntoma inicial mas frecuente fue el dolor abdominal (n=9, 47,4%). Una tomografía computarizada con contraste fue realizada en todos los casos. Sólo 3 tumores (15,8%) eran funcionales y la mayoría correspondía a un estadio II al diagnóstico (n=9, 47,4%). Ningún paciente presentaba metástasis. De los 19 pacientes,18 (94,7%) requirieron cirugía con intención curativa, mientras que a uno (5,3%) se le realizó radioterapia adyuvante. El abordaje abierto se usó en 17 pacientes (89,5%), mientras que a 2 pacientes (10,5%) se les realizó una técnica laparoscópica. Complicaciones postquirúrgicas ocurrieron en 8 pacientes (42,1%), de las cuales ninguna fue de grado IV o V. La mediana de seguimiento fue de 66 meses (rango 3-312). La mayoría de los pacientes (n=15, 78,9%) permanecieron libres de enfermedad únicamente con un manejo quirúrgico. Ninguno recibió terapia adyuvante con mitotane. Cuatro pacientes (21%) presentaron metástasis metacrónicas y 3 (15,8%) recurrencia local tras una mediana de tiempo de 10,5 meses (rango 2-60) y 9,3 meses (rango1,5-30), respectivamente. La tasa de supervivencia globala los 5 años fue del 47,4%. CONCLUSIONES: Nuestros resultados confirman tanto la naturaleza impredecible del carcinoma adrenocortical como la aceptación del rol primario de la cirugía en su manejo. El uso de un agente adyuvante fue menos frecuente en esta serie respecto a lo respaldado actualmente. Sin embargo, un manejo multidisciplinar debería ser el primer paso a seguir en el tratamiento de esta rara enfermedad.

Outcomes following surgical management of adrenocortical carcinoma: a single-center experience / Resultados después del manejo quirúrgico del carcinoma adrenocortical: una experiencia de un solo centro

Objetive: Adrenocortical carcinoma(ACC) is a rare and heterogeneous disease, with challenging management and poor prognosis. Surgery withcurative intent is the preferred treatment option for localized disease, with a reported 5-year survival rate of55% for complete resections. However, owing to thehigh risk of recurrence there is a need for adjuvant therapies, such as mitotane, an adrenolytic drug, or irradiation, while in advanced disease the standard of careis a combined chemotherapy scheme. The aim of thisstudy was to report our experience in the surgical management and outcomes of ACC patients. Material and methods: A retrospective observational study was performed in a cohort of ACC patientswho had undergone surgical resection (open or laparoscopic approach) and were followed up at our tertiary hospital. Patients with localized or locally advanced disease were included in the analysis. All medical records,including clinical, surgical, pathologic, and follow-updata, were collected and analyzed. Results: A total of 19 ACC patients were managedat our center between August 1990 and August 2013.The median age at diagnosis was 50.5 years (range19–72), and most patients were males. Abdominalpain was the most common clinical presentation (n=9,47.4%). Abdominal contrast-enhanced computed tomography (CT) was performed in all cases. Only 3 tu-mors (15.8%) were functional and most were stage II atdiagnosis (n=9, 47.4%). No patient presented metastasis. Of the 19 patients, 18 (94.7%) underwent surgerywith curative intent, while one (5.3%) received adjuvantradiotherapy (ART). The open approach was used in17 patients (89.5%), while the remaining 2 (10.5%)underwent laparoscopy. Postoperative complicationsoccurred in 8 patients (42.1%); none were of grade IVor V. Median follow-up was 66 months (range 3–312).The majority of patients (n=15, 78.9%) were diseasefree with surgery alone. None received adjuvant mitotane therapy...(AU)

Objetivo: El carcinoma adrenocorticales una enfermedad heterogénea y rara que conllevaun manejo complicado y cuyo pronóstico es malo. Anteuna enefermedad localizada el manejo quirúrgico es deelección, observando una tasa de supervivencia a los 5años del 55% en resecciones completas. Sin embargo,debido a la alta tasa de recurrencias, se requiere complementar el manejo con una terapia adyuvante comoes el caso del mitotane, un agente adrenolítico, o laradioterapia. En casos de enfermedad avanzada la terapia de elección incluye una pauta de quimioterapiacombinada. El objetivo del presente estudio es reportarnuestra experiencia en el manejo quirúrgico y resultadosobtenidos de los pacientes con diagnóstico de carcinoma adrenocortical. Materiales y métodos: Se realizó un estudio observacional de una cohorte de pacientes diagnosticados de carconinoma adrenocortical que requirieronun manejo quirúrgico (abierto o laparoscópico) y querealizaron su seguimiento en nuestro hospital terciario.Se incluyó a pacientes con enfermedad localizada ylocalmente avanzada en el análisis. Todos los dados clínicos, quirúrgicos, patológicos y de seguimiento fueronrecolectados para el análisis. Resultados: Entre agosto del 1990 y agosto del2013 un total de 19 pacientes diagnosticados decarcinoma adrenocortical fueron tratados en nuestrocentro. La mediana de edad al diagnóstico fue 50,5años (rango 19-72), siendo la mayoría hombres. Elsíntoma inicial mas frecuente fue el dolor abdominal(n=9, 47,4%). Una tomografía computarizada con contraste fue realizada en todos los casos. Sólo 3 tumores(15,8%) eran funcionales y la mayoría correspondíaa un estadio II al diagnóstico (n=9, 47,4%). Ningúnpaciente presentaba metástasis. De los 19 pacientes,18 (94,7%) requirieron cirugía con intención curativa,mientras que a uno (5,3%) se le realizó radioterapiaadyuvante...(AU)

Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma: Oncologic Outcomes and Prognostic Factors in a Contemporary Cohort.

Introduction: Appropriate risk stratification and complete tumor ablation are the key factors to optimize the oncologic outcomes of patients undertaking endoscopic management for upper urinary tract urothelial carcinoma (UTUC). We aimed to identify risk factors associated to tumor recurrence and progression in a contemporary cohort of patients diagnosed and treated with the latest endourologic technologies. Patients and Methods: Forty-seven patients were selected between January-2015 and March-2019 for an endoscopic management of UTUC. Last generation of digital ureteroscopes with image-enhancing technologies were used for the detection of the lesions. The retrograde approach was the most frequent access (n = 45/47). The confocal laser endomicroscopy and multiple biopsy devices were variably used according to site and tumor presentation for their characterization. Holmium and Thulium lasers were variably used, with their combination being the preferred approach in case of larger lesions. Primary endpoints included the identification of factors associated with UTUC recurrence and progression, and bladder tumor recurrence. Results: Median follow-up (FU) was 24 months (interquartile range 17-44). On multivariate analysis, bladder cancer (BC) recurrence was associated to previous contralateral UTUC (hazard ratios: 5.08 confidence interval [95% CI: 1.35-18.94], p < 0.05) and tumor size (hazard ratios: 1.07 [95% CI: 1.00-1.14], p < 0.05). UTUC recurrence was associated to incomplete clearance after primary treatment (hazard ratios: 4.99 [95% CI: 1.15-21.62], p < 0.05), while UTUC progression was significantly related to the number of UTUC recurrences (hazard ratios: 3.10 [95% CI: 1.27-7.53], p < 0.05). No significant survival differences in BC/UTUC recurrence, as well as in UTUC progression, were detected between risk groups. No Clavien-Dindo grade >2 were detected; one patient developed ureteric stricture at 7-month FU. Limitations involve retrospective nature of the study and relatively small number of patients. Conclusions: The appropriate use of latest technology may enhance the oncologic outcomes of the endoscopic management of UTUC without compromising the safety of the approach. Among the prognostic factors identified in our series, UTUC recurrence seems to be associated to disease progression.

Endoscopic Combined Intrarenal Surgery for Stone Formation After Previous Laparoscopic and Open Renal Surgery.

Background: Nonabsorbable sutures used during renal surgery represent a known substratum for stone growth. We hereby describe two cases of nephrolithiasis secondary to permanent suture material, originally placed during conservative renal surgical procedures and afterward migrated into the caliceal system, managed with endoscopic combined intrarenal surgery (ECIRS) with subsequent complete renal clearance. Case Presentation: Case 1. A 54-year-old male, with history of laparoscopic excision of a left parapelvic cyst, presenting with left inferior caliceal stone. Case 2. A 79-year-old female, who underwent open enucleation of a left renal pelvis tumor 15 years before. She presented with bilateral lithiasis, including a staghorn stone in the left renal pelvis. Both patients underwent left ECIRS by two surgeons, revealing the presence of suture devices, which were completely removed. Abdominal CT at 1 month after surgery did not show residual lithiasic fragments in both cases. Conclusion: To prevent the risk of stone formation, it is mandatory to use nonabsorbable suture agents sparingly during conservative renal surgery and furthermore to remove all foreign material from the collecting system because they have the potential for calculi growth. In this sense, ECIRS technique may also avoid further open or minimally invasive surgery and the use of suture instruments.

Primary Angiosarcoma of the Kidney: Case Report and Comprehensive Literature Review.

PURPOSE: Angiosarcoma (AS) is an aggressive malignant tumour of endothelial origin, most frequently compelling the skin. The kidney is a rare site of primary occurrence of AS with a quite challenging diagnosis and poor prognosis, mainly due to its raw metastasising power. We described our first case of AS treatment. A comprehensive literature review in this field is also carried out. PATIENTS AND METHODS: We report the case of a 56-years-old man with radiological appearance of an 11 cm poor vascularised left renal mass. The pre-operative imaging ruled out distant metastases and inferior vena cava thrombosis. Thus, after radioembolization, we performed a transperitoneal open radical nephrectomy with regional lymphadenectomy with the removal of the middle portion of the ileo-psoas muscle, followed by two lines of adjuvant chemotherapy. We analysed all the papers concerning primary kidney AS until December 2018. RESULTS: Estimated intraoperative blood loss was 200 mL with an operative time of 100 minutes. No postoperative complications were recorded, with the patient discharge in the 8th postoperative day. The pathological assessment showed a pT3a N0, M0 tumour compatible with AS of the kidney. An immune-histochemical study showed a vascular positive for CD31, CD34, Fli-1 with a Ki-67/Mib 1 of 50%. One month after surgery the patient began adjuvant chemotherapy with gemcitabine. After 45 days from surgery, a Computed Tomography scan showed lung and liver metastases with disease relapse in the left kidney lodge. The response to the first-line treatment was excellent, unlike the second-line, encountering a chemo-refractory disease. The cancer-specific survival was of 15 months. We included 66 cases in our review. CONCLUSION: This is the first case of treatment of kidney AS performed at our Institute. Our findings added new information about the unclear biology and progression of this subset of tumours, demonstrating an abysmal prognosis.

Uroflow stop test with electromyography: a novel index of urinary continence recovery after RARP.

PURPOSE: Urinary incontinence (UI) is one of the most bothersome surgical side effects after robot-assisted radical prostatectomy (RARP). Alteration of both smooth and striate urethral sphincter occurs after RARP. Since the contraction of perineal muscles is involved in the complex mechanism of urinary continence, the uroflow stop test (UST) seems to predict early continence recovery after RARP. The UST was added of perineal surface electromyography (EMG) evaluation to evaluate the latency time (LT) between muscular contraction and the complete stop of urine flow. Our aim was to present UST-EMG as a new tool in the investigation of UI, implying pelvic floor integrity, and to evaluate whether an early return (≤ 3 months) to preoperative LT could be associated with early recovery of UC (≤ 3 months). METHODS: After prospectively enrolling 137 patients who underwent RARP with a minimum follow-up of 6 months, we identified two groups: Group 1 (93 patients) with early (≤ 3 months) pre-surgical LT recovery and Group 2 (44 patients) with late > 3 months or not able to reach pre-surgical LT recovery. RESULTS: Between the two groups, there were significant differences in terms of different surgical technique (nerve-sparing versus non-nerve-sparing) and pads use at 3 and 6 months after RARP (p < 0.05). No differences were recorded neither in postoperative maximum flow-rate, nor in postoperative symptoms score. CONCLUSIONS: UST with EMG can be considered as a noninvasive, reproducible and easily performable tool. LT is applicable in the clinical evaluation to predict urinary continence recovery after RARP.

Fournier's Gangrene and Intravenous Drug Abuse: an Unusual Case Report and Review of The Literature.

Fournier's gangrene is a potentially fatal emergency condition characterized by necrotizing fasciitis and supported by an infection of the external genital, perineal and perianal region, with a rapid and progressive spread from subcutaneous fat tissue to fascial planes. In this case report, a 52-year-old man, with a history of hepatitis C-virus (HCV)-related chronic liver disease and cocaine use disorder for which he was receiving methadone maintenance therapy, was admitted to the Emergency Department with necrotic tissue involving the external genitalia. Fournier's gangrene is usually due to compromised host immunity, without a precise cause of bacterial infection; here it is linked to a loco-regional intravenous injection of cocaine. A multimodal approach, including a wide surgical debridement and a postponed skin graft, was needed. Here we report this case, with a narrative review of the literature.