Efficacy and safety profile of GreenLight laser photoselective vaporization of the prostate in ≥ 75 years old patients: results from the Italian GreenLight Laser Study Group.

BACKGROUND: Benign Prostatic Obstruction (BPO) is the most common non-malignant urological condition among men and its incidence rise with age. Among prostate treatments, GreenLight laser seems to reduce bleeding and would be safer in the aging population. AIMS: We aimed to compare the functional outcomes and safety profile of < 75 years old (Group A) and ≥ 75 years old (Group B) patients. METHODS: In a multicenter setting, we retrospectively analyzed all the patients treated with GreenLight Laser vaporization of the prostate (PVP). RESULTS: 1077 patients were eligible for this study. 757 belonged to Group A (median age 66 years) and 320 to Group B (median age 78 years). No differences were present between the two groups in terms of prostate volume, operative time, hospital stay, PSA decrease over time after surgery, complications and re-intervention rate with a median follow-up period of 18 months (IQR 12-26). Nevertheless, focusing on complications, GreenLight laser PVP demonstrated an excellent safety profile in terms of hospital stay, re-intervention and complications, with an overall 29.6% complication rate in older patients and only two cases of Clavien III. Functional outcomes were similar at 12 month and became in favor of Group A over time. These data are satisfactory with a Qmax improvement of 111.7% and an IPSS reduction of 69.5% in older patients. DISCUSSION AND CONCLUSIONS: GreenLight laser photoselective vaporization of the prostate is a safe and efficient procedure for all patients, despite their age, with comparable outcomes and an equal safety profile.

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

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

The Use of a Combination of Vaccinium Macracarpon, Lycium barbarum L. and Probiotics (Bifiprost®) for the Prevention of Chronic Bacterial Prostatitis: A Double-Blind Randomized Study.

INTRODUCTION: To evaluate the efficacy of Bifiprost® + Serenoa Repens 320 mg versus Serenoa Repens 320 mg alone for the prevention of chronic bacterial prostatitis (CBP) due to enterobacteriaceae. METHODS: Between September 2016 and September 2018, 120 patients with CBP at the National Institutes of Health (NIH type II) with recurrent infections due to enterobacteriaceae (Escherichia Coli and Enterococcus faecalis) were enrolled and randomized into 2 groups each to receive Bifiprost® + Serenoa Repens 320 mg (Group A) or Serenoa Repens 320 mg alone (Group B) daily for 24 weeks (after receiving a proper antibiotic treatment with subsequent culture negativization). The primary endpoint was the reduction in the episodes of prostatitis. The secondary endpoint evaluated was the score of the NIH-Chronic Prostatitis Symptom Index (NIH-CPSI). Evaluation was performed at baseline and at 12, 24, and 36 weeks. RESULTS: The patients of the Group A experienced a significantly larger reduction in the prostatitis episodes than the Group B at 24 and 36 weeks, but they did not experience a significantly larger reduction at 12 weeks. After 12 weeks of treatment, the mean NIH-CPSI score was reduced in both groups compared with baselines, but no significant differences were seen between the Group A and Group B. On the contrary, we observed a significant difference in the mean NIH-CPSI score between the 2 groups at 24 and 36 weeks. CONCLUSION: The association of Bifiprost® and Serenoa Repens 320 mg improves the prevention of the episodes of CBP due to enterobacteriaceae and ameliorates prostatitis-related symptoms after 6 months of therapy. The long-term impact on the entero-urinary route was also seen 3 months after the end of the treatment.

Laparoscopic management of recurrent ureteropelvic junction obstruction following pyeloplasty: a single surgical team experience with 38 cases.

PURPOSE: To describe and analyze our experience with Anderson-Hynes transperitoneal laparoscopic pyeloplasty (LP) in the treatment of recurrent ureteropelvic junction obstruction (UPJO). MATERIALS AND METHODS: 38 consecutive patients who underwent transperitoneal laparoscopic redo-pyeloplasty between January 2007 and January 2015 at our department were included in the analysis. 36 patients were previously treated with dismembered pyeloplasty and 2 patients underwent a retrograde endopyelotomy. All patients were symptomatic and all patients had a T1/2>20 minutes at pre-operative DTPA (diethylene-triamine-pentaacetate) renal scan. All data were collected in a prospectively maintained database and retrospectively analyzed. Intraoperative and postoperative complications have been reported according to the Satava and the Clavien-Dindo system. Treatment success was evaluated by a 12 month-postoperative renal scan. Total success was defined as T1/2≤10 minutes while relative success was defined as T1/2between 10 to 20 minutes. Post-operative hydronephrosis and flank pain were also evaluated. RESULTS: Mean operating time was 103.16±30 minutes. The mean blood loss was 122.37±73.25mL. The mean postoperative hospital stay was 4.47±0.86 days. No intraoperative complications occurred. 6 out of 38 patients (15.8%) experienced postoperative complications. The success rate was 97.4% for flank pain and 97.4% for hydronephrosis. Post-operative renal scan showed radiological failure in one out of 38 (2.6%) patients, relative success in 2 out of 38 (5.3%) patients and total success in 35 out of 38 (92.1%) of patients. CONCLUSION: Laparoscopic redo-pyeloplasty is a feasible procedure for the treatment of recurrent ureteropelvic junction obstruction (UPJO), with a low rate of post-operative complications and a high success rate in high laparoscopic volume centers.

Regulatory T cells, interleukin (IL)-6, IL-8, vascular endothelial growth factor (VEGF), CXCL10, CXCL11, epidermal growth factor (EGF) and hepatocyte growth factor (HGF) as surrogate markers of host immunity in patients with renal cell carcinoma.

OBJECTIVE: To identify a phenotype that could be informative and prognostic in patients with renal cell carcinoma (RCC) peripheral blood was evaluated for TH1, TH2, regulatory T cells (Tregs), natural killer (NK) and NKT cells and for cytokines/chemokines. PATIENTS AND METHODS: Peripheral blood from 77 patients with RCC and 40 healthy controls was evaluated by flow cytometry using monoclonal antibodies against CD4, CD25, FoxP3, CD45RA, CD45RO, CD152, CD184, CD279, CD3, CD16, CD56, CD161, CD158a, CD4, CD26, CD30, CD183 and CD184. A concomitant evaluation of 38 molecules was conducted in patients' serum using a multiplex biometric ELISA-based immunoassay. RESULTS: The number of NK cells CD3⁻/CD16⁺, CD3⁻/CD16⁺/CD161⁺ (NK) and CD3⁻/CD16⁺/CD161⁺/CD158a⁺ (NK- Kir 2+) was greater in the patients with RCC (P < 0.05); and the number of Treg cells CD4⁺/CD25(high+)/FOXP3⁺ and the subset CD4⁺/CD25(high+)/FOXP3⁺/CD45RA⁺ (naïve) and CD45R0⁺(memory) cells, were greater in the patients with RCC (P < 0.001). An increase in the following was observed in the serum of patients with RCC compared with healthy controls: interleukin (IL)-4, IL-6, IL-8, IL-10, G-CSF, CXCL10, CXCL11, hepatocyte growth factor (HGF) and vascular endothelial growth factor (VEGF). According to Ingenuity Pathway Analysis (IPA), CXCL10, IL-6, IL-8, epidermal growth factor (EGF), HGF and VEGF were associated with a network that controls cellular movement, tissue development and cellular growth. Kaplan-Meier analysis for disease-free survival showed that high numbers of CD4⁺/CD25(high+)/FOXP3⁺/CD45RA⁺ (Treg naïve) and low numbers of CD3⁻/CD16⁺/CD161⁺/CD158a⁺ (NK-Kir+) cells predict short disease-free survival in patients with RCC. CONCLUSION: Concomitant evaluation of Treg (CD4⁺/CD25(high+)/FOXP3⁺ and CD4⁺/CD25(high+)/FOXP3⁺/CD45RA⁺) and of six soluble factors (IL-6, IL-8 ,VEGF, CXCL10, CXCL11, EGF, HGF) might be a surrogate marker of host immunity in patients with RCC.

MRI-Cavernosography: A New Diagnostic Tool for Erectile Dysfunction Due to Venous Leakage: A Diagnostic Chance.

Erectile dysfunction caused by venous leakage is a vascular disease in which blood fails to accumulate in the corpora cavernosa due to the abrupt drainage of blood from the penis secondary to an abnormal venous network that affects 1 to 2% of men under 25 years old and about 10 to 20% over 60 years old, who do not raise a sufficient erection for penetrative sex. The study of the venous leak and its characterization in young patients with erectile dysfunction represent a diagnostic challenge, and imaging remains the best way to diagnose this condition. In the article, it is described the methods of execution and the diagnostic role of the cavernous MRI in the study of vasogenic erectile dysfunction from the venous leak, proposing it as a good alternative to the cavernous CT, considering the satisfactory results in terms of diagnostic interpretation, the absence of ionizing radiation, the higher soft tissue resolution of the imaging method and the lower administration of contrast agent.

The Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration Project: Development of Criteria for Reporting Adverse Events During Surgical Procedures and Evaluating Their Impact on the Postoperative Course.

BACKGROUND: Intraoperative adverse events (iAEs) are surgical and anesthesiologic complications. Despite the availability of grading criteria, iAEs are infrequently reported in the surgical literature and in cases for which iAEs are reported, these events are described with significant heterogeneity. OBJECTIVE: To develop Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration criteria to standardize the assessment, reporting, and grading of iAEs. The ultimate aim is to improve our understanding of the nature and frequency of iAEs and our ability to counsel patients regarding surgical procedures. DESIGN, SETTING, AND PARTICIPANTS: The present study involved the following steps: (1) collecting criteria for assessing, reporting, and grading of iAEs via a comprehensive umbrella review; (2) collecting additional criteria via a survey of a panel of experienced surgeons (first round of a modified Delphi survey); (3) creating a comprehensive list of reporting criteria; (4) combining criteria acquired in the first two steps; and (5) establishing a consensus on clinical and quality assessment utility as determined in the second round of the Delphi survey. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Panel inter-rater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α. RESULTS AND LIMITATIONS: The umbrella review led to nine common criteria for assessing, grading, and reporting iAEs, and review of iAE grading systems led to two additional criteria. In the first Delphi round, 35 surgeons responded and two criteria were added. In the second Delphi round, 13 common criteria met the threshold for final guideline inclusion. All 13 criteria achieved the consensus minimum of 70%, with agreement on the usefulness of the criteria for clinical and quality improvement ranging from 74% to 100%. The mean inter-rater agreement was 89.0% for clinical improvement and 88.6% for quality improvement. CONCLUSIONS: The ICARUS Global Collaboration criteria might aid in identifying important criteria when reporting iAEs, which will support all those involved in patient care and scientific publishing. PATIENT SUMMARY: We consulted a panel of experienced surgeons to develop a set of guidelines for academic surgeons to follow when publishing surgical studies. The surgeon panel proposed a list of 13 criteria that may improve global understanding of complications during specific procedures and thus improve the ability to counsel patients on surgical risk.

Massive intra-abdominal recurrence after robotic-assisted radical cystectomy: A case report and critical appraisal of literature.

INTRODUCTION: Over the years, the robotic surgery is gaining increasing importance in the treatment of bladder cancer. Some doubts remain about the oncological safety of robotic approach and alerts have been raised about the occurrence of atypical recurrences, including peritoneal carcinomatosis and port-site metastasis. CASE PRESENTATION: The patient referred to our Emergency Department because of acute confusional state probably due to severe anemia and sepsis. A left nephroureterectomy, left hemicolectomy with end colostomy and the surgical excision of the huge mass was performed through a xipho-pubic incision associated to another left peri-stomal incision. The histological specimen analysis showed a high-grade sarcoma, not otherwise specified (sarcoma, NOS-type), measuring 29 cm × 8 cm × 5 cm in diameters. The left kidney and ureter were not infiltrated by the neoplasm while serosa membranes and muscular layers of left colon were infiltrated by the mass. The patient died because of a cardiac arrest 4 days after surgery. DISCUSSION: RARC is a safe and feasible alternative to open radical cystectomy (ORC) with satisfactory operative time, little blood loss, and low transfusion rates. Despite this, RARC is associated with a low, but not neglectable, risk of atypical metastases like peritoneal implants and port-site metastasis. Although a small amount (7%) of RARC were performed in non-urothelial variants of bladder cancer, the sarcomatoid one can be related to a greater risk of atypical recurrence and special precaution should be taken to reduce potential causes of tumor seeding.

Perioperative outcomes of patients undergoing urological elective surgery during the COVID-19 pandemic: a national overview across 28 Italian institutions.

INTRODUCTION: The aim of this study was to assess the safety of elective urological surgery performed during the pandemic by estimating the prevalence of COVID-19-like symptoms in the postoperative period and its correlation with perioperative and clinical factors. MATERIAL AND METHODS: In this multicenter, observational study we recorded clinical, surgical and postoperative data of consecutive patients undergoing elective urological surgery in 28 different institutions across Italy during initial stage of the COVID-19 pandemic (between February 24 and March 30, 2020, inclusive). RESULTS: A total of 1943 patients were enrolled. In 12%, 7.1%, 21.3%, 56.7% and 2.6% of cases an open, laparoscopic, robotic, endoscopic or percutaneous surgical approach was performed, respectively. Overall, 166 (8.5%) postoperative complications were registered, 77 (3.9%) surgical and 89 (4.6%) medical. Twenty-eight (1.4%) patients were readmitted to hospital after discharge and 13 (0.7%) died. In the 30 days following discharge, fever and respiratory symptoms were recorded in 101 (5.2%) and 60 (3.1%) patients. At multivariable analysis, not performing nasopharyngeal swab at hospital admission (HR 2.3; CI 95% 1.01-5.19; p = 0.04) was independently associated with risk of developing postoperative medical complications. Number of patients in the facility was confirmed as an independent predictor of experiencing postoperative respiratory symptoms (p = 0.047, HR:1.12; CI95% 1.00-1.05), while COVID-19-free type of hospitalization facility was a strong independent protective factor (p = 0.02, HR:0.23, CI95% 0.07-0.79). CONCLUSIONS: Performing elective surgery during the COVID-19 pandemic does not seem to affect perioperative outcomes as long as proper preventive measures are adopted, including nasopharyngeal swab before hospital admission and hospitalization in dedicated COVID-19-free facilities.

Post-Operative Acute Urinary Retention After Greenlight Laser. Analysis of Risk Factors from A Multicentric Database.

PURPOSE: Greenlight laser is a mini-invasive technique used to treat Benign Prostatic Obstruction (BPO). Some of the advantages of GreenLight photoselective vaporization (PVP) are shorter catheterization time and hospital stay compared to TURP. Post-operative acute urinary retention (pAUR) leads to patients' discomfort, prolonged hospital stay and increased health care costs. We analyzed risk factors for urinary retention after GreenLight laser PVP. MATERIALS AND METHODS: In a multicenter experience, we retrospectively analyzed the onset of early and late post-operative acute urinary retention in patients undergoing standard or anatomical PVP. The pre-, intra- and post-operative characteristics were compared betweene patients who started to void and the patients who developed post-operative urinary retention. RESULTS: The study included 434 patients suitable for the study. Post-operative acute urinary retention occurred in 39 (9%). Patients with a lower prostate volume (P < .001), an adenoma volume lower than 40 mL (P < .001), and lower lasing time (P = .013) had a higher probability to develop pAUR at the univariate analysis. The multivariate logistic regression confirmed that lower lasing time (95% CI: 0.86-0.99, OR = 0.93, P = .046) and adenoma volume (95% CI: 0.89-0.98, OR = 0.94, P = .006) are correlated to pAUR. Furthermore IPSS ≥ 19 (95% CI: 1.19- 10.75, OR = 2.27, P = .023) and treatment with 5-ARI (95% CI: 1.05-15.03, OR = 3.98, P = .042) are risk factors for pAUR. CONCLUSION: In our series, post-operative acute urinary retention was related to low adenoma volume and lasing time, pre-operative IPSS ≥ 19 and 5-ARI intake. These data should be considered in deciding the best timing for urethral catheters removal.

An outcomes analysis of penile prosthesis implantation following radical cystoprostatectomy and urinary diversion: a multicentric retrospective cohort study.

There is limited scientific literature regarding the management outcomes for end-stage erectile dysfunction (ED) following radical cystoprostatectomy (RCP). This study aims to evaluate the surgical outcomes of penile prosthesis (PP) implantation. A retrospective analysis over 17 years (2004-2017) was performed from the clinical records of patients in four tertiary referral centres, whom previously had undergone RCP, followed by PP implantation for end-stage ED. Outcome measures include both intra and postoperative complications, operative duration, a 5-point Likert hematoma scale as well as length of hospital stay. Additionally, a matched-pair cohort analysis was performed, dividing patients in 2 groups according to the type of urinary diversion (neobladder versus ileal conduit/cutaneous ureterostomy). The median time elapsed between RCP and PP implantation was 38 months (IQR 20-56). The median follow-up was 18 months (IQR 12-156). A 3-piece inflatable PP was implanted in 43 patients (91.5%) whereas a semirigid device was implanted in the remainder. Reservoir position was extra-peritoneal (utilising a separate abdominal incision) in 24 patients (54.8%), while an ectopic high-submuscular placement was preferred in the remainder. PP infection and mechanical failure occurred in 1 (2.1%) and 3 cases (6.3%) respectively. The comparative analysis of surgical outcomes did not show any statistically significant difference between the two groups. Our evidence suggests that PP implantation in patients with refractory ED following RCP may represent a safe and effective procedure associated with a low incidence of complications. The main limitation of this study is represented by the non-randomised, retrospective nature as well as the lack of patients' functional outcomes and the limited follow-up.

Operative profile, safety and functional outcomes after GreenLight laser prostate surgery: results from a 12 months follow-up multicenter Italian cohort analyses.

BACKGROUND: Over the two past decades, GreenLight laser therapy has been considered a valid alternative for the treatment of lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia/benign prostatic obstruction (BPH/BPO). However, the debate on the effectiveness of laser therapy compared to conventional techniques is still open. The aim of our study is to analyze and describe the use of GreenLight laser prostate surgery in Italy, with regard to the surgical techniques performed and the surgical and functional outcomes at mid-term follow-up. METHODS: From March 2012 to July 2018, patients who underwent GreenLight laser prostate surgery for LUTS due to BPH/BPO from 19 Italian centers were included. The following parameters were evaluated in the population: age, prostate volume, prostate adenoma volume, PSA tot, Qmax at uroflowmetry (UFM), International Prostatic Symptoms Score (IPSS), previous therapy for LUTS, use of anticoagulants and antiplatelet drugs. We recorded also the kind of anesthesia, mean laser time (min), mean irradiation time (min), TURP conversion/completion rate, postoperative day of catheter removal, postoperative acute urinary retention (AUR), hospital stay, variation of hematocrit (Ht) and hemoglobin levels (Hb). Early complications were classified according to the Clavien-Dindo classification, the re-operation rate within 30 days and after 30 days, the late complications and the Patient Global Impression of Improvement were also collected. Changes over time in terms of blood loss and functional outcomes (IPSS and Qmax at the UFM at 6 and 12 months) were tested with Student's test for paired samples. We assumed P≤0.05 as level of statistical significance. RESULTS: Overall, 1077 were enrolled in the study, 554 (56.4%) were treated with standard vaporization and 523 (48.6%) with anatomical vaporization. Student's t-test for paired samples showed no statistically significant differences in terms of reduction of Ht preoperative vs. Ht postoperative (42.80±3.91 vs. 39.93±5.35 95% CI P=0.3) and preintervention and postintervention Hb levels (14.28±1.46 vs. 13.72 P=0.35). Compared with the preoperative Qmax (8.60±2.64), the 6- and 12-month UFM showed a significant improvement [19.56±6.29, P<0.01 and 19.99±5.92 P<0.01]. In terms of IPSS variation, compared to the baseline level (22±5.51) the 6- and 12-month follow-up confirmed a significant reduction (8.01±4.41 P<0.01 and 5.81±4.12 P<0.01 respectively). Postoperative complications were CD0, CD1, CD2, CD3, CD4 in 33.0%,35.3%, 2.9%, 0.3%, and 0.6%. CONCLUSIONS: To the best of our knowledge, this is one of the most numerous surgical series of GreenLight laser vaporization and with the longest follow-up. This technique should be considered as a safe and effective alternative in the treatment of secondary LUTS to BPH.

Distal corporoplasty for distal cylinders extrusion after penile prosthesis implantation.

INTRODUCTION: Distal extrusion of cylinders is a potential complication of the penile prosthesis implantation. Several methods have been proposed for repairing a distal penile erosion. We present our preliminary experience in "Distal corporoplasty" technique. METHODS: We enrolled 18 consecutive patients whose underwent a distal corporoplasty with simultaneous reimplantation of an "AMS 700 inflatable penile prosthesis (LGX)" from January 2013 to November 2015 at our hospital. All procedures were performed by a single surgical team. Intraoperative and postoperative complications have been classified and reported according to Satava6 and Clavien-Dindo (CD) system.7 Mean values with standard deviations (±SD) were computed and reported for all items. RESULTS: Mean age of the patients was 53.61 (±11.90) years. Mean body max index (BMI) was 24.22 (±2.51). Mean operative time was 85.2 (±13.1) minutes. Blood losses were minimal. No intraoperative complications are reported according to Satava classification. Four out of 18 patients (22.22%) experienced postoperative complications according to CD system. All patients had sexual intercourse for the first time postsurgery after a mean of 59.11 ± 2.08 days. Mean follow-up was 22.11 (±9.95). DISCUSSIONS: Distal extrusion of cylinders is a potential complication of the penile prosthesis implantation. Distal corporoplasty was first described by Mulcahy. He reported a series of 14 patients with a follow-up of about 2 years with optimal functional outcomes. Moreover, distal corporoplasty resulted in shorter operative time, better function, less pain, and fewer recurrences than Gortex windsock repair.10 In our experience, distal corporoplasty is a simple and safe procedure in the treatment of distal cylinders extrusion when the prosthetic material is not exposed to the exterior.

Emergent Embolization of a Very Late Detected Pseudoaneurysm at a Lower Pole Subsegmental Artery of the Kidney after Clampless Laparoscopic Partial Nephrectomy.

Renal artery pseudoaneurysm is a rare but life-threatening condition. Its incidence is higher after minimally invasive partial nephrectomy (PN) than after the open approach. We reported a case of a renal artery pseudoaneurysm occurred about four months after a clampless laparoscopic PN. A 49-year-old female underwent a clampless laparoscopic PN for a right renal tumor with high surgical complexity. The patient experienced an intraoperative blood loss from renal bed and the surgeons performed a deep medullary absorbable suture. Three months after surgery the patient underwent a renal ultrasonography with good results. The patient came to our emergency department 115 days after surgery with a hypovolemic shock stage 3. Her CT scan showed a pseudoaneurysm of a lower pole vessel of the right kidney. She underwent a superselective embolization of the segmental renal artery. The surgical complexity of the tumor, the anatomical relationships with the renal sinus and the deep medullary suture could be responsible for the development of the pseudoaneurysm. The authors presented an unusual case of a very late detected pseudoaneurysm of a renal vessel, suggesting that all very complex renal tumors removed with a minimally invasive technique should be followed up closely at least during the first six-months in order to early detect this major complication.

Spondylodiscitis: a rare complication following percutaneous nephrostomy.

Spondylodiscitis is an inflammation of the intervertebral disc and the adjacent vertebral bodies. The spondylodiscitis can not only be a complication of medical interventions such as an operation near spinal column but also urogenital and vascular interventions and intravenous catheter use. A 71-year-old man was admitted to our emergency department with fever and severe abdominal pain. Antibiotic therapy had been performed with intravenous administration of 2 g of ceftriaxone and the patient underwent the placement of a percutaneous nephrostomy according to Seldinger technique. After 1 week, the patient experienced a severe pain at the lumbar tract of the vertebral column associated with a moderate abdominal pain and septic fever. A magnetic resonance imaging (MRI) of the lumbar spine showed widespread impregnation of the upper portion of L3 and the lower portion of L2 compressing the spinal roots as well as the ileopsoas muscle such as a spondylodiscitis. Liquor culture showed an increase of liquor immunoglobulin G, total liquor protein and was positive for Extended-spectrum beta-lactamases (ESBL) - producing Escherichia coli. After the antibiotic therapy, the spondylodiscitis resolves without important sequelae. In the present case report, we describe a very rare complication of percutaneous nephrostomy tube placement, despite of the prophylactic antibiotic therapy according to the most recent guidelines. Predisposing factors to spondylodiscitis include the very young and elderly, the immunosuppressed, diabetic individuals and a general debilitating disease such as renal failure. This case suggests the importance of remembering spondylodiscitis when septic fever and back pain occurs following the placement of a percutaneous nephrostomy in a septic patient.

Rare complication after a transrectal ultrasound guided prostate biopsy: a giant retroperitoneal hematoma.

Common complications related to transrectal ultrasound (TRUS) guided prostatic needle biopsy are hematuria, hematospermia, and hematochezia. To the best of our knowledge, we report the second case of a very large hematoma extending from the pelvis into the retroperitoneal space in literature.A 66-year-old man with a serum prostate-specific antigen (PSA) of 5.4 ng/ml was admitted to our department for a TRUS-guided prostatic needle biopsy. Laboratory values on the day before biopsy, including coagulation studies, were all normal. The patients did not take any anticoagulant drugs. No immediate complications were encountered. Nevertheless, 7 hours after the biopsy, the patient reached our emergency department with severe diffuse abdominal pain, hypotension, tachycardia, and confusional state. He underwent an ultrasonography and then a computed tomography (CT) scan that showed "a blood collection in the pelvis that extending to the lower pole of left kidney associated with a focus of active contrast extravasation, indicating active ongoing prostate bleeding." Consequently, he underwent a diagnostic angiography that showed no more contrast extravasation, without the need of embolization. Management of hematoma has been conservative and hematoma was completely reabsorbed 4 months later.

Emergency embolization of actively bleeding small renal angiomyolipoma with a fast growth in four months.

Angiomyolipoma (AML) is the most common benign tumour of the kidney and is composed of smooth muscle cells, blood vessels and fat elements. AMLs are usually casually discovered when the kidneys are imaged for other reasons. Their first presentation is often a spontaneous retroperitoneal haemorrhage or bleeding into the urinary collection system, which can be life-threatening. The bleeding tendency is related to the irregular, aneurysmal, tortuous blood vessels that compose the tumor. The greatest risks for bleeding are tumour size and grade of the vascular component of the tumour. Moreover, the risk of bleeding is proportional to the size of the lesion (it is higher in AMLs with a diameter more than 4 cm). Shock due to a grave haemorrhage from AML rupture is called Wunderlich syndrome that is clinically characterized by the Lenk's triad: acute flank pain, a flank mass and hypovolemic shock.Other symptoms and signs may be present: haematuria, palpable mass, flank pain, urinary tract infections, renal failure or hypertension. Small AMLs usually require no therapy, although follow-up is recommended in order to follow its growth. Larger or symptomatic lesions can be electively embolized and/or resected with a partial nephrectomy. AMLs that present with retroperitoneal haemorrhage frequently require emergency embolization. We describe a case of an actively bleeding small renal AML, with a rapid growth, without any evidence for big aneurysmal vessels, who underwent an emergency embolization at our hospital.

Laparoscopic management of recurrent ureteropelvic junction obstruction following pyeloplasty: a single surgical team experience with 38 cases

ABSTRACT Purpose To describe and analyze our experience with Anderson-Hynes transperitoneal laparoscopic pyeloplasty (LP) in the treatment of recurrent ureteropelvic junction obstruction (UPJO). Materials and methods 38 consecutive patients who underwent transperitoneal laparoscopic redo-pyeloplasty between January 2007 and January 2015 at our department were included in the analysis. 36 patients were previously treated with dismembered pyeloplasty and 2 patients underwent a retrograde endopyelotomy. All patients were symptomatic and all patients had a T1/2>20 minutes at pre-operative DTPA (diethylene-triamine-pentaacetate) renal scan. All data were collected in a prospectively maintained database and retrospectively analyzed. Intraoperative and postoperative complications have been reported according to the Satava and the Clavien-Dindo system. Treatment success was evaluated by a 12 month-postoperative renal scan. Total success was defined as T1/2≤10 minutes while relative success was defined as T1/2between 10 to 20 minutes. Post-operative hydronephrosis and flank pain were also evaluated. Results Mean operating time was 103.16±30 minutes. The mean blood loss was 122.37±73.25mL. The mean postoperative hospital stay was 4.47±0.86 days. No intraoperative complications occurred. 6 out of 38 patients (15.8%) experienced postoperative complications. The success rate was 97.4% for flank pain and 97.4% for hydronephrosis. Post-operative renal scan showed radiological failure in one out of 38 (2.6%) patients, relative success in 2 out of 38 (5.3%) patients and total success in 35 out of 38 (92.1%) of patients. Conclusion Laparoscopic redo-pyeloplasty is a feasible procedure for the treatment of recurrent ureteropelvic junction obstruction (UPJO), with a low rate of post-operative complications and a high success rate in high laparoscopic volume centers.