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.

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.

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.

Ureteral endometriosis: proposal for a diagnostic and therapeutic algorithm with a review of the literature.

INTRODUCTION: The ureteral involvement in deep pelvic endometriosis in usually asymptomatic and might lead to a silent loss of renal function. As a matter of fact, the diagnosis and the treatment modalities are still a matter of debate. MATERIALS AND METHODS: We performed a literature review by searching the MEDLINE database for articles published in English between 1996 and 2010, using the key words urinary tract endometriosis, ureteral endometriosis, diagnosis and treatment. We found more than 200 cases of ureteral endometriosis (UE). RESULTS: The disease most commonly affects a single distal segment of the ureter, with a left predisposition in most of the patients. Two major pathological types of UE may be distinguished: intrinsic and extrinsic. The symptoms are usually nonspecific and owing to secondary obstruction. The diagnosis has to be considered as a step- by-step procedure, starting from physical examination to highly detailed imaging methods. Nowadays, the treatment is usually chosen according to the type of UE, the site lesion and the distance to the ureteral orifice, with the use of JJ stents remaining a matter of debate. CONCLUSIONS: A close collaboration between the gynecologist and the urologist is advisable, especially in referral centers. Surgical treatment can lead to good results in terms of both patient compliance and prognosis.

Diagnosis and treatment of bladder endometriosis: state of the art.

BACKGROUND: The bladder is the most common affected site in urinary tract endometriosis, being diagnosed during gynecologic follow-up. The surgical urological treatment might lead to good results. STUDY OBJECTIVE: To define the state of the art in the diagnosis and treatment of bladder endometriosis. METHODS: We performed a literature review by searching the MEDLINE database for articles published between 1996 and 2011, limiting the searches to the words: urinary tract endometriosis, bladderendometriosis, symptoms, diagnosis and treatment. RESULTS: Deep pelvic endometriosis usually involves the urinary system, with the bladder being affected in 85% of cases. The diagnosis has to be considered as a step-by-step procedure. Currently, the treatment is usually surgical, consisting of either transurethral resection or partial cystectomy, and eventually associated with hormonal therapy. The hormonal therapy alone counteracts only the stimulus of endometriotic tissue proliferation, with no effects on the scarring caused by this tissue. The overall recurrence rate is about 30% for combined therapies and about 35% for the hormonal treatment alone. CONCLUSIONS: The bladder is the most common affected site in urinary tract endometriosis. Most of the time, this condition is diagnosed because of the complaint of urinary symptoms during gynecologic follow-up procedures for a deep pelvic endometriosis: a close collaboration between the gynecologist and the urologist is advisable, especially in highly specialized centers. The surgical urological treatment might lead to good results in terms of patients' compliance and prognosis.

Urodynamics after TURP and HoLEP in urodynamically obstructed patients: are there any differences at 1 year of follow-up?

OBJECTIVES: To compare urodynamic findings after holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TURP) for the treatment of benign prostatic hyperplasia-related bladder outlet obstruction. METHODS: From January to October 2002, 100 consecutive patients with benign prostatic hyperplasia with obstructive lower urinary tract symptoms were randomized to surgical treatment with either HoLEP (group 1, n = 52) or TURP (group 2, n = 48). All patients were preoperatively assessed using the International Prostate Symptom Score and quality-of-life question, total serum prostate-specific antigen measurement, transrectal ultrasonography, and complete urodynamic study. The operative time, catheterization time, and overall hospital stay were also recorded for both groups. All patients were assessed at 1, 6, and 12 months postoperatively using a complete urodynamic evaluation. RESULTS: All patients were obstructed preoperatively (Schäfer grade greater than 2). Both groups were comparable in terms of age, total serum prostate-specific antigen level, International Prostate Symptom Score, and urodynamic results. At 1, 6, and 12 months of follow-up, no statistically significant differences were recorded in terms of detrussor pressure at maximal urinary flow rate, Schäfer grade (linear passive urethral resistance relation), maximal urinary flow rate, International Prostate Symptom Score, and quality-of-life score. In the HoLEP group, the catheterization time and hospital stay were significantly shorter. Transitory lower urinary tract symptoms after 3 months of follow-up and dysuria were more frequent in the HoLEP group than in the TURP group, although at 12 months of follow-up, the results were comparable. CONCLUSIONS: Both HoLEP and TURP were equally effective in relieving bladder outlet obstruction. Although associated with greater early self-resolving irritative symptoms, HoLEP can guarantee a shorter catheterization time and hospital stay with longer operative times, proposing itself as an attractive alternative to standard TURP.

Pfannenstiel versus vertical laparotomy in patients undergoing radical retropubic prostatectomy with spinal anesthesia: results of a prospective, randomized trial.

OBJECTIVE: To evaluate the impact of a standard vertical laparotomy versus a Pfannenstiel transverse laparotomy on intra-, peri-operative, and 6-month follow-up outcome in patients undergoing radical retropubic prostatectomy with pelvic lymphadenectomy with spinal anesthesia. METHODS: Between January 2003 and June 2003, 69 age-matched consecutive patients with clinically localized prostate cancer underwent radical retropubic prostatectomy with pelvic lymphadenectomy with spinal anesthesia and were randomized into Group 1 (vertical laparotomy: 35 patients) and Group 2 (Pfannenstiel laparotomy: 34 patients). An extensive analysis of the critical intra-, peri-operative, and 6-month follow-up clinical parameters was performed. RESULTS: Both the hemodynamics and the biochemical balance were not significantly different between the two groups. Overall blood loss (p = 0.78), autologous (p = 0.88) and homologous (p = 0.36) blood transfusions were similar regardless of the type of laparotomy. Surgical time was not significantly (p = 0.27) different between the two groups. Similarly, the two forms of laparotomy did not differ regarding the length of the surgical incision (p = 0.21), as measured at the end of the procedure. Post-operative oxygen saturation percentage by pulse oximetry, as well as post-op sedation score, were not significantly different (p = 0.06 and p = 0.97, respectively). Waiting time in the post-operative holding area (p = 0.15), and pain score in the post-operative holding area (p = 0.9) as well as on post-operative day 1 (p = 0.1) were not significantly different between the two groups. The rate of first flatus passage and of unassisted ambulation were similar regardless of the type of laparotomy during post-operative day day 1. The two types of incision made it possible to remove a similar (p = 0.34) number of pelvic lymph nodes and were associated to a similar rate of positive surgical margins among pT2 patients. At the 6-month follow-up the occurrence of a pelvic lymphocele and of deep venous thrombosis was similar in the two groups (p = 0.6 and p = 0.16, respectively). Complete urinary continence and spontaneous erectile function recovery was reported in a similar number of patients regardless of the type of surgical incision (p = 0.59 and p = 0.40, respectively). CONCLUSIONS: These results suggest that a Pfannenstiel transverse suprapubic laparotomy does not result in a significantly different outcome from a standard vertical laparotomy in patients undergoing a radical retropubic prostatectomy with pelvic lymphadenectomy with L2-L3 spinal anesthesia for clinically localized prostate cancer.

Overall clinical outcomes after nerve and seminal sparing radical cystectomy for the treatment of organ confined bladder cancer.

PURPOSE: We assessed postoperative clinical outcomes such as day and nighttime urinary continence and overall sexual function in patients who underwent nerve and seminal sparing cystectomy with ileocapsuloplasty compared with patients after standard cystoprostatectomy with similar orthotopic urinary reservoir. MATERIALS AND METHODS: A total of 27 patients (mean age 52 years, range 36 to 61) with superficial high risk or muscular invasive T2 bladder cancer underwent radical nerve and seminal sparing cystectomy with ileocapsule anastomosis. Postoperative clinical outcomes such as urinary continence, voiding patterns and urodynamic parameters were evaluated at 3, 6 and 12 months, while overall sexual function was determined at baseline and at 6 and 12-month followup. RESULTS: Nerve and seminal sparing cystectomy provides better outcomes in terms of urinary and urodynamic parameters compared to standard cystoprostatectomy. Furthermore, fully normal postoperative erectile function and satisfactory overall sexual quality of life were documented at early and delayed followup in all patients. A retrograde ejaculation with reliable sperm retrieval from urine was also documented. CONCLUSIONS: Although these findings need to be confirmed in a larger patient population, when respecting rigorous patient selection criteria and careful postoperative surveillance, nerve and seminal sparing cystectomy seems to offer satisfactory clinical and functional outcomes. From an oncological point of view, long-term followup is of paramount importance to confirm whether this surgical procedure can be proposed as a valid choice of treatment for young, fully potent and socially active patients with organ confined bladder cancer.