Robotic-assisted vs. open ureteral reimplantation: a multicentre comparison.

PURPOSE: Open ureteral reimplantation is considered the standard surgical approach to treat distal ureteral strictures or injuries. These procedures are increasingly performed in a minimally invasive and robotic-assisted manner. Notably, no series comparing perioperative outcomes and safety of the open vs. robotic approach are available so far. METHODS: In this retrospective multi-center study, we compared data from 51 robotic ureteral reimplantations (RUR) with 79 open ureteral reimplantations (OUR). Both cohorts were comparatively assessed using different baseline characteristics and perioperative outcomes. Moreover, a multivariate logistic regression for independent predictors was performed. RESULTS: Surgery time, length of hospital stay and dwell time of bladder catheter were shorter in the robotic cohort, whereas estimated blood loss, postoperative blood transfusion rate and postoperative complications were lower than in the open cohort. In the multivariate linear regression analysis, robotic approach was an independent predictor for a shorter operation time (coefficient - 0.254, 95% confidence interval [CI] - 0.342 to - 0.166; p < 0.001), a lower estimated blood loss (coefficient - 0.390, 95% CI - 0.549 to - 0.231, p < 0.001) and a shorter length of hospital stay (coefficient - 0.455, 95% CI - 0.552 to - 0.358, p < 0.001). Moreover, robotic surgery was an independent predictor for a shorter dwell time of bladder catheter (coefficient - 0.210, 95% CI - 0.278 to - 0.142, p < 0.001). CONCLUSION: RUR represents a safe alternative to OUR, with a shorter operative time, decreased blood loss and length of hospital stay. Prospective research are needed to further define the extent of the advantages of the robotic approach over open surgery.

Robot-assisted radical prostatectomy for the treatment of radiation-resistant prostate cancer: surgical, oncological and short-term functional outcomes.

OBJECTIVE: The objective of this study was to assess the surgical, oncological and short-term functional outcomes in patients undergoing salvage robot-assisted radical prostatectomy (SRARP) for the treatment of radiation-resistant prostate cancer. PATIENTS AND METHODS: The records of 3,500 men who underwent RARP from February 2006 to July 2011 were retrospectively reviewed. All peri- and postoperative data were recorded prospectively in our database. A total of 13 patients (0.37%) who had undergone SRARP for the treatment of radiation-resistant prostate cancer were identified. RESULTS: The primary treatment was external beam radiotherapy in 7 patients (53.8%) and brachytherapy in 6 patients (46.2%). The interval from radiotherapy to biochemical recurrence (BCR) varied from 12 to 108 months (median 48.9). Neurovascular bundle preservation was performed in 3 patients (23.1%). No intraoperative or major complications were encountered. Minor complications were encountered in 4 patients (30.7%). At 12 months, 7 patients were continent (53.8%), 3 exhibited mild incontinence (23.1%) and 3 (23.1%) were incontinent. Regarding potency, none of the patients were potent at 6 months, but 3 patients (23.1%) were potent at 1 year. Regarding BCR, 3 of the patients (23.1%) never reached a prostate-specific antigen nadir of zero, and during the follow-up period only 3 patients (23.1%) exhibited BCR. No disease-specific mortality was evident during follow-up. CONCLUSIONS: Although early in its development, it appears that SRARP is technically feasible and offers satisfactory surgical, oncological and short-term functional outcomes.

Robot-assisted radical prostatectomy in patients with a pathologic prostate specimen weight ≥100 grams versus ≤50 grams: surgical, oncologic and short-term functional outcomes.

INTRODUCTION: The objective of this study is to evaluate the surgical, oncological and short-term functional outcomes in patients with a pathologic prostate specimen weight ≥100 g versus patients with a pathologic prostate specimen weight ≤50 g undergoing robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: The records of 4,000 men who underwent RARP from February 2006 to April 2012 were reviewed retrospectively. A total of 185 men had a pathologic prostate specimen weight ≥100 g (group A). A matched pairs analysis was performed using our database to identify men with a pathologic prostate specimen weight ≤50 g but with equivalent clinicopathologic characteristics to serve as the control group (group B). RESULTS: Our results indicated that although the intraoperative results were more than satisfying in patients with large glands, there is a significant increase in blood loss, operative time needed, increased need for bladder neck reconstruction as well as an increase in intraoperative complications. Nevertheless, patients with large glands exhibit less aggressive tumors, less positive surgical margins and a lower incidence of biochemical recurrence. Regarding functional outcomes, patients with larger glands had no difference regarding continence rates when compared to patients with smaller glands but exhibited significantly lower potency rates. CONCLUSIONS: Although RARP in patients with a pathologic prostate specimen weight ≥100 g is technically challenging, in experienced hands it can be considered a safe procedure with excellent surgical, oncological and functional outcomes. Nevertheless, this conclusion is limited, in that it is from a single institution with a large case volume and may not be reflective of outcomes at centers with smaller volumes and less experience.

Multicentric comparative analysis of Retzius versus Retzius sparing robotic assisted simple prostatectomy in the management of large prostate glands.

AIM: Robot-assisted simple prostatectomy (RASP) is a minimally invasive alternative to open simple prostatectomy in the management of patients with large prostate glands suffering from moderate-to-severe lower urinary tract symptoms (LUTS). Our study aimed to evaluate two transvesical robotic approaches in order to compare functional outcomes and postoperative complications. MATERIALS AND METHODS: Clinical data from 111 consecutive patients from three tertiary robotic centers were retrospectively collected. Patients were divided into two groups depending on the surgical approach: 58 Retzius sparing and 53 Retzius approach RASP. We evaluated peri-operative outcomes (operating time, blood loss, transfusion rate, length of hospital stay), as well as intra-operative and early complications using a Clavien Dindo scale. Fisher's exact test, chi-square test and Mann-Whitney U test were applied for statistical analyses. A p-value <0.05 was considered statistically significant. RESULTS: Neither subgroup differed significantly in age (p = 0.104), Charlson comorbidity index (p = 0.088) or prostate volume (p = 0.507), total IPSS score (0.763) and Qmax (p = 0.651). Total complication rates were lower for the Retzius approach subgroup (19 vs 11.9%) without reaching statistical significance in multivariate analysis (HR = 1.21, 95% CI = 0.17 - 8.44, p = 0.84). No significant differences based on IPSS total score and Qmax could be observed between the two subgroups during follow-up. CONCLUSIONS: Both RASP approaches provide similar results in terms of functional outcomes and present a good safety profile in the management of large prostatic adenomas. Larger trials are needed in order to establish the indications for each robotic technique.

Challenges in Diagnosis of Uretero-Arterial Fistulas after Complex Pelvic Oncological Procedures-Single Center Experience and Review of the Literature.

Introduction: Uretero-arterial fistula (UAF) represents a rare condition that manifests as massive or intermittent hematuria and requires collaboration between a urologist, vascular surgeon and interventional radiologist. In this article, we present our experience with UAF diagnosis, treatment pathways and the results of a nonsystematic review of the literature published in the last decade regarding modern diagnostic procedures. Material and method: We analyzed the clinical data of nine consecutive patients from our institution diagnosed with UAF in the interval of 2012-2022 who underwent open or endovascular surgical treatment. We reviewed patient characteristics, diagnoses and treatment pathways. The literature search resulted in 14 case series, published from 2012 to 2022, describing a total of 670 cases of UAF. Results: The mean age of patients in our cohort was 65.3 years (IQR: 51-79). UAFs were more common in women (77.7%). All patients presented a history of surgical intervention and ir-radiation for pelvic malignancy with permanent ureteric stenting. Overall, 88.8% of patients had urinary diversion, either via ileal conduit or cutaneous ureterostomy. The most common clinical manifestation of UAF was gross hematuria with or without clots accompanied by flank pain due to stent obstruction, while three patients presented with hypovolemic shock. Angiography represents the best option for diagnosis, followed by angioCT, with a sensitivity of 59.83% and 47.01%, respectively. There is no definitive imaging modality associated with high accuracy in detecting UAF and negative findings do not exclude the disease. In emergency cases with massive bleeding, surgical exploration remains the most appropriate management option for both diagnosis and treatment. Endovascular stent graft placement is preferred over open surgery in stable hemodynamic patients. Conclusions: Uretero-arterial fistulas represent a life-threatening complication and must be treated with great awareness. Angiography represents the best modality for diagnosis, followed by computed tomography. However, there is no definitive imaging modality and, in some cases, open approach remains the only option for diagnosis and treatment.

Urethral diverticulum with massive lithiasis presenting as a scrotal mass.

Urethral diverticula in men are uncommon clinical entities. Their clinical manifestations include urinary tract infection, hematuria, irritative or obstructive voiding symptoms, ventral bulging and displacement of the penile shaft. Male urethral diverticulum with massive lithiasis presenting as a scrotal mass with stress urinary incontinence as the main symptom is extremely rare. Herein, we present such a case.

Sexual dysfunction after rectal surgery: a retrospective study of men without disease recurrence.

INTRODUCTION: Sexual dysfunction is a frequent complication of visceral surgery after rectal resections as a result of carcinoma of the rectum. AIM: The purpose of our study is to assess the incidence and form of sexual dysfunction in our own population of patients. METHODS: The study comprised all patients who had undergone surgery for carcinoma of the rectum at the Erlangen Surgery University Hospital, Germany, in the period 2000-04. All male patients were retrospectively surveyed and asked to complete standardized (International Index of Erectile Function 15) questionnaires regarding their pre- and postsurgical sexual function. One hundred and forty-five questionnaires could be analyzed. The statistical evaluation was conducted with aid of the SPSS statistics program. The univariate analysis was carried out with the chi-square test and the U-test (Mann-Whitney Test). MAIN OUTCOME MEASURES: Erectile dysfunction, libido, and ability to have and sustain ejaculation and orgasm (both before and after surgery in each case) were among the dependent variables when compiling the data. The impact various surgical procedures and radiochemotherapy had on the severity of the sexual dysfunctions was analyzed. The scope of the postoperative urological care given was also assessed. RESULTS: Erectile dysfunction was confirmed in N=112 patients (77.3%) after surgery (P-value<0.001). Other parameters such as orgasm capacity (4.1% vs. 16.5%), ejaculation ability (1.4% vs. 12.4%) and libido (3.4% vs. 22%) also showed a marked deterioration postoperatively. Postoperative erectile dysfunction was present in 77% of the patients with a colostomy and in 88.5% of the patients who had received neoadjuvant radiation. CONCLUSIONS: Male erectile dysfunction is a frequent complication after rectal resection as a result of carcinoma of the rectum. The high incidence of sexual dysfunctions results from the radical nature of the procedure and from additional radiation or colostomy therapy. These patients need accompanying urological care for treatment of their sexual dysfunction.

Empyema of the ureteral stump. An unusual complication following nephrectomy.

A ureteral stump, which is the segment of the ureter left in place after nephrectomy, may occasionally give rise to a pathologic process called ureteral stump syndrome, which is clinically interpreted as febrile urinary tract infections, lower quadrant pain, and hematuria. Empyema of the ureteral stump, which belongs to this syndrome, is an uncommon disease entity presenting with a reported incidence of 0.8-1%. We present a case of empyema of the ureteral stump in a female patient 5 years postnephrectomy for a nonfunctioning kidney, and discuss the clinical presentation, radiologic diagnosis, and therapeutic options of this uncommon disease entity.

Radical nephrectomy and nephroureterectomy in patients over 80 years old.

PURPOSE: The aim of this study was to discover if elderly patients exhibit comparable outcomes and survival benefits to those achieved in younger patients. MATERIALS AND METHODS: We assessed 35 patients over 80 years old treated by radical nephrectomy or nephroureterectomy for malignant and inflammatory conditions within the previous 4 years. A multivariate analysis regarding survival and recovery was conducted and included various preoperative parameters. The subjective opinion of patients or patient's relatives (in cases where the patient had past away) was estimated by answering the following questions: (a) are you satisfied with your decision to undergo the operation? (b) would you undergo it once more if needed? (c) would you advise it to a patient your age? RESULTS: The median age was 83.5 years. Radical nephrectomy with a flank approach was performed in 65.7% of cases and nephroureterectomy with a transabdominal approach in 34.3% of cases. The median recovery was 13 weeks. During a median follow-up of 31 months (range 12 to 53), 80% of patients were disease free. The remaining 20% passed away demonstrating a median survival of 25 months (range 13-38). Eighty-eight percent of patients were satisfied with their decision to undergo the operation, 91.4% would undergo it once more if needed and 91.4% would advise it to a patient their age. CONCLUSIONS: Radical nephrectomy and nephroureterectomy are safe and effective in well-selected patients over 80 years old. Elderly patients exhibit comparable preoperative outcomes and survival benefits to those achieved in younger patients. Various preoperative clinical variables that effect the survival of patients but not their recovery could be identified.

Anaplastic sarcoma of the kidney.

Wilms tumor can appear with a wide spectrum of morphologic features and can sometimes cover or delay the recognition of other clinicopathologic entities of the kidney. We present a case of a new tumor entity of the kidney, namely the anaplastic sarcoma of the kidney, a tumor of high malignancy.

A rare case of urinary bladder leiomyosarcoma accompanied by prostate cancer.

Non-urothelial neoplasms of the bladder account for less than 5% of all bladder tumors. Sarcoma constitutes the most usual mesenchymal malignancy of the bladder, with leiomyosarcomas being the most common type of sarcoma in adults. A coexistence of this rare tumor with another malignancy has not been reported, to our knowledge. This report demonstrates a case of high-grade bladder leiomyosarcoma cancer with prostate cancer in a 72-year-old patient. The most striking features of this case include the rapid disease progression that confirms the highly aggressive nature of this uncommon disease.

A case of a large seminal vesicle cyst associated with ipsilateral renal agenesis.

The diagnosis of seminal vesicle cysts is often delayed or missed as a result of both their rarity and wide spectrum of potentially confusing clinical and imaging findings they can produce. Although rare, they should be considered in men, especially with a history of renal agenesis, who exhibit o inexplicable irritable voiding symptoms, perineal discomfort or other genitourinary complaint of unclear etiology. We introduce such a case, and discuss its symptoms, radiological findings and its therapeutic approach.

Spontaneous rupture of the urinary bladder 10 years after curative radiotherapy.

It has been reported that the rate of clinically relevant side effects following curative radiotherapy for primary carcinoma is about 3% for urologic complications. Such complications include hematuria, fibrosis, and cystitis. An extremely rare, but dangerous, medical complication following curative radiotherapy that can also be noted is spontaneous bladder perforation. We present such a case of a 27-year-old patient with spontaneous bladder perforation, who was initially misdiagnosed because of its rarity as well as unspecific clinical and laboratory findings.

Dry gangrene of the penis induced by a bullring for sexual stimulation purposes.

Dry gangrene of the penis is a critical clinical condition provoked by vascular compromise that can lead to severe complications. Although usually caused by diabetes mellitus or due to end-stage renal disease, in these last years, there has been an increase of penile gangrene incidents induced by penile strangulation due to constricting devices for sexual stimulation purposes. We present such a case and discuss the correct approach for treatment of this unusual condition.

Urinary bladder leiomyosarcoma in adults.

INTRODUCTION: Non-urothelial neoplasms of the bladder account for fewer than 5% of all bladder tumors. Sarcoma constitutes the most usual mesenchymal malignancy of the bladder, with leiomyosarcomas being the most common type of sarcoma in adults. PATIENTS AND METHODS: The records of seven patients presenting to two different institutions with bladder leiomyosarcomas between 2003 and 2007 and between 2000 and 2007, respectively, were examined. Cystoscopy, with transurethral resection of the bladder tumor was initially performed in all patients, with leiomyosarcoma being initially diagnosed on the basis of examination of the transurethral specimen. RESULTS: There were N = 5 men and N = 2 women with a median age of 64.8 years at presentation. All seven patients underwent a definitive surgical procedure. Complete resection with negative surgical margins was achieved in all seven patients (100%). MSKCC stage included 86% of patients with stage 3 (N = 6) and 14% with stage 2 (N = 1). A low-grade tumor was evident in one patient only, with the remaining 86% exhibiting a high-grade tumor. DISCUSSION: Leiomyosarcomas of the bladder have always been considered as a highly aggressive entity and little is known about their origin, clinicopathologic presentation, and the survival factors associated with them. Contemporary studies suggest that these tumors may have a better prognosis than once believed. Leiomyosarcomas require aggressive surgical extirpation and, when surgical resection is possible, radical cystectomy with wide margins is the rule and should be performed. Strict adherence to standard surgical technique has resulted in low rates of positive surgical margins and low rates of local tumor recurrence.

Renal cell carcinoma under 35 years of age: comparison of survival rates for symptomatic and asymptomatic patients.

INTRODUCTION: Recent studies suggest that RCC detected in young adults is likely to be more symptomatic and potentially aggressive, since young patients are less likely to undergo radiologic examinations unless they have symptoms. The aim of this study is to identify the clinical, biological and histological entities of RCC in young patients, and to compare survival rates for symptomatic and asymptomatic patients. PATIENTS AND METHODS: A review of 2,510 records of patients with RCC from 1965 to 2007 was conducted. Thirty-four patients under 35 years old were identified. The Kaplan-Meier system was used to calculate the cumulative survival rate at five and ten years post-surgery as well as the survival prognoses for patients who presented with symptoms and for patients for whom RCC was incidentally diagnosed. RESULTS: The differences in cumulative survival rates at five and ten years between patients who presented with symptoms and patients whom RCC was incidentally diagnosed were not significant (P = 0.06). The Kaplan-Meier system used to calculate the cumulative survival rate at five and ten years postsurgery yielded survival rates of 79.4% at five years and 73.5% at ten years, respectively. DISCUSSION: The biological and histological entities as well as the survival prognosis for RCC in young patients are similar to those for patients who present with RCC in the sixth and seventh decades of life. Additionally, young adults are likely to be more symptomatic, but the difference in survival between patients with symptoms and those without symptoms is not statistically significant.

Preoperative Stating of Pelvic Lymph Nodes in Prostate Cancer Patients via Endorectal Magnetic Resonance Imaging.

BACKGROUND/AIM: The aim of this study was to evaluate the diagnostic sensitivity, specificity and accuracy of endorectal magnetic resonance imaging (e-MRI), as a preoperative staging modality in the diagnosis of lymph node metastasis (LNM) in patients with prostate cancer (PCa). PATIENTS AND METHODS: Retrospectively, we analyzed data from N=168 patients who underwent radical prostatectomy (RP) between 2004 and 2013 at two tertiary medical centres. Prior to RP all patients underwent an e-MRI. Inclusion criteria were: PSA levels >20 ng/ml or Gleason score >7. Examinations were performed on a closed 1.0-T system combined with an endorectal body phased-array coil, imaging results were correlated with histopathology. RESULTS: 10.7% (N=18 patients) had histologically-proven LNM. e-MRI was true-positive in N=6 (33.3%) and false-negative N=12 patients (66.6%). N=150 (89.3%) patients without LNM e-MRI were true-negative in 96% and false-positive in 4%. Sensitivity was 96%, specificity was 33%, accuracy was 64.5%. CONCLUSION: e-MRI can be considered a useful preoperative staging modality in diagnosis of LNM.