Rectal advancement flap plus adipose lipofilling (RAFAL) for the treatment of rectourethral fistulas after radical prostatectomy.

BACKGROUND: Rectourethral fistula (RUF) is a rare but significant complication after radical prostatectomy. Many different approaches have been used, but none of them has become the standard of care. METHODS: We present our series of seven patients treated with a transanal rectal advancement flap plus the injection of mesenchymal stem cells, to facilitate the healing of the fistula. Mesenchymal cells were obtained by a new mechanical device known as LIPOGEMS®. We called this technique RAFAL (rectal advancement flap plus adipose lipofilling). In all patients the RUF was a complication of laparoscopic radical prostatectomy. Fistula size ranged from 0.3 to 0.5 cm (median 0.4 cm). RESULTS: After a median follow-up of 53 months (range 6-163 months), 2 out of 7 patients experienced RUF recurrence. In both cases recurrence was successfully treated by the York-Mason technique in one case and by redo RAFAL in the other. Success rate of RAFAL was 71% (5 of 7). The total success rate of primary RAFAL and redo- RAFAL was 85.7% (6 of 7). No short- or long-term complications were seen. CONCLUSIONS: In our patient population this new procedure was safe and effective.

Laparoscopic total mesorectal excision for rectal cancer: experience of a single center with a series of 174 patients.

BACKGROUND: Laparoscopic total mesorectal excision for low rectal cancer is not considered a gold standard treatment due to the high conversion rate and the long operation time. METHODS: A retrospective review examined a surgical series of 174 laparoscopic low rectal resections involving total mesorectal excision (1995-2006), with particular reference to technical points as well as surgical and oncologic outcomes. Miles operations and partial mesorectal excisions were excluded. RESULTS: The cancer affected the low rectum in 110 cases and the medium rectum in 64 cases. A total of 68 patients were subjected to neoadjuvant radiochemotherapy. The anastomosis was mechanical for 83.3% of the cases and intersphinteric through the perineum for 16.6% of the cases. Protective ileostomy was performed in 112 cases. The conversion rate was 4.6%. The mesorectum remained intact in 91.6% of the cases and was partially interrupted in 15 of the cases. In no case was it totally discontinued. The postoperative morbidity rate was 16.7%, and the mortality rate was 0.57%. The incidence of anastomotic fistulas was 14.4%. The percentage was higher for males (18.6 vs 8.3%) and correlated with the low distance of the tumor from the anal verge (18.2 vs 7.8%) and the absence of a protection ileostomy (20.9 vs 10.7%). After an average follow-up period of 48.6 months (range, 24-149 months), six patients (3.44%) experienced a pelvic recurrence. The 5-year overall survival rate was 75.4%, and the disease-free survival rate was 61.9%. CONCLUSION: Laparoscopic total mesorectal excision for low rectal cancer is safe and effective, allowing surgical and oncologic outcomes similar to those reported for open surgery.

The TramEC "double cross" mesh: a new experience for repairing groin hernia. Our experience with 280 patients.

AIM: The purpose of this work is to provide a detailed account of a new technique for open prosthesis hernioplasty, a technique that makes use of a pre-shaped TramEC mesh made of polypropylene monofilament and created by the author. Specific descriptions are offered in regard to the shape of the mesh, the hernioplasty technique and the physiopathologic characteristics. METHODS: From 2000 to 2001, a total of 280 hernioplasties were performed with the TramEC technique. A follow-up of these patients was done after 1 week, after 3 months and after 1 year. An ecography of the groin was executed on all patients after 1 week in order to verify the presence of seromas. RESULTS: No recurrence was observed in 55.7% of patients examined after 1 year. Two patients (1.2%) experienced chronic but not debilitating pain. CONCLUSION: The author believes that with the TramEC mesh a precise overlap is formed between the mesh itself and the floor of the groin canal, thus creating the conditions required for avoiding empty spaces in order to favour the fibroplasias and amalgamation of tissues: basic parameters in avoiding recurrences. In addition, the mesh not only repairs the hernial defect but also strengthens the internal inguinal ring by virtue of its "double cross" structure. Because of the device's anatomical shape and the simplicity of the technique, we optimise the operation in terms of time and reproducibility.