Mesh Graft Urethroplasty-Still a Safe and Promising Technique in Mostly Unpromising Complex Urethral Strictures.

Long urethral strictures or even recurrent urethral strictures, mostly with scar tissue showing insufficient healing tendencies, are defined as complex and represent a big challenge in modern reconstructive urology. Initially, the treatment of complicated urethral strictures was associated with a high failure rate (20-40%) due to the growth of hair in the neourethra and a lack of sufficient suitable epithelium when scrotal skin was used. Although much effort was put into tissue engineering recently, harvesting and transplanting autologous tissue represent the standard of care for urethral substitution or augmentation. Since 1977, two-staged urethroplasty with the usage of free foreskin or 0.1 mm thick meshed skin from the upper leg was performed in complicated cases and was initially described in 1984 and 1989 by Schreiter and Schreiter and Noll, respectively. In stage 1, the graft is harvested by cutting the skin thinly above the hair follicles and transplanted as a plate around the opened urethra. In stage 2, after 8-12 weeks, the neourethra is formed. Success rates of up to 84% are described. Considering the complexity of the strictures in which mesh graft urethroplasty is usually performed, the reachable success rates are outstanding, especially considering that this surgery is most likely the last opportunity to prevent perineostomy or even urinary diversion. This article describes the surgical technique and embeds the mesh graft urethroplasty in today's literature to underline its importance in the surgical management of complex urethral strictures.

Anterior Urethroplasty Using a New Tissue Engineered Oral Mucosa Graft: Surgical Techniques and Outcomes.

PURPOSE: We investigated whether tissue engineered material may be adopted using standard techniques for anterior urethroplasty. MATERIALS AND METHODS: We performed a retrospective multicenter study in patients with recurrent strictures, excluding those with failed hypospadias, lichen sclerosus, traumatic and posterior strictures. A 0.5 cm2 oral mucosa biopsy was taken from the patient cheek and sent to the laboratory to manufacture the graft. After 3 weeks the tissue engineered oral mucosal MukoCell® graft was sent to the hospital for urethroplasty. Four techniques were used, including ventral onlay, dorsal onlay, dorsal inlay and a combined technique. Cystourethrography was performed 1 month postoperatively. Patients underwent clinical evaluation, uroflowmetry and post-void residual urine measurement every 6 months. When the patient showed obstructive symptoms, defined as maximum urine flow less than 12 ml per second, the urethrography was repeated. Patients who underwent further treatment for recurrent stricture were classified as having treatment failure. RESULTS: Of the 38 patients with a median age of 57 years who were included in study the strictures were penile in 3 (7.9%), bulbar in 29 (76.3%) and penobulbar in 6 (15.8%). Median stricture length was 5 cm and median followup was 55 months. Treatment succeeded in 32 of the 38 patients (84.2%) and failed in 15.8%. Success was achieved in 85.7% of ventral onlay, 83.3% of dorsal onlay, 80% of dorsal inlay and 100% of combined technique cases. No local or systemic adverse reactions due to the engineered material were noted. CONCLUSIONS: Our findings show that a tissue engineered oral mucosa graft can be implanted using the same techniques suggested for anterior urethroplasty and native oral mucosa, and guaranteeing a similar success rate.

Complications and mortality after radical cystectomy for bladder transitional cell cancer.

PURPOSE: We evaluated early postoperative complications and 3-month mortality after radical cystectomy using a standardized method to report complications. MATERIALS AND METHODS: We retrospectively collected data on all 358 consecutive patients who underwent radical cystectomy for nonmetastatic bladder transitional cell carcinoma at a tertiary academic referral center from January 2002 to December 2006. The Martin criteria were used to report complications, which were graded according to a 5-grade modification of the Clavien system. RESULTS: A total of 231 complications occurred in 174 patients (49%), of which 13% were grades 3 to 5. The 3-month mortality rate was 3%. After evaluating the whole patient cohort American Society of Anesthesiologists score was the only covariate significantly associated with grade 3 to 5 complications on univariate analysis. Subgroup analysis limited to patients with an orthotopic ileal neobladder showed that female gender (HR 0.204, p = 0.017) and American Society of Anesthesiologists score (HR 2.851, p = 0.013) were independent predictors of grade 3 to 5 complications on multivariate analysis. CONCLUSIONS: When applying a standardized methodology to report early morbidity, about 50% of patients undergoing radical cystectomy had complications within 3 months of surgery. Although most complications were minor, about 13% of patients experienced grade 3 to 5 events, resulting in a 3-month mortality rate of 3%. American Society of Anesthesiologists score was significantly associated with major complications, while on subgroup analysis in patients who received an orthotopic ileal neobladder female gender was also an independent predictor of major complications.

Learning curve and preliminary experience with da Vinci-assisted laparoscopic radical prostatectomy.

OBJECTIVE: To report our initial experience in the treatment of prostate cancer with robotic-assisted laparoscopic radical prostatectomy (RALP), evaluating our results in terms of learning curve, postoperative outcomes and positive surgical margins. MATERIAL AND METHODS: From April 2005 to February 2006, a single surgeon performed 41 RALP using the da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, Calif., USA). Clinical and pathological data were collected prospectively and analyzed by a researcher from outside our clinic. The main perioperative parameters assessed were the following: operative time, blood loss, transfusion rate, conversion rate, intra- and postoperative complications, hospitalization time, catheterization time, and positive surgical margin rate. To evaluate the learning curve, patients were stratified into three groups: from case 1 to 10 (group 1), from case 11 to 20 (group 2), and from case 21 to 41 (group C). RESULTS: Median operative time was 210 min. Mean blood loss was 400 ml, with 9.8% of the patients receiving blood transfusions. Conversion to open surgery occurred in 2 cases (4.9%), while 4 postoperative complications (9.7%) were reported. Median times of hospitalization and catheterization were 7 days. Positive surgical margins were detected in 26.8% of the cases (6.9% among pT2 patients). Operative time (p < 0.001), blood loss (p = 0.02), transfusion rate (p = 0.006), and postoperative complication rates (p = 0.03) reduced along the learning curve. CONCLUSION: RALP is a feasible and reproducible technique, with a short learning curve and low perioperative complication rate. Even during the initial phase of the learning curve, good results were obtained with regard to postoperative complications and oncological outcome.

Prognostic accuracy of an artificial neural network in patients undergoing radical cystectomy for bladder cancer: a comparison with logistic regression analysis.

OBJECTIVE: To compare the prognostic performance of an artificial neural network (ANN) with that of standard logistic regression (LR), in patients undergoing radical cystectomy for bladder cancer. PATIENTS AND METHODS: From February 1982 to February 1994, 369 evaluable patients with non-metastatic bladder cancer had pelvic lymph node dissection and radical cystectomy for either stage Ta-T1 (any grade) tumour not responding to intravesical therapy, with or with no carcinoma in situ, or stage T2-T4 tumour. LR analysis based on 12 variables was used to identify predictors of overall 5-year survival, and the ANN model was developed to predict the same outcome. The LR analysis, based on statistically significant predictors, and the ANN model were the compared for their accuracy in predicting survival. RESULTS: The median age of the patients was 63 years, and overall 201 of them died. The tumour stage and nodal involvement (both P<0.001) were the only statistically independent predictors of overall 5-year survival on LR analysis. Based on these variables, LR had a sensitivity and specificity for predicting survival of 68.4% and 82.8%, respectively; corresponding values for the ANN were 62.7% and 86.1%. For LR and ANN, the positive predictive values were 78.6% and 76.2%, and the negative predictive values were 73.9% and 76.5%, respectively. The index of diagnostic accuracy was 75.9% for LR and 76.4% for ANN. CONCLUSIONS: The ANN accurately predicted the survival of patients undergoing radical cystectomy for bladder cancer and had a prognostic performance comparable with that of LR. As ANNs are based on easy-to-use software that can identify nonlinear interactions between variables, they might become the preferred tool for predicting outcome.

Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review.

OBJECTIVE: To review the literature available on robot-assisted laparoscopic radical prostatectomy (RALP). METHODS: A literature search was performed using EMBASE, MEDLINE, and Web Science databases through a "free text" protocol, including the following terms: robotic radical prostatectomy, da Vinci, and radical prostatectomy. Three of the authors separately reviewed the records to select the papers relevant for the topic of the review, with any discrepancies solved by open discussion. The selected articles were recorded in an electronic database and analysed by version 13.0 SPSS software. RESULTS: We identified 71 manuscripts. Eleven papers focused on surgical technique, and 35 manuscripts reported clinical, pathologic, and/or follow-up data. Seven studies included clinical data concerning surgical series with fewer than 10 patients, whereas the remaining 26 series reported larger surgical series of RALP. RALP turned out to be a feasible procedure, with limited blood loss, favourable complication rates, and short hospital stays. Positive surgical margin rates decreased with the surgeon's experience and technique improving, reaching percentages similar to those of retropubic and laparoscopic series. The available oncologic data are only preliminary. Especially interesting are the data on postoperative continence rates, whereas results on potency, although promising, are based only on a limited number of patients and have to be considered as incomplete and premature. CONCLUSION: Literature showed that RALP had a short learning curve and interesting postoperative results, especially with regard to continence recovery. The available data on recovery of erectile function and oncologic follow-up are still incomplete.

[Prevention of venous thromboembolism in urologic neoplasms]. / Profilassi del tromboembolismo venoso in urologia oncologica.

PURPOSE: We report our past experience on a sample of patients who underwent pelvic surgery to treat infiltrating bladder tumours. RESULTS: We observed the highest incidence of TVP (33.3%, 3 out of 9) in those patients with higher risk due to anaesthesia and type of surgery. One of our patients died of pulmonary embolism. DISCUSSION: Abdominal pelvic surgery in tumour-bearing patients can be risky due to high incidence of distal and proximal venous thrombosis often resulting in fatal pulmonary embolism (EP). The general risk factors should be evaluated. The diagnosis of venous thrombosis can be difficult to achieve only by clinical examination. Heparin administration as well as surgical techniques and physiotherapy are used as prophylactic measures to reduce the risk of venous thrombosis and to speed up recovery. Nowadays, there is an increasing risk of running into legal problems if appropriate measures to minimise the thromboembolism are not taken.

[Obstructive uropathy secondary to recurrent pelvic endometriosis: description of a clinical case]. / Uropatia ostruttiva secondaria ad endometriosi pelvica recidivante: descrizione di un caso clinico.

The typical presentation of endometriosis is pelvic pain. Patients with with endometriosis often have associated fertility disorders even if their relationship with the symptoms and signs of endometriosis is not evident. The first line of treatment for endometriosis must be surgery. In case of infertility the preferred approach is laparoscopic, maybe in association with medical treatment and possibly followed up by a second-look. In cases with relevant pelvic pain and involvement of other organs, laparotomy is necessary, particularly when a deep endometriosis is infiltrating the uterosacral ligaments, the rectovaginal septum and the bladder. Medical treatment of endometriosis is based upon the hormone-dependency of the endometriotic lesions inducing a resting status. Adhesions, endometriomas or fibrous sequelae do not respond to medical treatment. We describe a case of recurrent endometriosis treated with radical surgery for relevant lesions and fibrous adhesions of ureters with consequent bilateral hydronephrosis.

Trombosis venosa profunda en pacientes con cistectomía radical de salvación / Deep venous thrombosis in patients undergoing salvage radical cystectomy

OBJETIVOS: La presentación de trombosis venosa profunda en pacientes tumorales, ya fue observada por Trousseau, el siglo pasado. Las alteraciones de la coagulación que ocurren en pacientes tumorales pueden causar trombosis venosa profunda (TVP), especialmente en pacientes con metástasis. La quimioterapia antitumoral, puede incluso incrementar el riesgo de trombosis. En este trabajo presentamos nuestra experiencia. MÉTODO: Hemos analizado las historias clínicas de pacientes sometidos a cistectomía radical de salvación. RESULTADOS: Hemos encontrado la incidencia muy alta de TVP (33,3 por ciento; 3 de 9), en pacientes con riesgo anestésico alto y necesidad de cirugía urgente. Uno de nuestros pacientes falleció de trombosis pulmonar. CONCLUSIONES: El diagnóstico de TVP y trombosis pulmonar, no siempre es fácil y es necesario hacer todas las pruebas para llegar al diagnóstico (examen clínico, test analíticos, etc...) (AU)