The role of vacuum-assisted closure (VAC) therapy in the management of FOURNIER'S gangrene: a retrospective multi-institutional cohort study.

PURPOSE: To explore the role of vacuum assisted closure (VAC) therapy versus conventional dressings in the Fournier's gangrene wound therapy. PATIENTS AND METHODS: This is a retrospective multi-institutional cohort study. Data of 92 patients from nine centers between 2007 and 2018 were retrospectively analyzed. After surgery, patient having a local or a disseminated FG were managed with VAC therapy or with conventional dressings. The 10-weeks wound closure cumulative rate and OS were analyzed. RESULTS: Of the 92 patients, 62 (67.4%) showed local and 30 (32.6%) a disseminated FG. After surgery, 19 patients (20.7%) with local and 14 (15.2%) with disseminated FG underwent to VAC therapy; 43 (46.7%) with local and 16 (17.4%) with disseminated FG were treated using conventional dressings. The multivariable logistic regression analysis demonstrated that the VAC in patients with disseminated FG led to a higher cumulative rate of wound closure than patients treated with no-VAC (OR = 6.5; 95% CI 1.1-37.4, p = 0.036). The Kaplan-Meier survival curves for the OS showed a significant difference between no-VAC patients with local and disseminated FG (OS rate at 90 days 0.90, 95% CI 0.71-0.97 vs 0.55, 95% CI 0.24-0.78, respectively; p = 0.039). Cox regression confirmed that no-VAC patients with disseminated FG showed the lowest OS (hazard ratio adjusted for sex and age HR = 3.4, 95% CI 1.1-10.4; p = 0.033). CONCLUSIONS: In this large cohort study, VAC therapy in patients with disseminated FG may offer an advantage in terms of 10-weeks wound closure cumulative rate and OS at 90 days after initial surgery.

Saphenous-sparing laparoscopic inguinal lymphadenectomy.

INTRODUCTION: Inguinal lymphadenectomy is an integral part in the management of penile cancer. Video endoscopic in-guinal lymphadenectomy (VEIL) is emerging as a minimally invasive treatment to reduce postoperative complications. MATERIALS AND METHODS: 62 years old man underwent glansectomy for a squamous cell carcinoma (pT1b). At the physical examination one left inguinal lymph node was detectable (cN1). The chest-abdomen-pelvis CT was negative for me-tastasis. A 10-mm optical trocar and two 5mm operating trocar were placed. The optical trocar was placed in the apex of Scarpa's triangle after a skin incision and after the creation of a subcutaneous space by blunt finger dissection. The pCO2 was 8-10mmHg. The surgical technique involved the removal of superficial lymph nodes according to the scheme described by Deseler and of the deep lymph nodes. Sparing main venous structures and closing lymphatic vessels is im-portant to reduce post operative complications. At the end of the procedure, a suction drain was placed per side. RESULTS: Operative time was 90 minutes per side. Drains were removed on the seventh postoperative day. Hospital stay was 8 days and no postoperative complications occurred. The total number of nodes removed was 16 (8 per side) with 2 superficial positive nodes on the left side. CONCLUSION: ILND is burned by a high complication rate. VEIL provides a less invasive approach and a saphenous-sparing technique ensures a lower complication rate, reducing lymphorrhea, skin necrosis and wound complications (1-3). In experienced laparoscopic hands, VEIL is a safe and effective treatment.

Renal angiomyolipoma with renal vein invasion.

Renal angiomyolipoma is a uncommon benign tumor, considered an hamartoma. The lesion, usually benign, can be single or multiple and well-circumscribed. In letterature only few cases of infiltrating angiomyolipomas have been described. The aim of the paper is to describe a paradigmatic case of a giant kidney angiomyolipoma, not associ- ated with tuberous sclerosis, invading the pelvis and the renal vein. The lesion have been discovered incidentally during abdominal ultrasound for other pathology. Owing to the extent of the lesion and the appreciable risk of bleeding, we opted for surgical treatment.

ProACT in the management of stress urinary incontinence after radical prostatectomy. What happens after 8 years of follow up? monocentric analysis in 42 patients.

OBJECTIVES: Stress urinary incontinence is defined by a complaint of any involuntary loss of urine on effort or physical exertion or on sneezing or coughing and represents a major complication after radical prostatectomy. According to surgical technique, incidence of post-prostatectomy incontinence varies from open (7-39.5%), laparoscopic (5-33.3%) or robotic-assisted (4-31%) approaches. The ProACT® device (Uromedica, Inc., MN) is a possible surgical option for the treatment of this condition. METHODS: We retrospectively analyzed surgical records of consecutive patients underwent ProACT® implantation in our department between January 2006 to November 2010. We collected data at 6 and 12 months after surgical approach about the daily pad use, International Prostatic Symptoms Score and its quality of life domain. RESULTS: 42 patients were included in the final analysis. Most patients (92.9%) received minimally invasive surgery for treating prostate cancer. During the follow up after 6 and 12 months, the daily pad, International Prostatic Symptom Score and its quality of life domain significantly improved compared to preoperative outcomes. The logistic regression analysis found that presence of comorbidities was the only predictive factor of low satisfaction rate (PGE-I > 2) in patients who underwent ProACT® implant. CONCLUSIONS: ProACT® implant represents an effective and safe treatment for post-prostatectomy stress urinary incontinence with a high satisfaction degree and a low rate of complications.

The microbiological profile of patients with Fournier's gangrene: A retrospective multi-institutional cohort study.

OBJECTIVES: To evaluate the role of the microbiological profile and of disease-related factors in the management of patients affected with Fournier's gangrene (FG). PATIENTS AND METHODS: Data regarding patients admitted for FG at nine Italian Hospitals (March 2007-June 2018) were collected. Patients were stratified according to the number of microorganisms documented: Group A - one microorganism; Group B - two microorganisms; Group C - more than three microorganisms. Baseline blood tests, dedicated scoring systems, predisposing risk factors, disease's features, management and post-operative course were analyzed. UpSet technique for visualizing set intersections in a matrix layout and Cuzick's nonparametric test for trend across ordered groups were used. RESULTS: Eighty-one patients were available for the analysis: 18 included in Group A, 32 in Group B, 31 in Group C. The most common microorganism isolated was Escherichia coli. In Group B-C, Escherichia coli was often associated to Enterococcus faecalis, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Statistically significant positive association was highlighted among the number of pathogens (Group A vs B vs C) and serum C-reactive Protein (p < 0.001), procalcitonin (p = 0.02) and creatinine (p = 0.03). Scoring systems were associated with the number of microorganisms detected (p < 0.02). A significant association between the number of microorganisms and the use of VAC therapy and need of a fecal diversion was found (p < 0.02). The number of microorganisms was positively associated with the length of stay (LOS) (p = 0.02). Ten weeks after initial debridement, wound closure was achieved in 11 (91.7%), 22 (84.6%) and 20 (80%) patients in Group A, B, and C, respectively, with no differences in overall survival. CONCLUSION: Polymicrobial infections in FG are positively associated with inflammatory scores, the need for fecal diversion and the LOS. This results may help the counseling and the clinical management of this rare niche of patients.

The role of renal biopsy to improve small renal mass diagnosis and management: are there predictive factors for a higher detection rate?. The first Italian study of 100 cases.

BACKGROUND: Incidence of small renal masses (SRMs) has increased over the last decade: in order to reduce overtreatment of benign lesions, renal tumor biopsy (RTB) has been advocated. The primary aim of this study were to establish the rate of diagnostic biopsies and the concordance rate between RTB and surgical pathology with regard to tumor histology. The secondary aim was to identify what predictive factors are associated with an initial diagnostic biopsy. METHODS: We retrospectively analyzed RTB performed in our center in patients with SRMs between 2015 and 2017. We assessed patient demographics and clinical status, lesion characteristics and procedural factors. The categorical variables were tested with the chi-square test. We used univariate and multivariate analysis to identify what factors are indicative of non-diagnostic biopsies. We used the SPSS statistics v. 23. RESULTS: We performed a total of 100 RTBs to management 94 patients. The initial biopsy was diagnostic in 88 patients (67 malignant and 21 benign lesion). The six remaining patients had repeat biopsies, of which four were diagnostic. Complications rate was 5% prevalently local hematoma treated with surveillance. Agreement between biopsy and surgical histology was found in 94% of cases. On contingency analysis and on univariate and multivariate analysis, these factors (age, tumor size, exophytic location, and type of imaging used) were not predictive with diagnostic biopsy. CONCLUSIONS: RTB for SRMs helps establish pre-treatment diagnosis, reduce overtreatment, with a low risk of complications and high diagnostic rate. In our experience, we did not find predictive factors more likely associated with a diagnostic biopsy.

Fusion US/MRI prostate biopsy using a computer aided diagnostic (CAD) system.

BACKGROUND: The aim of this study was to investigate the impact of computer aided diagnostic (CAD) system on the detection rate of prostate cancer (PCa) in a series of fusion prostate biopsy (FPB). METHODS: Two prospective transperineal FPB series (with or without CAD assistance) were analyzed and PCa detection rates compared with per-patient and per-target analyses. The χ2 and Mann-Whitney test were used to compare categorical and continuous variables, respectively. Univariable and multivariable regression analyses were applied to identify predictors of any and clinically significant (cs) PCa detection. Subgroup analyses were performed after stratifying for PI-RADS Score and lesion location. RESULTS: Out of 183 FPB, 89 were performed with CAD assistance. At per-patient analysis the detection rate of any PCa and of cs PCa were 56.3% and 30.6%, respectively; the aid of CAD was negligible for either any PCa or csPCa detection rates (P=0.45 and P=0.99, respectively). Conversely in a per-target analysis, CAD-assisted biopsy had significantly higher positive predictive value (PPV) for any PCa versus MRI-only group (58% vs. 37.8%, P=0.001). PI-RADS Score was the only independent predictor of any and csPCa, either in per-patient or per-target multivariable regression analysis (all P<0.029). In a subgroup per-patient analysis of anterior/transitional zone lesions, csPCa detection rate was significantly higher in the CAD cohort (54.5%vs.11.1%, respectively; P=0.028), and CAD assistance was the only predictor of csPCa detection (P=0.013). CONCLUSIONS: CAD assistance for FPB seems to improve detection of csPCa located in anterior/transitional zone. Enhanced identification and improved contouring of lesions may justify higher diagnostic performance.

A retrospective multicentric analysis on testicular torsion: is there still something to learn?

INTRODUCTION AND AIM: Speedy diagnosis are mandatory in testicular torsion, nevertheless some cases of irreversible ischemia still occur. In this study we analysed the results of patients undergoing surgical exploration for acute scrotum. MATERIALS AND METHODS: A multicentric retrospective clinical evaluation was carried out on patients who underwent urgent scrotal exploration at 12 different departments in North-Eastern Italy. Data included complete anagraphic information, clinical presentation, numeric pain rating scale, previous testicular surgery, Doppler serial ultrasonography (US) evaluation and concordance with surgical findings, testicular mobility, surgical treatment, staged or concurrent treatment of the contralateral gonad. Statistical analysis was conducted both for descriptive and inferential statistics with SPSS v26. RESULTS: Three hundred and sixty-eight cases were collected between January 2010 and June 2019. The time between symptom onset and ER access time was within 6 h in majority of patients. However, 17.4% of subject presented after more than 12 h. In patients undergoing US, this showed signs of ischemia in 237 patients (77.2%) and normal vascularisation in 70 (22.8%) of whom 26 had signs of testicular torsion at surgical exploration. Overall, the US data were concordant with the surgical findings in 254 cases (82.7%). A significant association was found between time-to-evaluation and time-to-treatment and the need for orchiectomy (p < 0.01). CONCLUSION: Testicular torsion management is still challenging in terms of time-saving decision making. Scrotal US is helpful, but even in the contemporary its sensitivity is low era in a non-neglectable number of cases, therefore surgical exploration is warranted in acute scrotum when torsion cannot be ruled out, even when US shows vascularisation.

Laparascopic heminephrectomy in horseshoe kidney: a case report.

We present a case of laparoscopic transperitoneal heminephrectomy involving a large renal cell carcinoma of 7 cm centrally located on the left side of a horseshoe kidney in a 48 years old male patient detected by ultrasound scan and CT scan.

Chylous ascites following laparoscopic adrenalectomy: case report and literature review.

We report a case of chylous ascites developing the first post-operative day after laparoscopic adrenalectomy. The early initiation of treatment with total parenteral nutrition and somatostatin analog led to rapid resolution of the ascites. To the best of our knowledge, this is the first case of chylous ascites after laparoscopic adrenalectomy and we report it to stress the need for greater awareness and attention (meticulous dissection, permanent use of hemoclips and/or suture ligatures instead of electrocautery) even for simpler laparoscopic urologic procedures.

"Capio" for laparoscopic radical prostatectomy: a useful device.

Vesico-urethral anastomosis is a technically challenging part of the laparoscopic radical prostatectomy. Our aim was to simplify the anastomosis-step by adopting a new device "Capio" (Boston Scientific), already known in open surgery, together with "Alesix" (Applied), a device used in hand assisted laparoscopy.

Laparoscopic transperitoneal adrenalectomy for adrenocortical oncocytoma.

A middle aged male patient (39 year old) presented with right renal pain. During evaluation a small renal stone was found in the right kidney, and a mass 6 cm in diameter related to the upper pole of the left kidney was discovered. An endocrinologic evaluation was negative and a laparoscopic transperitoneal adrenalectomy was performed. Final pathology was adrenocortical oncocytoma with malignant potential.

Laparoscopic nephron sparing surgery: a multi-institutional European survey of 592 cases.

Laparoscopic Nephron Sparing Surgery (LNSS) is a technically challenging procedure. Technical aspects and the outcome of LNSS are investigated. A total of 592 LNSS procedures were collected from 12 Centres, either in extraperitoneal or transperitoneal fashion. Mean tumor size was 2.2 cm. Eight centers reported on tumor position for a total of 407 cases with 338 exophytic tumors (83%) and 69 deep lesions (17%). Four centers, accounting for 185 cases, did not report on tumor position. All the centers performed their LNSS by clamping the hilum. The warm ischemia time was < 30 min in all the centers. The positive margin rate was 2% (12/592). Hemostatic agents and/or sealant or tissue glues were used in 86% of cases (511/592). Types of sealants used included: gelatine matrix (Floseal), fibrin gel (Tissucol), bovine serum albumin (BioGlue) and cianacrylate (Glubran). Two Centres never used sealants, one center used only sealants without suturing and 9 centers used a combination of sealants and bolstering-sutures. The intraoperative open conversion rate was 3.5% (21/592). Postoperative complications included bleeding in 15/592 (2.5%) and urine leak in 13/592 (2.1%). No tumor seeding was reported. LNSS has similar results of open partial nephrectomy. The use of hemostatic agents and/or sealants or tissue glues during LNSS is largely diffuse in European centers and may be an effective add on reducing bleeding and urine leakage when used in combination with bolstering-suturing.

A Novel Technique for Robotic Simple Prostatectomy: An Evolution of Retzius-sparing Technique.

OBJECTIVE: To present a novel surgical concept by using the trans-Douglas approach to perform a robotic-assisted simple prostatectomy (RASP) for high-volume benign prostate hyperplasia. This transposition from oncological surgery enables performance of a better bladder neck sparing adenomectomy with good functional results. MATERIALS AND METHODS: The index patient is a 67-year-old man with a history of severe urinary flow outlet obstruction. Combination medical therapy is not effective. Transrectal ultrasound scan detected a 130-cm3 enlarged prostate with middle lobe. The International Prostate Symptoms Score (IPSS) was 30. The patient was scheduled for a RASP with a trans-Douglas approach to preserve the bladder neck. The patient was put in 30° Trendelenburg position. Six ports were placed across the lower abdomen: four 8-mm robotic trocars and 2 assistant trocars (12 and 5 mm). The parietal peritoneum was incised at the anterior surface of the Douglas space, according to the access to the prostate described by Bocciardi. The Denonvillier fascia was opened, seminal vesicles were exposed, and above the vesicles, the prostatic capsule was incised. The adenoma, together with the middle lobe, was split by the capsule from the base to the verumontanum. The bladder neck was advanced and remodeled to the distal urethral mucosa and then closed to the prostatic capsule by a double-layer suture. The peritoneal breach was closed. RESULTS: The operation time was 120 minutes. Blood loss was 80 cc. There was no perioperative or postoperative complication. The catheter was removed after 4 days. Uroflowmetry showed a peak flow of 30 mL/s. Pathologic examination was negative for tumor. After 60 days, the IPSS score was 8. CONCLUSION: Trans-Douglas-RASP is a safe and effective minimally invasive treatment for benign prostate hyperplasia. It is a novel technique to perform bladder neck sparing prostatic adenomectomy and could be 1 more field of application of robotic technology.

Robotic-assisted partial nephrectomy: experience on 60 cases.

INTRODUCTION: Laparoscopic partial nephrectomy is still one of the more challenging procedures in urology. Minimizing warm ischemia time (WIT) and bleeding requires efficient intracorporeal suturing. In addition, achieving negative surgical margins requires complete excision of the tumor. Robotic-assisted partial nephrectomy (RALPN) adds the advantages offered by the "Da Vinci system" to laparoscopy, such as the 3-D vision, and the better degree of freedom of surgical instruments. OBJECTIVE: The objective of this study is to report our experience with RALPN. METHODS: From August 2009 to October 2012, 60 patients underwent RALPN for kidney cancer. The average age of the patients (35 female, 25 male) was 63 (range 48-80) years. Average BMI was 25 (range 21.8-29.7) kg/m2. Average tumor size was 3.2 cm (range 2-6.7 cm). All the procedures were performed by a transperitoneal approach. Ilar clamping was used in all cases: in 47 patients by one intracorporeal tourniquet for the artery and one for the vein; in three cases, ilar clamping was "en block" by Satinsky. RESULTS: Mean operative time was 167.2 min (140-250) with a WIT of 23.8 min (15-28). The mean estimated blood loss was 260 mL (50-300). In one case, nephrectomy was necessary because the tumor involved the renal pedicle. One patient had pulmonary embolism and one urinary leakage conservatively managed.Pathologic examination revealed clear cell renal cell carcinoma in 58 patients, oncocytoma in one patient, and angiomyolipoma in one patient. All resection margins were free from tumor. CONCLUSIONS: Partial nephrectomy, facilitated by robotic technology, is more and more frequently performed as a safe and effective minimally invasive procedure.

Neoadjuvant sunitinib effectiveness in T4 renal clear cell carcinoma: a case report.

INTRODUCTION: Sunitinib therapy showed an improvement in survival of patients with metastatic renal cell carcinoma. MATERIALS AND METHODS: A 51-year-old man, with Eastern Cooperative Oncology Group Score (ECOG) of 0, presented at our Institute in March 2012 for macrohematuria and urinary retention. A computed tomography (CT) scan of the abdomen showed a right renal lesion. The lesion had a diameter of 15 cm and was developing towards the liver, in the absence of cleavage planes between the liver and kidney. A 12 mm finding, suspected as secondary lesion, was detected at the level of the VII hepatic segment. Neoadjuvant chemotherapy with Sunitinib was proposed. RESULTS: The patient underwent a ultrasound-guided biopsy, which confirmed the presence of Clear Cell Carcinoma. The patient began chemotherapy treatment in May 2012 according to the scheme SUNITINIB 50 mg daily for 4 weeks every 6 weeks. After four courses of treatment, according to RECIST criteria for solid tumors, 40% (9 cm vs 15 cm) regression of the primary tumor and 33% (8 mm vs 12 mm) regression of the secondary lesion were observed at a CT scan of the abdomen. In February 2013, Laparoscopic Adrenal-Sparing Radical Nephrectomy was performed. At a follow-up of 3 months, performed with a thorax and abdomen CT scans, there was a complete remission of hepatic secondary lesion and no areas of secondary localization of disease. CONCLUSION: This case report showed the effectiveness of neoadjuvant chemotherapy with Sunitinib. The use of this chemotherapy agent can change the approach to the management of cRCC.

Comparison of Contrast-Enhanced Ultrasound Scan (CEUS) and MRI in the follow-up of cryoablation for small renal tumors. Experience on 25 cases.

INTRODUCTION: Percutaneous ablation in the kidney is now performed as a standard therapeutic nephron-sparing option in patients who are poor candidates for resection. Its increasing use has been largely prompted by the rising incidental detection of renal cell carcinomas with cross-sectional imaging and the need to preserve renal function in patients with comorbid conditions, multiple renal cell carcinomas, and/or heritable renal cancer syndromes. To date, clinical studies indicate that cryoablation is an effective therapy with acceptable short- to intermediate-term outcomes and with a low risk in the appropriate setting. 
This article focuses on the efficiency of contrast enhanced ultrasound scan (CEUS) as compared to contrast enhanced magnetic resonance imaging (MRI) during the follow-up after cryoablation of small renal tumors.
 MATERIAL & METHODS: In our Department, percutaneous or laparoscopic assisted cryoablation is offered in the treatment of small renal masses. 
Between January 2009 and January 2013, 25 patients (pts) were treated with laparoscopic assisted cryoablation or percutaneous cryoablation for renal tumors <3.5 cm in pts unfit for surgery. All pts had severe comorbidities (ASA score 3). Transperitoneal laparoscopic approach was performed in 11 pts, extraperitoneal approach in 3 pts, percutaneous technique was performed in 11 patients. "Tru-cut biopsy" of the renal mass was always performed before cryoablation.
 The SeedNet system (Galil Medical, Arden Hills, MN) was used in 12/25 pts; the Precise system (Galil Medical, Arden Hills, MN) was used in 13/25 pts. In all cases, IceRod needles were used. Real-time ultrasound guidance was used to localize the tumour and to monitor the progression of "iceball". A double "freeze-thaw cycle" was used. 
All pts had MRI and CEUS before cryoablation and the follow-up consisted in CEUS/MRI every 3 months during the first year and every 6 months thereafter.
 RESULTS: The mean age of the 25 pts was 67.7 years (range 56-79); 5 pts were females and 20 were males. The mean tumor size was 2.8 cm (range 1.5-3.5). No patient required conversion to open procedure. 19 tumors were located at the lower pole, 4 were interpolar and 2 tumors were located at the upper pole. There were no intraoperative complications. The mean hospital stay was 4 days (range 1-7). Two pts required a blood transfusion; there was no statistically significant difference between preoperative and postoperative serum creatinine levels. The biopsy showed RCC in all cases. In 24/25 patients both CEUS and MRI showed no enhancement. In 1/25 pts, during the follow-up, CEUS and MRI showed a well visible recurrence at the perfusion study. It was histologically confirmed. The final results of CEUS and MRI were concordant in all pts. CONCLUSIONS: CEUS is effective during the follow-up of renal tumor cryoablation. It could be an alternative technique to standard CT and MRI, with some advantages: low cost, short time consuming procedure, no radiation exposure, reduced amount of contrast agent (1-2 mL) and rare adverse reactions.

Is ureteral stent placement by the transurethral approach during robot-assisted radical prostatectomy an effective option to preoperative technique?

Ureteral stent placement may be needed in patients undergoing robot-assisted radical prostatectomy (RARP) in cases of a large median lobe or previous transurethral surgery to prevent damage to the ureteral orifices. Unpredictable anatomic variants or technical difficulties in bladder neck section may necessitate intraoperative stent placement. We describe our original, simple, and feasible transurethral stent placement technique during RARP, which could be a valid option to preoperative technique.