Proper 6-branch suburethral autologous sling tensioning during robotic assisted radical prostatectomy with the intraopeartive use of retrograde perfusion sphincterometry: the technique.

The aim of this paper is to describe our surgical technique and results of proper 6-branch autologous sling tensioning during RALP employing intraoperatively the Retrograde Perfusion Sphincterometry (RPS). Between May 2016 and February 2020, 374 patients underwent RALP with the 6-branch suburethral autologous sling tensioned under intraoperative guidance of RPS. Surgical procedure: Retrograde Leak Point pressure (RLPP) was evaluated by means of RPS after pneumoperitoneum induction (RLPPp), after urethrovescical anastomosis (RLPPa) and during proper sling tensioning (RLPPs). The goal of the sling tensioning was to obtain at the end of the procedure similar pressures as after pneumoperitoneum induction (RLPPs ≅ RLPPp). Intraoperative variables, postoperative complications, and continence recovery outcomes were assessed. A descriptive statistical analysis was performed. Sling positioning and tensioning was feasible in all patients. Mean operative time was 215 min. Proper sling tensioning allowed for the possibility to restore sphincteric efficacy to preoperative value (RLPPs vs. RLPPp (42.5 vs. 42.6) cmH2O). Urinary continence was achieved, respectively, in 58%, 67%, 74%, 88% and 92% of patients after 24 h, 10 days, 1 month, 6 months and 1 year after catheter removal. In conclusion, RPS revealed a valid option for proper autologous 6-branch sling tensioning during RALP, offering the possibility to restore sphincteric apparatus efficiency to its preoperative status to improve EUC.

A rare case of multi-focal human TB after BCG instillation for non-muscle-invasive bladder cancer.

OBJECTIVE: To describe a left epididymitis and para-aortical involvement caused by Mycobacterium tuberculosis hominis reactivation after bacillus Calmette-Guérin instillation for non-muscle-invasive bladder cancer. PATIENT AND METHODS: A Caucasian male, aged 76 years, exposed to bacillus Calmette-Guérin for a high-grade non-muscle-invasive bladder cancer in 2015, reported painful and progressive left scrotal swelling with purulent discharge from a cutaneous fistulous track that yielded, on liquid culture, a pan-susceptible Mycobacterium tuberculosis hominis strain. Moreover, after 6 months of anti-tuberculosis treatment, an abdominal peri-aortic mass, sized 4 cm, was found and a surgical biopsy showed necrotizing granulomas; however, although smear microscopy and Xpert MTB/Rif™ performed on fresh biopsy sample were positive, liquid cultures resulted negative, indicating treatment efficacy. RESULTS: Numerous peculiar and multi-organ involvement due to BCGitis after intravesical immunotherapy have been previously described, including 17 scientific articles about epididymitis, however, no reports so far showed reactivation of Mycobacterium tuberculosis hominis after bacillus Calmette-Guérin treatment. CONCLUSION: Although BCGitis is more prevalent in patients undergoing bacillus Calmette-Guérin instillation for non-muscle-invasive bladder cancer, tuberculosis by other species of Mycobacterium tuberculosis should be always ruled out by molecular and conventional microbiology in patients with a history of Mycobacterium tuberculosis hominis exposure.

Ischemia of the glans 24 hours after circumcision: A case report and therapeutic solution.

INTRODUCTION:: Circumcision is a common surgical procedure, typically performed under local anesthesia and somehow also as outpatient clinic. Although complications are rare and most frequently related to the procedure itself, ischemia of the glans may occur as a major complication and can be related to local ischemia following dorsal penile nerve block. CASE DESCRIPTION:: We describe the case of a 33-year-old patient who underwent circumcision at our institution and, 24 h after the procedure, developed an acute ischemia of the glans; a re-intervention was performed in emergency setting to ensure a large, not-tightened circular suture under the glans, and low-molecular-weight heparin and antiplatelet therapy was introduced to achieve anti-coagulative/antiaggregant effects. After 48 h, the skin returned to its normal color and in 7 days the penile glans achieved complete remission of the ischemic aspect. A 6-month follow-up confirmed regular outcomes with normal erectile functions. CONCLUSION:: The treatment we proposed to treat acute post-circumcision ischemia of the glans is a simple and effective one, with a perfect aesthetic and functional outcome observed within 4 weeks and confirmed at 6-month follow-up.

Intraoperative Retrograde Perfusion Sphincterometry to Evaluate Efficacy of Autologous Vas Deferens 6-Branch Suburethral Sling to Properly Restore Sphincteric Apparatus During Robot-Assisted Radical Prostatectomy.

OBJECTIVE: The aim of this study is to describe (urodynamically) the effect of the use of a 6-branch autologous suburethral sling, made with absorbable sutures and vas deferens, to support the bladder neck and urethra during robot-assisted laparoscopic prostatectomy (RALP) to improve early urinary continence (EUC) recovery. MATERIALS AND METHODS: Retrograde leak point pressure (RLPP) was intraoperatively evaluated, by means of retrograde perfusion sphincterometry (RPS), in 77 patients (mean age ± standard deviation [SD]: 65.64 ± 7.23 years, mean body mass index ± SD: 26.69 ± 3.89) scheduled to undergo RALP at our institution. RLPP was evaluated before (RLPPb) and after pneumoperitoneum induction (RLPPp). RLPP was then evaluated after urethrovesical anastomosis (RLPPa) and after proper sling tensioning (RLPPs), with the aim to obtain the same pressure as after pneumoperitoneum induction. EUC recovery, defined as the use of no pad, was assessed 10 days, 30 days, and 6 months after catheter removal. RESULTS: RPS and proper autologous 6-branch sling positioning were feasible in all patients, without perioperative complications and negligible impact on overall operative time. Pneumoperitoneum induction increased, similarly, RLPP in all patients. An important decrease of sphincteric capability was evident after prostate removal and the following urethrovesical anastomosis, while proper sling tensioning allowed for restoration of sphincteric apparatus capability to its presurgical status (mean RLPPs 40.84 cmH2O vs RLPPp 40.39 cmH2O, p = 0.942). EUC recovery within 10 days after catheter removal was achieved in 59 (77%) patients and progressively improved over time. CONCLUSIONS: RPS, intraoperatively performed during RALP, allows for precise evaluation of the impact of the surgical procedure on sphincteric apparatus competence. Moreover, the use of the 6-branch suburethral sling, in association with RPS, allows for restoration of the proper supporting system to the urethral sphincter, similar to the preoperative condition, offering the basis for EUC recovery after radical prostate surgery.

Simple vs six-branches autologous suburethral sling during robot-assisted radical prostatectomy to improve early urinary continence recovery: prospective randomized study.

We have recently described the use of a retropubic suburethral autologous sling created and placed during robotic radical prostatectomy (RARP). In this study, we assess the effectiveness of newly designed six-branches compared to two-branches suburethral autologous sling in improving early urinary continence (UC) recovery. 120 patients submitted to RARP were prospectively randomized according to the intraoperative positioning of six-branches (group 1, n = 60) or two-branches autologous sling (group 2, n = 60) obtained by different configuration of a same tract of vas deferens removed. Early UC recovery was assessed at 5 (catheter removal), 10 and 30 days postoperatively through the daily number of pads used and the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) score. UC was defined as the non-use of pad. Chi square test and Wilcoxon test were used to investigate UC recovery between the two groups. Moreover, post-voiding residual was evaluated in each patient at the same time. At catheter removal, UC rate was in groups 1 and 2, 60 and 35% (p = 0.02); at 10 days 70 and 46% (p = 0.03); at 30 days 87 and 70% (p = 0.04), respectively. One patient in group 1 experienced acute urinary retention at the time of catheter removal and was treated uneventfully with a further 7-day catheterization. These preliminary data indicate that newly designed six-branches suburethral autologous sling is able to increase the rate of early UC recovery compared to the two-arms sling previously described by us.

Evaluation of surgery risk factor associated to antithrombotic therapy in patients who underwent colorectal surgery.

BACKGROUND: Use of antiplatelet therapy in western people is common. The risk of bleeding related to surgical procedure or invasive procedure is higher.We want to analyse the correlation between colorectal surgery, antiplatelet therapy and postoperative surgical complications. METHODS: We categorized: 176 cases treated for colorectal cancer and we recorded the following data: type of surgery, body max index (BMI), haemoglobin value (Hb); preoperative prothrombin time (PT) and blood transfusions pre and postoperative and during surgery. The analysis focused on two groups: patients who received antiplatelet therapy (AT - antiplatelet therapy) and patients who didn't receive this therapy (NAT - not antiplatelet therapy). RESULTS: In the group of patients who underwent right emicolectomy, haemoglobin values were lower in patients who received antithrombotic therapy than in patients who didn't receive this therapy with a statistical significance (p < 0,05); the same datum resulted in patients who underwent left emicolectomy. Normal weight patients that received antiplatelet therapy had lower values of haemoglobin without statistical significance (p value not significant). Overweight patients who underwent therapy with antiplatelet agents had lesser Hb value than group that didn't performed this therapy (p < 0,05). Patients who received AT showed a bigger percentage of blood transfusions regardless of type of surgery than the second group with statistical significance Normal weight patients showed a different incidence of blood transfusions between patients who underwent antiplatelet therapy (50%) and patients who didn't receive this therapy (29%) with statistic significance (p < 0,05). Overweight patients didn't present this significant difference. We analyzed the incidence of post-operative complications in normal weight patients and overweight patients and we showed that the incidence of complications, both minor and major, was higher in patients who underwent antiplatelet therapy than in the second group regardless of weight CONCLUSIONS: Antiplatelet therapy in patients who underwent invasive surgery changes the incidence of some risk factors, such as bleeding, and of post-operative complications. This result underlines the importance of careful handling and preparation in patients receiving antithrombotic agents that have to undergo invasive surgery. KEY WORDS: Antithrombotic therapy, Bleeding, Colorectal Surgery, Risk factor.

Side docking of the da Vinci robotic system for radical prostatectomy: advantages over traditional docking.

The standard low lithotomic position, used during robot-assisted radical prostatectomy (RARP), with prolonged positioning in stirrups together with steep Trendelenburg may expose the patient to neurapraxia phenomena of the lower limbs and can rarely be used in patients with problems of hip abduction. To overcome these hurdles, we evaluated the clinical benefits of "side docking" (SD) of the da Vinci(®) robotic system in comparison to "traditional docking" (TD). A cohort of 120 patients submitted to RARP were prospectively randomized into two groups by docking approach: SD with the patient supine with lower limbs slightly abducted on the operating table, and TD docking time, intraoperative number of collisions between the robotic arms and postoperative neurological problems in the lower limbs were noted. Descriptive statistics was used to analyze outcomes. Docking time was shorter for the SD group [SD: median 13 min (range 10-18); TD: median 21 min (range 15-34)]. None in the SD group and six of 60 patients (10%) in the TD group suffered from temporary (<30 days) unilateral neurological deficits of the lower limbs. In both groups no collisions between the robotic arms occurred. The SD approach is technically feasible. It does not cause collisions between the robotic arms, and is a reliable method for reducing the setup time of RARP. The supine position of the patient may prevent neurological complications of the lower limbs. Based on these results, SD has become the standard docking technique used by our department.

Incidental retroperitoneal paraganglioma in patient candidate to radical prostatectomy: Concurrent surgical treatments by robotic approach.

We report a case of a 75-year-old male with biopsy-proven prostate cancer and candidate for radical prostatectomy. The patient's medical history includes hypertension and atrial fibrillation in prophylactic treatment; however, he was suffering from recurrent paroxysmal episodes of supraventricular tachycardia. Abdominal magnetic resonance performed for prostate cancer staging detected a non-lymphatic inter-cavo-aortic mass of 42 × 37 × 43 cm. Results of biochemical screening confirmed the clinical diagnosis of symptomatic paraganglioma. The patient was subjected in a single robotic session for concurrent excision of the inter-aortocaval mass and radical prostatectomy with bilateral pelvic lymph-node dissection. During the procedure, there were no anesthesiological or surgical complications. The postoperative course was uneventful and the patient was discharged on postoperative day 5. Six months after surgery, his prostate-specific antigen level was undetectable and the abdominal magnetic resonance imaging was negative for local recurrence or metastasis of paraganglioma. No more episodes of tachycardia were reported or antihypertensive therapy was necessary.

Retropubic Intracorporeal Placement of a Suburethral Autologous Sling During Robot-Assisted Radical Prostatectomy to Improve Early Urinary Continence Recovery: Preliminary Data.

BACKGROUND AND PURPOSE: Urinary continence (UC) recovery remains bothersome for patients even after robot-assisted radical prostatectomy (RARP). We describe the first retropubic suburethral autologous sling created and placed during RARP. The surgical technique and preliminary data regarding its effectiveness in improving early UC recovery are presented. PATIENTS AND METHODS: Between November 2013 and February 2014, 60 patients who underwent RARP at a single high-volume center were prospectively randomized into sling and nonsling groups. Early UC was assessed at 5 days (time of catheter removal), 10 days, and 30 days postoperatively by the daily number of pads used and the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) score. Sling-related operative time and urethral erosion were also analyzed. Chi-square and independent sample t tests were used to investigate surgical and functional outcomes between groups. RESULTS: Complete data were available for all patients. Mean ± standard deviation (SD) numbers of pads used daily in nonsling and sling groups, respectively, were 1.9 ± 1.2 versus 1.7 ± 1.4 (P = 0.5) at 5 days, 1.8 ± 1.3 versus 1.3 ± 1.3 (P = 0.1) at 10 days, and 1.1 ± 1.2 versus 0.4 ± 0.8 (P = 0.01) at 30 days. At 1 month, mean ± SD ICIQ-UI-SF scores in nonsling and sling groups, respectively, were 4.8 ± 4.6 versus 1.8 ± 3.4 (P = 0.01); sling patients were associated with pad-free status (76% vs 46%, P = 0.03). The advantage in UC recovery was also observed in sling patients at 3, 6, and 12 months postoperatively. Surgical time did not differ between groups, and in sling patients, no cases of urethral erosion or uroflowmetry suggestive of urinary obstruction were found. Limitations included the small sample size and the lack of assessment of morphologic and urodynamic changes produced by the sling. CONCLUSIONS: The suburethral autologous sling is technically feasible and may improve early UC recovery after RARP. These preliminary results should be confirmed in a larger sample of patients.

Beyond the learning curve of the Retzius-sparing approach for robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of the first 200 patients with ≥ 1 year of follow-up.

BACKGROUND: Robot-assisted laparoscopic radical prostatectomy (RARP) has become the main surgical option for localized prostate cancer. We recently developed a new approach for RARP, passing through the pouch of Douglas and avoiding all the Retzius structures involved in continence and potency preservation. OBJECTIVE: To report the functional and oncologic results of our first 200 patients operated on using this new approach. DESIGN, SETTING, AND PARTICIPANTS: This was a prospective, noncontrolled case series including the first 200 consecutive patients undergoing this kind of surgery (January the 1st, 2010 to December the 31st, 2011). SURGICAL PROCEDURE: Retzius-sparing RARP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: All perioperative, oncologic, and functional data were prospectively recorded. Potency was defined as an International Index of Erectile Function-5 questionnaire score >17; continence was defined as use of no pad or of one safety liner. Oncologic results were reported as positive surgical margins (PSM) and 1-yr biochemical disease-free survival (1y-bDFS). Recurrence was defined as a repeated prostate-specific antigen >0.2 ng/ml. Complications were graded according to the Clavien-Dindo system. The first 100 patients (group 1) were compared with the second 100 (group 2) to evaluate the learning curve effects. RESULTS AND LIMITATIONS: The median patient age was 65 yr. Comparing the two groups, transfusions were needed in 8% versus 4% of cases in groups 1 and 2, respectively (p=0.02). There was one Clavien-Dindo grade 3b in group 1 versus one grade 3a complication in group 2. In patients with pT2 disease, PSMs were recorded in 22.4% of those in group 1 versus 10.1% in group 2 (p=0.045). 1y-bDFS was 89% in group 1 versus 92% in group 2. For groups 1 and 2, respectively, immediate continence was reached in 92% versus 90% of patients, and the 1-yr continence rate was 96% versus 96%. Considering the 77 potent patients aged <65 yr who underwent bilateral intrafascial nerve-sparing surgery, 40.4% of those in group 1 versus 40% of those in group 2 reached their first intercourse within 1 mo; at 1 yr of follow-up, these figures had increased to 81% versus 71%, respectively (p=0.162). The main limitation of this study is its noncontrolled nature. CONCLUSIONS: We demonstrated Retzius-sparing RARP to be oncologically safe and to result in high early continence and potency rates. Long-term, prospective, comparative, and possibly randomized studies are needed.

Impact of venous tumour thrombus consistency (solid vs friable) on cancer-specific survival in patients with renal cell carcinoma.

BACKGROUND: To our knowledge, the impact of venous tumour thrombus (VTT) consistency in patients affected by renal cell carcinoma (RCC) has never been addressed. OBJECTIVE: To analyse the effect of VTT consistency on cancer-specific survival (CSS). DESIGN, SETTING, AND PARTICIPANTS: We retrospectively analysed 174 consecutive patients with RCC and renal vein or inferior vena cava (IVC) VTT who underwent surgical treatment between 1989 and 2007 at our institute. INTERVENTION: All patients underwent radical nephrectomy and thrombectomy. MEASUREMENTS: Pathologic specimens were reviewed by a single uropathologist. In addition to traditional pathologic features, the morphologic aspect of the tumour thrombus was evaluated to distinguish solid from friable patterns. The prognostic role of thrombus consistency (solid vs friable) on CSS was assessed by means of Cox regression models. RESULTS AND LIMITATIONS: The VTT was solid in 107 patients (61.5%) and friable in 67 patients (38.5%). The presence of a friable VTT increased the risk of having synchronous nodal or distant metastases, higher tumour grade, higher pathologic stage, and simultaneous perinephric fat invasion (all p < 0.05). The median follow-up was 24 mo. The median CSS was 33 mo; the median CSS was 8 mo in patients with a friable VTT and 55 mo in patients with a solid VTT (p < 0.001). On multivariable analyses, the presence of a friable VTT was an independent predictor of CSS (p = 0.02). The power of our conclusion may be somewhat limited by the relatively small study population and the retrospective nature of the study. CONCLUSIONS: In patients with RCC and VTT, the presence of a friable thrombus is an independent predictor of CSS. If our finding is confirmed by further studies, the consistency of the tumour thrombus should be introduced into routine pathologic reports to provide better patient risk stratification.

The extent of tumour fat invasion affects survival in patients with renal cell carcinoma and venous tumour thrombosis.

OBJECTIVE: • To investigate the effect of presence and extent of tumour fat invasion (TFI) - perinephric invasion (PFI), renal sinus fat invasion (RSFI) or both PFI and RSFI - on cancer-specific mortality (CSM) in patients with renal cell carcinoma (RCC) and venous tumour thrombus (VTT). METHODS: • We examined 184 consecutive patients with RCC with VTT treated with nephrectomy between 1987 and 2007. Associations with CSM were evaluated by univariable and multivariable Cox proportional hazard models. RESULTS: • Median follow up was 21 months. The 5-year CSM-free survival estimates were 75%, 36% and 20% in patients with VTT without TFI, those with VTT with PFI or RSFI, and those with VTT with both PFI and RSFI, respectively (P < 0.001). In multivariable analyses, presence of either PFI or RSFI was associated with a two-fold increased risk of CSM, whereas presence of both PFI and RSFI was associated with a three-fold increased risk of CSM, relative to VTT-only cases. • The inclusion of the variable describing the presence and extent of TFI in a base model including pT stage, Fuhrman grade and presence of nodal disease and metastatic disease significantly increased the accuracy in predicting CSM (+2.1%; P < 0.001) in patients with VTT. CONCLUSIONS: • Patients affected by RCC with VTT and TFI have a higher risk of CSM relative to cases with VTT only. Patients with both PFI and RSFI showed increased CSM compared with patients with either PFI or RSFI. • Our results suggest TFI should be accurately evaluated and included in routine pathological reports to provide better patient risk stratification.

Renal sinus fat invasion in pT3a clear cell renal cell carcinoma affects outcomes of patients without nodal involvement or distant metastases.

PURPOSE: According to the 2002 American Joint Committee on Cancer TNM classification, perinephric and renal sinus fat invasion are classified as pT3a renal cell carcinoma. However, only a few studies have assessed the impact of sinus fat invasion on patient survival and with controversial results. We analyzed the impact of sinus fat invasion on cancer specific survival in a cohort of patients with pT3a clear cell renal cell carcinoma. MATERIALS AND METHODS: We retrospectively analyzed data on 115 consecutive patients treated with open radical nephrectomy for unilateral, sporadic pT3a clear cell renal cell carcinoma at our department from 1989 to 2006. All pathological specimens were rereviewed by a single uropathologist. The prognostic role of sinus fat invasion in cancer specific survival was assessed by Cox proportional hazards regression models. RESULTS: Ten patients had direct ipsilateral adrenal invasion and were excluded from analysis. A total of 105 patients with clear cell renal cell carcinoma were evaluated. Median followup was 38 months. In the overall population sinus fat invasion did not reach independent predictive status in terms of cancer specific survival on multivariate Cox regression analysis after adjusting for age, performance status, tumor dimension, tumor grade, synchronous metastases, nodal involvement, sarcomatoid differentiation and coagulative necrosis. In the subset of patients with pNx/pN0 M0 (83) the actuarial 5-year cancer specific survival was 71.9% and 45.5% for those with perinephric fat invasion only and sinus fat invasion, respectively (p = 0.025). Sinus fat invasion achieved an independent predictive role on multivariable Cox regression analysis (p = 0.048, HR 2.06). CONCLUSIONS: Sinus fat invasion in clear cell renal cell carcinoma significantly affects cancer specific survival in patients without nodal or distant metastases. However, sinus fat invasion is not associated with worse cancer specific survival in cases of metastatic disease.