Laparoscopic and Open Nephron-Sparing Surgery for Radius Exophytic/Endophytic Nearness Anterior/ Posterior Location Nephrometry Score 7 and Higher Kidney Tumors: A Comparison of Oncological and Functional Outcomes Using the Pentafecta Score.

OBJECTIVE: This study aimed to evaluate oncological and functional outcomes of nephron- sparing surgery by comparing open and laparoscopic approaches in a consecutive series of patients with intermediate and high complexity renal masses. MATERIALS AND METHODS: We retrospectively reviewed all nephron-sparing surgery cases in 2 referral centers from January 2013 to January 2020. Tumor complexity was graded according to radius exophytic/endophytic nearness anterior/posterior location nephrometry score. Patients with a single kidney tumor with a radius exophytic/endophytic nearness anterior/posterior location score ≥ 7 were evaluated. Exclusion criteria were solitary kidney, multiple/bilateral tumors, and a low radius exophytic/endophytic nearness Anterior/Posterior location score (<7). Patients were divided according to the surgical approach: the laparoscopic tumor enucleation and the open wedge resection groups. The Trifecta and Pentafecta score achievement rates were assessed. RESULTS: Two hundred thirteen patients were included in the analysis, 76 in laparoscopic tumor enucleation group and 137 in the open wedge resection group. There were no statistically significant differences in preoperative data between laparoscopic tumor enucleation and open wedge resection groups, except for the higher percentage of T1a masses in the latter group. The mean 24-hour blood loss and length of stay were higher in the open wedge resection group. Minor and major postoperative complication rates were comparable. No significant difference in terms of the Trifecta score was reported. Pentafecta score was achieved in 35/76 (46.1%) and 61/137 (44.5%) cases in the laparoscopic tumor enucleation and open wedge resection groups, respectively. CONCLUSION: Our study showed that laparoscopic tumor enucleation was associated with significantly lower blood and length of stay. Postoperative complications and the achievement of the Pentafecta score were similar in both surgical approaches.

The use of ultrasound in the evaluation of postoperative pneumothorax and lung re-expansion in patients after lung resection.

INTRODUCTION: Many clinical studies have shown ultrasonography (US) is useful for the diagnosis of different abnormalities involving pleura; chest ultrasound (CUS) is widely used to detect pneumothorax in patients, but there is no data on its use for the follow-up of lung re-expansion after lung resection. MATERIALS AND METHODS: We performed a unicentric observational study all patients between January 2018 and May 2021 undergoing lobectomy in which lung re-expansion was assessed daily with chest ultrasound (CUS) and chest radiography (CXR) until chest drainage was removed. Ultarsound clinical signs indicating a pneumothorax were: the detection of a positive lung point, absence of sliding or a consistent stratosphere sign with an absence of lung pulse, B-lines, I-lines or consolidations. RESULTS: Sensitivity, specificity, PPV, NPV of CUS and CXR were, respectively: 86% vs. 98% (p = 0.002); 100% vs. 100% (p = 1.0); 94% vs. 75% (p = 0.231); and 94% vs. 99% (p = 0.7). CONCLUSIONS: Ultrasound is a method available also to the patient's bed, an easy-to-learn technique even for inexperienced operators, therefore it is a valuable tool for checking the post-lobectomy lung expansion, reduce the use of chest radiography. KEY WORDS: Chest ultrasound, Chest radiography, Pneumothorax.

The Role of Intraoperative Ultrasonography Associated with Clampless Technique in Three-Dimensional Retroperitoneoscopic Laparoscopic Enucleation of Completely Endophytic Renal Tumors.

Objectives: To evaluate perioperative and functional outcomes of clampless laparoscopic tumor enucleation for completely endophytic renal tumors with the guide of intraoperative ultrasonography. Methods: We analyzed patients with clinically completely endophytic tumors, renal tumors, who underwent clampless three-dimensional (3D) retroperitoneoscopic laparoscopic tumor enucleation between January 2012 and January 2021. Patients with exophytic tumors were excluded. Intraoperative ultrasonography was used to map out the mass in all surgeries. Results: Overall, 57 patients underwent clampless 3D retroperitoneoscopic laparoscopic tumor enucleation. Mean surgical time was 131 minutes, and mean estimated blood loss was 202 mL. Mean hospital stay was 4.7 days. Major and minor postoperative complications occurred, respectively, in 3 and 10 cases. Only a patient had a positive surgical margin. One-year renal function did not differ from baseline. Conclusion: Our study showed that clampless laparoscopic enucleation guided by laparoscopic ultrasonography ensured satisfactory outcomes for completely intrarenal tumors, with excellent renal function preservation 1 year after surgery.

Clampless Laparoscopic Tumor Enucleation for Exophytic Masses Greater Than 4 cm: Is Renorrhaphy Necessary?

Objective: To demonstrate the safety of clampless 3D laparoscopic tumor enucleation (cLTE) for exophytic T1b kidney masses, avoiding suture to achieve hemostasis. Methods: Between January 2010 and January 2021, 241 consecutive patients with an exophytic renal tumor underwent sutureless cLTE. Patients with predominantly endophytic growth or tumors 4 mm closer to the collecting system less were excluded. In all cases, an attempt was made to accomplish surgery without suturing kidney parenchyma. Data were obtained from a retrospective review of history and physical examinations, operative and pathology reports, anesthesia records during the hospital stay, and follow-up visits. Results: Among 241 patients who underwent cLTE, 148 had cT1a and 93 had cT1b renal tumor. The median tumor size was 32 mm, and the median R.E.N.A.L. (radius exophytic/endophytic nearness anterior/posterior location) score was 6. Renorrhaphy was necessary in 5 cases. The median operative time (OT) was 100 minutes, and the estimated blood loss (EBL) was 150 mL. The median 24-hour decrease in hemoglobin was 1.8 g/dL. The median length of stay was 4 days. Nineteen patients had postoperative complications: 3 cases had Clavien-Dindo (CD) 3a or more, 6 had CD2, and 10 had CD1. Comparing the T1a and T1b groups, except for the median OT and the EBL, no significant differences were observed in all the other variables analyzed. In both groups, renal function was preserved after 1 year from surgery. Conclusion: Our experience showed that sutureless cLTE is safe and feasible for T1b tumors leading to radical oncological outcomes and preserving renal function.

Laparoscopic single port radical prostatectomy in the 2020: Why not? Our experience.

OBJECTIVES: To analyze the feasibility, safety and advantages of Laparo-Endoscopic Single-site Surgery radical prostatectomy (LESS-RP) based on our personal experience. PATIENTS AND METHODS: Details of 520 patients were retrospectively analyzed, from 2009 to 2019. Extraperitoneal approach, with only two accesses (2.5 cm and 5 mm respectively) was used to perform radical prostatectomy. Perioperative characteristics and postoperative oncologic and functional outcomes are reported. RESULTS: The mean age was 66.6 ± 5.6 years. Mean PSA level was 9 ± 3.5 ng/ml. According to D'Amico classification, the percentage of patients with low-, intermediate-, and high-risk disease cases were 116 (22.4%), 275 (52.8%), and 129 (24.8%) respectively. Mean operative time was 156 ± 43 min. Mean estimated blood loss was 214 ± 93 ml. Positive surgical margins (PSMs) were detected in 110 (21.2%) patients. PSM rates in pT2 and pT3 stages were 20.1% and 22.9%, respectively. The overall complication rate was 9.2%, based on the modified Clavien classification. The 12 months continence and potency rates were 90.9% and 49.1%, respectively. The biochemical recurrence rate was 6.8%, at the median follow-up time of 26.7 months (IQR 12-32). CONCLUSIONS: Our analyses show that LESS-RP is a safe procedure, if performed by surgeons with adequate experience and skills. Unlike the classic laparoscopic prostatectomy, this technique allows better aesthetic and psychological results, reduced postoperative pain, and a faster return to normal daily activity with the same functional and oncological results.

Endoscopic resection of tracheal lobular capillary haemangioma with ultrasonically activated device.

We reported the case of a 55-year-old man with a large tracheal lobular capillary haemangioma attached to posterior tracheal wall and successfully managed with arterial embolization followed by endoscopic resection using Harmonic™ ACE Plus. Because of the high risk of bleeding, Harmonic™ was used in this case due to its ability to cut and cauterize simultaneously. The instrument jaw repeatedly grasped the attachment point of tumor, and then the cavitation effect, created by the longitudinal vibration of the blade tip, separated it from the posterior tracheal wall, reducing the risk of perforation. Yet, the ultrasonic energy denatured proteins and coagulated the vessels, preventing the bleeding during resection. No complications occurred during and after the procedure. Twelve-month follow-up showed no recurrence.

Management of vascular injury during VATS lobectomy with hemostatic matrix sealant agent: a case report.

Vascular injury is the most dreadful complication during a video-assisted thoracoscopic surgery (VATS) lobectomy and often lead to conversion to thoracotomy. While the rate of this event considerably drops with the progression on surgical team's learning curve, however, it is always useful to have an emergency plan to deal with it. The repairing approaches described in literature are mostly based on suction-compression angiorrhaphy technique (SCAT), involving a suture on the damaged vessels. In our case-report we display a good alternative to SCAT when we are dealing with small size lesions, without resorting to conversion. A 63-year-old with lung adenocarcinoma underwent a right upper VATS lobectomy: during the procedure, an iatrogenic lesion to intrascissural upper lobe artery occurred. We made use of suction and compression but, instead of performing a suture on the vessel, we applied hemostatic matrix sealant agent. The bleeding was effectively stopped and the wound sealed, allowing us to safely carry out the lobectomy without conversion to thoracotomy. No post-operative complications were highlighted and the patient was still alive after 6 months since the procedure. Our approach could be a useful addition to techniques already described and could be easily executed by surgeons still in learning curve. This is the first case of vascular injury managed specifically with only hemostatic matrix sealant agent described in literature and it has proven effective as well as the angiorrhaphy technique when it comes to small size artery lesions. Thanks to the easiness of sealant application, execution time of our method is shorter than a more complex repair in VATS, allowing inexperienced surgeons to fix the injury with little effort.

Laparoscopic radical nephrectomy with inferior vena cava thrombectomy: A combined retroperitoneal and transperitoneal approach.

Renal cell carcinoma with inferior cava thrombus indicates biologically aggressive cancer, so the complete surgical resection remains standard of care with best long-term outcomes. Laparoscopic radical nephrectomy with vena cava thrombectomy represents nowadays a mini-invasive surgical alternative to the classic open nephrectomy. We present the case of a patient with incidental diagnosis of a right renal mass with level II inferior cava thrombus completely managed with both retroperitoneal and transperitoneal approaches. The use of a double access was planned to ensure a safe and complete vascular control. In our opinion, optimal patient selection, extensive laparoscopic experience, and knowledge of both transperitoneal and retroperitoneal approaches are critical elements for the safe application of this technique, although this procedure remains challenging and technically demanding.

Montgomery T-tube for management of tracheomalacia: Impact on voice-related quality of life.

INTRODUCTION: Tracheostomy is a common procedure for management of tracheomalacia. However, the limitation to speak related to tracheostomy cannula could affect the quality of life. OBJECTIVES: we reported a new minimally invasive procedure to replace tracheostomy cannula with Montgomery T-tube to improve the ability of speaking. METHODS: This is a single center study including all consecutive patients undergoing the replacement of standard tracheostomy cannula with T-tube for management of tracheomalacia. The end-points were to evaluate (a) the changes in Voice-related quality of Life (V-RQOL) before and after T-tube placement; and (b) the complications related to T-tube. RESULTS: Eleven patients were included in the study. T-tube was placed using flexible bronchoscopy and laryngeal mask airway. A suture was inserted through the proximal end of T-tube. Once the stent was introduced with a clamp into the trachea, a traction was applied on the suture to facilitate the alignment of the upper end of the stent. The comparison of V-RQOL values before and after T-tube insertion showed a significant improvement in social/emotional (39.2 ± 6.1 vs 66.8 ± 1.9; P = .0001); physical functioning (21 ± 5.7 vs 56.4 ± 5.3; P = 0.0001) and total V-RQOL scores (33.9 + 5.4 vs 61.3 + 6.1; P = 0.0001). No complications were seen during the insertion of the stent. In two patients, T-tube was obstructed by mucus that resolved with aspiration using flexible bronchoscopy (mean follow-up: 18 ± 10 months). CONCLUSIONS: Our technique is simple and safe, not needing specific skills and/or cumbersome devices. The replacement of tracheostomy cannula with T-tube seems to improve the quality of voice without adding major complications.

The degree of satisfaction of women undergoing surgical repair of prolapse, compared with clinical and urodynamic findings.

OBIECTIVE: To assess the degree of satisfaction of women undergoing surgical repair of prolapse, compared with the clinical and urodynamic findings. MATERIALS AND METHODS: 72 women hospitalized for pelvic organ prolapse (POP) were enrolled in this prospective study. Patients underwent clinical evaluation and urodynamic study before and 4 months after POP repair. Women were assessed for urinary symptoms by micturition diary and patient perception of intensity of urgency scale. Women were also questioned about defecation and sexual life. POP repair was performed in all cases without the use of a mesh. Subjective evaluation was performed by patient global impression of improvement questionnaire. RESULTS: 56 women were evaluable. Improvements were found in all micturition symptoms and in particular in voiding symptoms. Feeling of vaginal bulging disappeared in all patients. A slight improvement was found in constipation; 62% of patients had a normal sexual life but 27% refrained from sexual activity. Judgement of patients was between "much improved" and "very much improved". CONCLUSIONS: Disappearance of the feeling of vaginal bulging was by far the best result. Improvements were found in most of the symptoms particularly in voiding symptoms and urodynamic findings.

Effect of Surgical Therapy on Urinary Symptoms and Urodynamic Findings in Patients with Uterine Myoma.

OBJECTIVE: To assess the relationship between uterine myomas, urinary symptoms, and urodynamic findings. STUDY DESIGN: A total of 49 women hospitalized for uterine myoma were eval- uated in this prospective study. Patients underwent- a detailed clinical evaluation and ukodynamic study. Uri- nary symptoms were as- sessed using 3-day micturi- tion diary and Patient Perception of Intensity of Urgency scale questionnaire. The dimensions of fibroma- tous uterus and single large myomas were evaluated by both transabdominal and transvaginal ultrasound. Urodynamic parameters and urinary symptoms were assessed before and 4 months after surgery. RESULTS: A total of 44 patients were evaluable at the end of the study: 32 out of 44 (72.8%) had urinary symptoms; 26 women underwent hysterectomy, and 18 had abdominal myomectomy. After surgery 87.5% of women were asymptomatic or showed improvement in urinary symptoms. Improvements were also seen in urodynamic parameters. CONCLUSION: Uterine myomas often result in uri- nary symptoms. Surgical therapy can result in signifi- cant improvements in symptoms as well as urodynamic findings.

Polyacrylamide hydrogel (bulkamid®) in female patients of 80 or more years with urinary incontinence.

INTRODUCTION: To assess the effectiveness of polyacrylamide hydrogel (Bulkamid®) in injection therapy for urinary incontinence in women of 80 or more years. MATERIALS AND METHODS: Twenty consecutive women mean age 84.5 (range 80-87) with stress or mixed urinary incontinence were enrolled in this prospective study. All subjects were evaluated at baseline and re-evaluated 7 days, 6,12,18 and 24 months after treatment. A detailed clinical evaluation, physical examination, daily pad count, urodynamic investigation and evaluation of urethral mobility by trans-labial ultrasound were performed. RESULTS: A statistically significant decrease in the number of pads was observed in the follow-up (p = 0.0002 after 24 months). Physical examination showed a statistically significant lack or reduced lost of urine with stress test (p = 0.0163 after 24 months). Urodynamic findings showed an increase of Valsalva leak point pressure, maximum urethral closure pressure and functional length. Maximum flow and post void residual were respectively observed to be significantly reduced and increased only after 7 days from injection therapy. Quality of life (QoL) assessed with the Incontinence Impact questionnaire short form (IIQ-7) showed a statistically significant improvement (p = 0.0001 after 24 months). Patient satisfaction assessed with the Visual Analogue Scale and Patient Global Impression of Improvement questionnaire respectively produced evaluation of ″satisfied″ and "much improved" even after 24 months. CONCLUSIONS: Polyacrylamide hydrogel (Bulkamid®) is an effective treatment with low morbility in patients of 80 or more years.

Polyacrylamide Hydrogel (Bulkamid) in Female Patients of 80 or More Years with Urinary Incontinence

Introduction: To assess the effectiveness of polyacrylamide hydrogel (Bulkamid ®) in injection therapy for urinary incontinence in women of 80 or more years. Materials and Methods: Twenty consecutive women mean age 84.5 (range 80-87) with stress or mixed urinary incontinence were enrolled in this prospective study. All subjects were evaluated at baseline and re-evaluated 7 days, 6,12,18 and 24 months after treatment. A detailed clinical evaluation, physical examination, daily pad count, urodynamic investigation and evaluation of urethral mobility by trans-labial ultrasound were performed. Results: A statistically significant decrease in the number of pads was observed in the follow-up (p = 0.0002 after 24 months). Physical examination showed a statistically significant lack or reduced lost of urine with stress test (p = 0.0163 after 24 months). Urodynamic findings showed an increase of Valsalva leak point pressure, maximum urethral closure pressure and functional length. Maximum flow and post void residual were respectively observed to be significantly reduced and increased only after 7 days from injection therapy. Quality of life (QoL) assessed with the Incontinence Impact questionnaire short form (IIQ-7) showed a statistically significant improvement (p = 0.0001 after 24 months). Patient satisfaction assessed with the Visual Analogue Scale and Patient Global Impression of Improvement questionnaire respectively produced evaluation of “satisfied” and “much improved” even after 24 months. Conclusions: Polyacrylamide hydrogel (Bulkamid®) is an effective treatment with low morbility in patients of 80 or more years. .

Solifenacin succinate versus percutaneous tibial nerve stimulation in women with overactive bladder syndrome: results of a randomized controlled crossover study.

AIMS: This study compared the effectiveness of solifenacin succinate (SS) versus percutaneous tibial nerve stimulation (PTNS) in women with overactive bladder syndrome (OABS). METHODS: A randomized controlled crossover study of 40 women with OABS was performed. Patients were randomized into two groups. In group A, patients received SS and then PTNS. In group B, patients underwent PTNS and then SS. Voiding diaries, quality of life surveys and patient perception of intensity of urgency questionnaire were performed before and after each treatment. The global impression of improvement questionnaire was performed at the end of the study. RESULTS: A reduction in the number of daily micturitions, episodes of nocturia and urge incontinence were found with both SS and PTNS in all groups, but PTNS showed a greater effectiveness than SS. There was an increase in voided volume in all groups with both SS and PTNS, but patients treated with PTNS had a greater increase. PTNS showed greater effectiveness in patient perception of urgency and quality of life. CONCLUSION: This study demonstrates the effectiveness of SS and PTNS In women with overactive bladder symptoms. However, greater improvements were found with PTNS.

Has the cost of anti-muscarinic a key role in the success rate of patients diagnosed with overactive bladder syndrome?

INTRODUCTION: Overactive bladder syndrome (OAB) is a chronic disease, the prevalence in the general population is reported to be 14-16%. Anti-muscarinic agents are considered the first-line pharmacological treatment for the management of OAB; although a long lasting therapy is indicated to reach a better control of OAB symptoms an high percentage of patients discontinue the cure after a brief period. Our attempt is to investigate whether the cost of solifenacin succinate may influence the long lasting regimen and patients' drug efficacy. MATERIALS AND METHODS: 70 consecutive women, with symptoms of OAB were enrolled in this randomized controlled study. In group A, all patients received solifenacin 5 mg by the urologist, without any cost; they were instructed to get the drug once daily for 4 months, differently, in group B, patients need to buy the drug which was administered as in the group A. Frequency, nocturia, incontinence, voided volume, were evaluated by a 3-day micturition diary. Overactive Bladder Questionnaire Short Form (OAB-qSF) was used to assess the impact of OAB symptoms on patients' quality of life (QoL). Urgency was assessed by patient's perception of intensity of urgency scale (PPIUS). Micturition-diary, OAB-qSF, PPIUS, were completed at baseline and after four months. RESULTS: A greater number of patients discontinued solifenacin in the group B who need to buy the drug. We observed significant differences in groups A and B in relation to frequency, nocturia, urge incontinence and voided volume comparing the pre and post treatment symptoms. The patients' perceptions of intensity of urgency and the PGI-I scale showed a significant improvement greater in group A in respect with group B. CONCLUSIONS: The cost of anticholinergic may be responsible for both early discontinuation of treatment and incomplete adherence to therapy with unsatisfactory results on symptoms and an incorrect assessment of the effectiveness of the drug by the urologist.

Current status of single-incision laparoscopic surgery: European experts' views.

Recent advances in minimally invasive surgery have centered on reducing the number of incisions required, which has led to the development of the single-incision laparoscopic technique. A panel of European single-incision laparoscopy experts met to discuss the current status of, and the future expectations for, the technique. The experts reached agreement on a number of statements and recommendations, which will support surgeons in adopting the technique. The panel agreed that the single-incision technique may offer a number of benefits to patients; however, further clinical data need to be published to confirm its value. An ideal training route for surgeons who are adopting the technique was agreed upon, as was the need for a single, large clinical registry of data.

Atypical Presentation of Acute Coronary Syndrome-Not ST Elevation: A Case Report.

We describe the unexpected case of a 70-year-old man, with medical history of ischemic heart disease and surgery for aneurysm of abdominal aorta, who comes to the emergency department complaining of low-back pain without other symptoms or signs of organic failure. After a few hours we see a deterioration of physical conditions with pulmonary oedema, increase of blood pressure, changing in the ECG pattern, and worsening of left ventricular function with progressive increase of biomarkers for myocardial necrosis. So this pain has revealed the premature symptom of an acute coronary syndrome (ACS). After a short time a subsequent cardiac arrest complicates the clinical situation. After resuscitation, the patient undergoes successfully to coronary angiography and performed a percutaneous transluminal coronary angioplasty (PTCA).

Ultrasound in acute urinary retention by mechanical obstruction in woman.

We referred our experience about ultrasound in the diagnosis of the acute urinary retention by mechanical obstruction in woman. We believe ultrasound has a very important role in imaging of the lower urinary tract because it simplicity and no jonizing radiation used. Anatomical pathologies of the bladder neck and urethra can be detected and documented in order to make the right therapy decision.