The dramatic COVID 19 outbreak in Italy is responsible of a huge drop of urological surgical activity: a multicenter observational study.

OBJECTIVE: To describe the trend in surgical volume in urology in Italy during the coronavirus disease 2019 (COVID-19) outbreak, as a result of the abrupt reorganisation of the Italian national health system to augment care provision to symptomatic patients with COVID-19. METHODS: A total of 33 urological units with physicians affiliated to the AGILE consortium (Italian Group for Advanced Laparo-Endoscopic Surgery; www.agilegroup.it) were surveyed. Urologists were asked to report the amount of surgical elective procedures week-by-week, from the beginning of the emergency to the following month. RESULTS: The 33 hospitals involved in the study account overall for 22 945 beds and are distributed in 13/20 Italian regions. Before the outbreak, the involved urology units performed overall 1213 procedures/week, half of which were oncological. A month later, the number of surgeries had declined by 78%. Lombardy, the first region with positive COVID-19 cases, experienced a 94% reduction. The decrease in oncological and non-oncological surgical activity was 35.9% and 89%, respectively. The trend of the decline showed a delay of roughly 2 weeks for the other regions. CONCLUSION: Italy, a country with a high fatality rate from COVID-19, experienced a sudden decline in surgical activity. This decline was inversely related to the increase in COVID-19 care, with potential harm particularly in the oncological field. The Italian experience may be helpful for future surgical pre-planning in other countries not so drastically affected by the disease to date.

[Salvage laparoscopic pyeloplasty in the worst case scenario: after failed open repair and endoscopic salvage]. / Pieloplastica laparoscopica di salvataggio "in the worst case scenario": dopo fallimento sia di pieloplastica open che di endopielotomia.

OBJECTIVES: We present the video of a laparoscopic correction of a left ureteropelvic junction obstruction in a patient who has already undergone previous surgical open pyeloplasty and subsequent acucise for failure of the first surgery. At 8 years after the second surgery, the patient showed a recurrence of the obstruction of the left ureteropelvic junction.
 It was decided to perform the retroperitoneal laparoscopic correction of the obstruction.
 MATERIALS AND METHODS: With the patient placed in a 90° flank position, 4 trocars are placed in the retroperitoneum space by the Hasson tecnique.
 After the creation of the retroperitoneum space, the Gerota's fascia is opened. The posterior layer of the Gerota's fascia appears very thickened at the level of the lower pole of the kidney and is very adherent with the surrounding structures, in particular the psoas muscle.
 Gerota's fascia is incised and removed from the previous surgery and the psoas muscle is identified. The distal lumbar ureter is tenaciously anchored to the psoas muscle. The lower pole of the kidney is freed from the adhesions of the previous surgery. The proximal ureter is hardly isolable for the presence of fibrosis. The renal pelvis is fixed to the psoas due to fibrotic tissue that is cut with scissors. Once the pelvis and the ureter are separated from the psoas, the surgery proceeds with the liberation of the pelvis from the adipose tissue and fibrosis that surround it. The pieloureteral obstruction is not easily identifiable. The renal pelvis is opened at the level of the ureteral junction, the ureter is spatulated on its medial side. The scar tissue is removed until well vascularized tissue is seen. The anastomosis between the ureter and pelvis is performed with 2 semicontinuous running sutures. Once the anterior plate of the anastomosis is completed a cystoscopic retrograde DJ ureteral stent insertion is performed. The procedure ends with the packaging of the posterior plate of the anastomosis with the second running suture.
 RESULTS: The operation lasted 180 minutes. The postoperative course was uneventful, the drain was removed on the second day and the bladder catheter on the 4th. The patient was discharged on the 5th day and the DJ ureteral stent was removed on the 21st post-operative day. 
 DISCUSSION: The laparoscopic reoperation in patients with previous open surgery interventions is definitely difficult. This kind of surgery has to be carried out after having gained considerable laparoscopy experience. Specifically, the reoperation of laparoscopic pyeloplasty after 2 previous intervention poses the following difficulties: the creation of appropriate space, dissection of the ureter and pelvis from the psoas muscle, appropriate mobilization of the lower pole of the kidney to get a "tension free" anastomosis, liberation of the pelvis and ureter from the tenaciously adherent fibrotic tissue, identification of the stenotic ureteropelvic junction.
 CONCLUSIONS: Laparoscopic pyeloplasty after failure of past interventions remains a difficult procedure that should only be performed after major laparoscopic experience. In experienced hands, redo laparoscopic pyeloplasty provides high success rates.

[Laparoscopic repair of enterovesical fistula in patient affected by left megaureter]. / Riparazione laparoscopica di fistola enterovescicale in paziente portatore di megauretere.

INTRODUCTION: Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. We present the case of EVF secondary to diverticular disease in a male with congenital megaureter. A laparoscopic repair of the colon vesical fistula was performed with colon resection. MATERIALS AND METHODS: With the patient in the Trendelenburg position -30° degrees on the right side, 5 trocars are positioned trans-peritoneally. The exploration of the abdominal cavity shows the sigmoid diverticular disease adhering tenaciously to the posterior wall of the bladder. The intestinal loops are medialized. The inferior mesenteric vein is isolated, clipped and divided. The mesosigma is isolated and the inferior mesenteric artery is closed 2 cm from its emergence from the aorta with EndoGIA™ 45 stapler. The left colon is isolated from its splenic flexure to the mesorectum. The peritoneum between the bladder and sigmoid colon at the site of the tenacious adhesions is incised. The left megaureter is isolated from the diverticular disease and the bladder is opened on the site of the fistula, to permit a wide resection of the fistula. The posterior wall of the bladder is then closed with double running sutures. Section of the rectum with EndoGIA™ 45 stapler. Extraction of 20 cm of sigma comprising diverticular disease by a 5 cm suprapubic laparotomy. The sigma is cut and the proximal head of the circular stapler is inserted and closed with a running suture. The left colon is put back in place into the peritoneal cavity. The laparotomy is closed and the surgery is reconverted into laparoscopy. A colorectal end-to-end anastomosis according to Knight Griffen is performed with ILS 29 circular stapler. The anastomosis is tested for leakage with hydropneumatic test: no evidence of spillage. A laminar drainage is placed close to the anastomosis and the incisions are closed. RESULTS: The operative time was 240 minutes. There were no intra- or post-operative complications. The bladder catheter was removed on day 7 after cystography. The patient was discharged asymptomatic on the 8th post-operative day. CONCLUSIONS: Laparoscopic treatment of enterovesical fistulas for benign disease is a safe and standardized procedure. It remains a difficult procedure with a conversion rate higher than laparoscopy for uncomplicated diverticulitis or malignancy. The procedure in a single session with intracorporeal bowel anastomosis is the standard.

[Laparoscopic removal of polycystic kidney through retroperitoneal approach: technical notes]. / Asportazione laparoscopica di rene policistico per via retroperitoneale: note di tecnica

INTRODUCTION: We present our technique of laparoscopic nephrectomy with intact specimen extraction for patient with autosomal dominant polycystic kidney disease (ADPKD). MATERIALS AND METHODS: A 5-port retroperitoneal laparoscopic approach was used to dissect the involved kidney, which was then removed intact through a Gibson modified incision. RESULTS: The operative time was 110 minutes. Blood loss accounted for 50 mL. There were no intra or post-operative complications. The hospital stay was 4 days. CONCLUSIONS: Laparoscopic nephrectomy for ADKD is technically feasible and clinically safe. The advantages of these technique compared to transperitoneal laparoscopy are the quick access to the hilar vessels and the strict extraperitoneal route, which prevent the risk of sepsis.

[Laparoscopic repair of rectovesical fistula after radical retropubic prostatectomy]. / Riparazione laparoscopica di fistola retto vescicale post prostatectomia radicale retropubica.

INTRODUCTION: We present the video of a laparoscopic repair of a rectovesical fistula after radical retropubic prostatectomy. The rectal lesion had not been detected during the first procedure. The rectal bladder fistula appeared on the 14th post-operative day. After three weeks from the procedure,the patient underwent a laparoscopic repair of the rectovesical fistula. A temporary external colon conduit was performed at the same time. MATERIALS AND METHODS: We performed a cystoscopy before the surgery; it showed a fistula behind the bladder neck at 5 o'clock, distally to the left ureteral orifice. Two ureteral stents were inserted into both the ureters to make sure not to determine any injury to these structures during the operation. With the patient in the supine position, we introduced 5 trocars with the Hasson technique trans-peritoneally. The pouch of Douglas was opened and the bladder was divided from the rectum.The bladder posterior wall was widely opened till reaching the rectal bladder fistula.The fistula was located distally to the left ureteral orifice, very close to the bladder neck. Through a blunt dissection, we divided the margins of the rectal fistula from those of the posterior bladder wall.Indeed, we performed a suture of the rectal wall without any tension. The rectal lesion was closed in a double-layer suture with 3-0 Vicryl.We introduced a probe into the rectum to make sure there was no leakage on the suture. A flap of peritoneum of the Douglas was put between bladder and rectum.We closed the longitudinal opening of the trigone and the bladder posterior wall through a continuous suture.An external colic conduit was packaged to guarantee the closure of the fistula. The left colon was put through the abdominal wall widening the 5 mm trocar opening located on the left pararectal space. RESULTS: The operative time was 240 minutes. There were no post-operative complications. The bladder catheter was removed at 1 month after surgery,only after performing a cystography, which showed no leakage.Two months later, the colostomy was closed. At a 12-month follow-up the patient had no fistula recurrence. CONCLUSIONS: The treatment of arectovesical fistula after radical prostatectomy remains a complex procedure: different types of corrective surgical approaches have been described. The laparoscopic approach is an alternative to standard procedures. The optical magnification allows a good view of the fistula in a very deep and narrow space. It also allows easy performing of the colostomy.

[Laparoscopic removal of voluminous right seminal vesicle neoplasm]. / Asportazione laparoscopica di voluminosa neoplasia della vescicola seminale destra.

INTRODUCTION: We present the case of a male adnexal tumor of probable Wolffian origin occurred to the right seminal vesicle of a 47-year-old man. MATERIALS AND METHODS: The patient presented with a 2-month history of hematospermia. The diagnosis was achieved by transrectal ultrasound, CT of the abdomen and pelvis, and biopsy of both prostate and seminal vesicle. The patient was counseled for laparoscopic excision of the right seminal vesicle. RESULTS: The right seminal vesicle, along with the tumor and the right vas deferens, were excised and clear margins were ensured by frozen section. Total operative time was 180 with 200 mL blood loss. The patient's recovery was uncomplicated and he was discharged on the fourth post-operative day. The histologic examination demonstrated a male adnexal tumor of probable Wolffian origin, which is a rare low-grade malignant neoplasm that has been previously described in the broad ligament, ovaries and retroperitoneum of females. The patient is free of relapse at a 20-month follow-up. CONCLUSIONS: This is the second report of this entity in a male. The laparoscopic approach for the excision of seminal vesicle neoplasms is a good treatment for its obvious benefits of minimal blood loss, short hospital stay and quick return to normal activity. The magnifications of the anatomical details of the pelvic floor help the surgeon in the dissection of the seminal vesicle from the other structures.

Dorsal free graft urethroplasty according to Barbagli. Minimum follow-up of 2 years.

Series of free graft methroplasties for structure of the urethra according to Barbagli. Fifteen men underwent dorsal free graft methroplasty for structures situated in the penile urethra in 6 cases, in the bulbous urethra in 7 and in the urethra geno bulbous in 2. The length of the structures ranged from 1.5 to 13 cm. In all the patients but one uroflow was satisfactory at a mean follow-up of 40 months. In one patient a reument structure occurred 8 months after treatment and was successfully treated with cold urethrotomy. In conclusion, dorsal free graft urethroplasty is a safe and fairly simple procedure in long bulbous stenosis and penile multi stenosis.

Interstitial cystitis.

Interstitial cystitis (IC) is still considered a rare disease, but in the future its incidence will probably be revised if tendency is that of considering interstitial cystitis on the basis of clinical rather than endoscopic-histological criteria. According to some urologists, cystodistension and vesical biopsy, even if not pathognomonic, are still effective up till now, at least for their prognostic-therapeutic value as well. If on one hand in the diagnosis of this condition symptoms tend to be of more and more value unlike instrumental investigations, on the other hand little has changed in therapy.

Pubo-vaginal sling.

The Authors discuss their experience in the use of pubo-vaginal sling in the treatment of female urinary stress incontinence. In the last 5 years (1997-2002) 35 patients with type 3 incontinence underwent pubo-vaginal sling with rectus fascia or porcine skin. Healing was obtained in 74.2%, de novo urgency in 5.7%, obstruction in 8.5% and persisting incontinence in 11.4% of cases. The developments of the technique have recently turned pubo-vaginal sling into a minimally invasive procedure with low morbidity. Its indications have therefore been extended to the point that it is now considered by many authors as the treatment of choice in any type of incontinence, whether associated with genital prolapse or not.

[Complications of urinary diversion after radiotherapy]. / Complications of urinary diversion after radiotherapy.

Primary radiation therapy may be recommended for patients with invasive bladder cancer, gynecological or prostatic cancer. When complications occur or in case of malignant recurrence, urinary diversion may be the best chance to restore an acceptable quality of life. The complication rate after this surgery is doubled. We report our experience in 32 patients submitted to urinary diversion after radiotherapy from 1985 to 2000: 2 enteric fistulas; 2 urinary fistulas; 5 stenosis of uretero-intestinal anastomosis were our complications. Radical cystectomy (24 cases) or anterior pelvic exenteration (8 females) preceded urinary diversion. Preoperative high-dose radiotherapy contributes to increased postoperative morbidity rates, particularly entero-enteric fistulas, uro-intestinal fistulas and stenosis of the uretero-intestinal anastomosis. In our experience, in most of the major urinary or enteric complications non surgical management was inefficient and surgical management was necessary.

[Pathology of the gynecologic ureter: our experience]. / Patologia dell'uretere ginecologico: nostra esperienza.

UNLABELLED: Endometriosis, surgery and radiotherapy are the main causes of ureteral injuries in gynaecologic pathology. MATERIALS AND METHODS: In this paper we present our experience about ureteral injuries. We treated 31 patients; 6 cases of endometriosis, 13 cases of pelvic radiotherapy for gynecologic tumors, 12 cases of ureteral injuries after gynecologic surgery. The treatments were different depending on the cause of the lesion and on the site of the lesion. In 3 cases we performed an ureteral-bladder implant with bladder psoas hitch, in 2 cases an end to end anastomosis was made. In 2 cases we made an ureteric substitution with Boari bladder flap. In 8 cases the ureteral stenting with DJ or a percutaneous nephrostomy was the solution. RESULTS AND CONCLUSIONS: In our experience good results can be obtained with ureteral implant and bladder psoas hitch. The end to end ureteral anastomosis had disappointing results in our hands. In case of ureteral fistula it would be better repair it as soon as possible. If the ureteral lesion is recognised during surgery and the loss of substance is not complete, the suture on stent can be performed.