How Can the COVID-19 Pandemic Lead to Positive Changes in Urology Residency?

The COVID-19 outbreak, in a few weeks, overloaded Italian hospitals, and the majority of medical procedures were postponed. During the pandemic, with hospital reorganization, clinical and learning activities performed by residents suffered a forced remodulation. The objective of this study is to investigate how urology training in Italy has been affected during the COVID-19 era. In this multi-academic study, we compared residents' training during the highest outbreak level with their previous activity. Overall 387 (67.1%) of the 577 Italian Urology residents participated in a 72-h anonymous online survey with 36 items sent via email. The main outcomes were clinical/surgical activities, social distancing, distance learning, and telemedicine. Clinical and learning activity was significantly reduced for the overall group, and after categorizing residents as those working only in COVID hospitals, both "junior" and "senior" residents, and those working in any of three geographical areas created (Italian regions were clustered in three major zones according to the prevalence of COVID-19). A significant decrease in outpatient activity, invasive diagnostic procedures, and endoscopic and major surgeries was reported. Through multivariate analysis, the specific year of residency has been found to be an independent predictor for all response modification. Being in zone 3 and zone 2 and having "senior" resident status were independent predictors associated with a lower reduction of the clinical and learning activity. Working in a COVID hospital and having "senior" resident status were independent predictors associated with higher reduction of the outpatient activity. Working in zone 3 and having "senior" resident status were independent predictors of lower and higher outpatient surgical activity, respectively. Working in a COVID hospital was an independent predictor associated with robotic surgical activity. The majority of residents reported that distance teaching and multidisciplinary virtual meetings are still not used, and 44.8% reported that their relationships with colleagues decreased. The COVID-19 pandemic presents an unprecedented challenge, including changes in the training and education of urology residents. The COVID era can offer an opportunity to balance and implement innovative solutions that can bridge the educational gap and can be part of future urology training.

PCNL in the prone position VS PCNL in the modified supine Double-S position: is there a better position? A prospective randomized trial.

The study was performed to evaluate the efficacy of our modified supine position (called "Double-S") in percutaneous nephrolithotripsy (PCNL) and to make a contribution to the question: "Is there a better position in PCNL?". The superiority of one position is still under debate in the scientific community. In our study, we described and compared our position with the standard prone one to evaluate the possible benefits. This is a prospective randomized clinical trial conducted for 17 months. It consisted of two sub-studies: trial A (patients with stones approachable with a single anterograde access) and trial B (patients with stones approachable with a single anterograde access combined with a retrograde access). A 1:1 randomization was performed in both trials to compare the supine Double-S position with the prone one. We found that the Double-S position presents the same safety and efficacy outcomes as the standard prone one. Moreover, we proved that this particular position can reduce the patient positioning time and effort sustained by professional nurses if compared to the prone one. The same outcomes were found in trial A and in trial B. Trial B confirms the efficacy of our position also when a combined access is needed. We proved that the Double-S position is safe and effective both in anterograde treatments and in combined anterograde-retrograde procedures with benefits in the positioning time and effort level.

Skin flap squamous cell carcinoma developed after urethroplasty.

OBJECTIVES: To describe our experience in diagnosis and treatment of urethral carcinoma following urethroplasty with a Orandi penile skin flap. MATERIAL AND METHODS: Our patient underwent to Orandi penile skin flap urethroplasty then developed a urethral epidermoid carcinoma on the flap approximately 15 years later. We treated this case with a partial penectomy surgery and perineostomy. Surgery was followed by chemotherapy with cisplatin and 5-fluorouracil. The progression of the disease led to a salvage surgery of total penectomy and asportation of testicles and scrotum. RESULTS: Despite the success of the surgery, the disease progressed and three months after the last surgical operation the patient died. CONCLUSIONS: Urethral carcinoma on skin flap is a rare complication of the urethroplasty surgery but with severe consequences, so we recommend to undertake a long-term urological follow up in patients undergone such kind of surgery.

Surgical approach to adrenal ganglioneuroma: Case report and literature review.

OBJECTIVE: Ganglioneuroma (GN) is a benign tumor with a slow growth that can originate from any paravertebral sympathetic plexus. It is usually asymptomatic or with nonspecific symptoms. TC and RM scan are helpful to study GN. It is usually represented by an ovalshaped retroperitoneal mass or, in case of adrenal impairment, by low radiologic contrast media attenuation. Surgical treatment is mandatory. Literature shows how the laparoscopic approach is the most used, especially in lesions that are 6 cm or smaller. Our purpose is to describe our experience on an incidental adrenal GN of about 5 cm treated by the laparoscopic transperitoneal approach. MATERIALS AND METHODS: A 33-year-old male had ultrasound occasional finding of an about 4 cm adrenal mass. TC and RM scan identified a retroperitoneal mass (max diameter 48 mm). The lesion was removed with a transperitoneal laparoscopic approach. RESULTS: No intraoperative or postoperative complications occurred. The patient was discharged 3 days after surgery. CONCLUSIONS: Up to the present laparoscopic surgery is the best approach for GN treatment.

A smart trick to perform a flexible renoscopy during percutaneous nephrolithotripsy.

Fluid leakage from the Ampltz sheath during flexible nephroscopy after PCNL prevents dilatation of the pelvi-calyceal system and adequate visualization. This video demonstrates a simple technique to prevent such leakage.

Early Repair of Post-hysterectomy Vesicovaginal Fistulae Through a Laparoscopic Transperitoneal Extravesical Approach. Experience of a Single Center.

OBJECTIVE: To verify the feasibility and effectiveness of the correction of vesicovaginal fistulae (VVF) through a laparoscopic transperitoneal extravesical approach and TachoSil application as interposition tissue. VVF are the most common fistulae of the urinary tract and even today there is no agreement over the preferred approach to treat this kind of pathologic condition. METHODS: We retrospectively analyzed the data of women who, from July 2010 to July 2017, underwent early laparoscopic transperitoneal extravesical VVF repair. Patients were placed in the lithotomy position. Five operating ports were placed. After the resection of the VVF, the vesical and vaginal edges were closed in two layers. Finally two layers of TachoSil (4 cm x 4 cm) were placed between the sutures. Several variables were considered in the perioperative period. Patients were re-evaluated at 1 and 3 months after surgery. RESULTS: Sixteen patients underwent VVF repair. Mean duration of the surgery was 106 minutes, mean length of stay was 3.2 days. No high grade complications according to Clavien-Dindo were reported. At 1 month all patients showed complete continence and at 3 months they reported a good quality of life. CONCLUSION: The laparoscopic approach described enables adequate repair of VVF. The use of Tachosil is straightforward and atraumatic, and may be considered as an alternative to tissue flap interposition. Finally, we confirm that the early approach is not a hazard in such a disabling disease and can be adopted to restore as soon as possible the good quality of life for patients.

Supine Percutaneous Nephrolithotripsy in Double-S Position.

BACKGROUND: At present, the percutaneous nephrolithotripsy (PCNL) is performed both in supine and in prone position. The aim of this paper is to describe an innovative position during PCNL. METHODS: We describe a supine position. The patient's legs are slightly abducted at the hips. The thorax is laterally tilted (inclination 30°-35°) and kept in the right position by one or two gel pads placed between the scapula and the vertebrae. External genitalia can be accessed at any time, so that it is always possible to use flexible instruments in the upper urinary tract. We used this position for a period of 12 months to treat with PCNL 45 patients with renal lithiasis. RESULTS: All the procedures were successfully completed without complications, using the position we are describing. The following are some of its benefits: an easier positioning of the patient; a better exposure of the flank for an easier access to the posterior renal calyces of the kidney; a lower risk of pressure injuries compared to positions foreseeing the use of knee crutches; the possibility of combined procedures (ECIRS) through the use of flexible instruments; and a good fluoroscopic visualization of the kidney not overlapped by the vertebrae. CONCLUSIONS: This position is effective, safe, easy, and quick to prepare and allows for combined anterograde/retrograde operations.

The Lithocatch (TM) by Boston Scientific: how to use it and how to solve a common problem.

INTRODUCTION: The Lithocatch (TM) basket is a immobilization device commercialized by Boston Scientific. It allows to collect multiple stone fragments from the ureter. The ability of the basket to capture a large number of stone fragments, is however responsible for a problem connected to its usage: the entrapment of the basket inside the ureter. In this video we explain how to use it and how to solve this problem. MATERIAL AND METHODS: After positioning the Lithocatch (TM) over the fragments, the basket is opened and it is rotated through a special handle to collect stones. One frequent problem occurs when too many fragments are collected at once, preventing the extraction of the device. We research our archives to extrapolate the total number of procedures carried out with the Lithocatch (TM) in the last two years and the total number of complications occurred. RESULTS: We experienced the above mentioned complication in 16 procedures (14% of the total) of 114 surgeries performed. The way described to solve this complication was efficient and did not produce any damage to the ureter or to the basket. CONCLUSION: The Lithocatch (TM) has an excellent ability to capture small stones so it allows to reduce the length of the procedure. Paying attention to limit the amount of fragments collected, it is possible to avoid the entrapment of the basket. If this complication occurs, the problem can be solved by reducing the size of the stone fragments. The preferable type of energy is the ballistic one.

Percutaneous Approach to a Complicated Case of Nephrolithiasis in a Pregnant Woman: A Case Study.

BACKGROUND: Lithiasis during pregnancy can be a serious problem representing a danger to both the mother and the fetus. Surgical intervention is needed in approximately one-third of patients reporting pain despite analgesia and/or signs of persistent infection and obstruction, but there is a lack of consensus in the scientific literature as to the use of the most appropriate procedure to treat this condition. CASE PRESENTATION: We describe our experience in the treatment of a complicated reno-ureteral lithiasis in a 27-year-old patient in the first trimester of pregnancy. The patient had a calcified ureteral stent with associated stone formation in the right kidney and a bladder stone at the distal extremity of the stent. She was treated by a combined approach by percutaneous nephrolithotripsy and transurethral cystolithotripsy. The procedure we performed was effective. CONCLUSION: Our experience reinforces the feasibility and safety of the kidney stone removal by the percutaneous approach also in a pregnant patient and supports the recommendations of the European guidelines: "in experienced centers, where necessary, percutaneous nephrolithotripsy should be considered." The technical precautions taken have proven to be valid and are supported by the current literature. Therefore, we feel they can be recommended.

[Repair of post-hysterectomy vesicovaginal fistulae: the state of the art]. / Fistole vescico-vaginali secondarie ad isterectomia. Stato dell'arte del trattamento.

In western countries, vesicovaginal fistulae (VVF) are mostly iatrogenic and in the majority of cases are secondary to hysterectomy. The golden standard for the treatment of VVF has remained largely unchanged since 1953 (Couvelaire): good visualization, good dissection, good approximation of the margins, and good urine drainage. However, several aspects are still being debated, including whether or not to pursue conservative repair, the timing for surgical repair, whether to perform excision of the fistula tract, the best type of surgical access, and whether or not to use tissue interposition. We decided to review the state of the art in the treatment of VVF, which are exclusively of a traumatic nature and non-radiated, by performing a bibliography search carried on Pubmed using keywords such as "vesicovaginal fistula". The search focused on recent articles and was largely restricted to the past 10 years.

[Treatment of lithiasis with infundibular axis at an acute angle to the calyx entry in PCNL]. / Trattamento della litiasi con asse infundibulare ad angolo acuto rispetto al calice d'ingresso nella PCNL.

INTRODUCTION: In the treatment of pyelo multi calyceal renal lithiasis, although we utilize both rigid and flexible instruments, the greatest challenge when trying to achieve a stone-free status after the procedure with a single access, is represented by the presence of residual caliceal stones difficult to reach for the length of the infundibular system in which they are localized, and major axis of it at an acute angle with respect to the axis of the cannula entrance. We describe our technique of treatment in these cases with no second access. MATERIALS AND METHODS: 55 cases of multiple lithiasis of the lower calyx at the end of PCNL for complex lithiasis were treated with the following technique. Using ultrasound and fluoroscopic guidance a puncture of the calyx adjacent to the cannula was performed. A standard Lubriglide guide (0.038", right or J) was introduced until the renal pelvis. Through a nephroscopic guidance, the guide was retrieved with a clamp and was taken out from the cannula; then the two leaders were locked together by a mosquito-mounted clamp. The guide traction towards the cannula allowed identifying, through the rigid nephroscope, the infundibulum where the lithiasis was located. The infundibulum was sectioned with monopolar electrode and it was possible to access the calyx affected by the lithiasis. RESULTS: In all treated cases it was possible to reach the lithiasis from the single initial percutaneous access and to eliminate them. Small bleedings were dominated by monopolar electrode. The Urography or uro-CT performed after three months showed no residual lithiasis; the infundibulum resumed its morphological characteristics. DISCUSSION: The described technique allows for a complete resolution of the lithiasis with no need of a second access or a retrograde approach, in situations where the combined use of flexible instruments does not allow solving the pathology.

[Endoscopic combined intra renal surgery (ECIRS) in prone position]. / La endoscopic combined intra renal surgery (ECIRS) in posizione prona.

INTRODUCTION: E.C.I.R.S. is currently used in Galdakao-modified supine Valdivia position, since it is thought to be capable of allowing the retrograde approach to the high urinary diseases. Our school developed some good experience in percutaneous procedures in the prone position, with no significant anesthetic complications; we have performed an evaluation of flexible retrograde endoscopy with percutaneous nephrolithotripsy in this position. MATERIALS AND METHODS: 21 patients (14 M - 7 F), with a mean age 44.5 years (range 27-62), with complex urolithiasis, underwent percutaneous nephrolithotripsy associated with flexible retrograde endoscopy (E.C.I.R.S.) in the prone position. The technique has followed these steps: patient's positioning in the prone position; flexible cystoscopy and insertion of guide 0.038" stiff Lubriglide flexible tip; ureteral sheath 11/13 Ch until the lumbar ureter; fixing the end of the sheath to the surgical drape with sutures or surgical instrument; catheter Nelaton transurethral 10 Ch to the side of the sheath; renal puncture and routine procedure for the nephrolithotripsy assisted by the flexible instrumentation by retrograde approach. The procedure ended with the application of a Re-entry Malecot nephrostomy tube (Boston Scientific). RESULTS: The ureteral sheath was easily applicable in the prone position for all patients, with no difference between males and females; its presence made it easier to enter and the progression of the flexible instrument by retrograde approach. Idem come sopra. There was no lengthening of operative time associated with retrograde instrumentation. The "stone free" status was obtained in 100% of cases. There were no complications. DISCUSSION: The stabilized ureteral sheath allows for the comfortable and secure combined endorenal prone procedure, with flexible instruments both in men and women, through a safe and effective technique.

[Use of TachoSil in laparoscopic enucleoresection of renal masses smaller than 4 cm: our preliminary experience of 41 cases]. / Utilizzo di Tachosil nell'enucleoresezione renale laparoscopica di masse inferiori a 4 cm: la nostra esperienza preliminare di 41 casi.

INTRODUCTION: In nephron-sparing surgery the use of new and various hemostatic materials has provided a significant support in the control of intraoperative hemostasis of resection bed. Objective of this study is to demonstrate the use of hemostatic material TachoSil in laparoscopic treatment of renal masses <4 cm. MATERIALS AND METHODS: 41 patients underwent laparoscopic renal enucleoresection. In all patients one or more hemostatic TachoSil sponges were used, affixed to the bed of resection; we retrospectively evaluated the efficacy and safety of this technique. Transperitoneal access in 39 patients with antero-lateral mass and retroperitoneoscopic access in 2 patients with middle-posterior mass. After performing a warm ischemia, we proceeded to mass enucleoresection by cold blade, and to hemostasis control by suturing open vessels on the resection bed with "central suturing" technique. After unclamping the renal artery, one or more hemostatic sponges of TachoSil were always used (fibrinogen and human thrombin) affixed to the bed section. RESULTS: No significant variations of Hb, BUN and Crs. 3 cases (6.9% of renal units) of intraoperative hemorrhage requesting blood transfusion, 2 cases (4.6% of renal units) of urinary leakage at low pressure, treated conservatively with retrograde application of ureteral stent DJ for 21 days; 2 patients underwent new laparoscopy and suture. The mean time to hemostasis, evaluated in terms of the absence of macroscopic intraoperative bleeding after the application of TachoSil, was 5.5 (3-16) minutes. Average hospital stay: 5.5 (4-11) days. FOLLOW-UP: 37.6 (5-84) months. DISCUSSION: The control of hemostasis is the key problem inherent to laparoscopic technique and can be approached using hemostatic agents. Currently hemostatic agents such as TachoSil ® are used increasingly as an adjuvant agent in the control of bleeding, having an excellent application in laparoscopic renal enucleoresection, and proving safe and effective in the treatment of tumors below 4 cm.

Impact of case volumes on the outcomes of percutaneous nephrolithotomy.

BACKGROUND: Previous studies have demonstrated relationships between case volumes and outcomes in surgery. Little is known about the impact of case volumes on the outcomes of percutaneous nephrolithotomy (PCNL). OBJECTIVE: To investigate the influence of case volumes on the efficacy and safety outcomes of PCNL. DESIGN, SETTING, AND PARTICIPANTS: From November 2007 to December 2009, prospective data were collected by the Clinical Research Office of the Endourological Society from consecutive patients over a 1-yr period in 96 centers globally. Data of 3933 patients in the Global PCNL study database were included in this study. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patients were divided into low- and high-volume groups based on the median annual case volume of their respective treatment center. Preoperative characteristics and outcomes were compared between the two groups. Case volume was treated as a continuous variable. The relationship between case volume and stone-free (SF) rate, complication rate, and duration of hospital stay was explored using multivariate regression analysis. RESULTS AND LIMITATIONS: SF rates were higher in high-volume centers (82.5% vs 75.1%; p value <0.001). Complication rates were lower in high-volume centers (15.9% vs 21.7%; p value 0.002), whereas the mean (standard deviation [SD]) duration of stay was shorter in high-volume centers (3.4 [2.6] vs 4.9 [3.7] d; p value <0.001). SF rate increased with case volume, whereas complication rate and duration of stay diminished with increasing case volumes after adjusting for stone burden, urine culture status, American Society of Anesthesiologists score, and the presence of staghorn stones. The highest SF rates were observed in centers with >120 cases per year. CONCLUSIONS: Centers that perform high numbers of PCNLs per year achieve better results. Both the efficacy and safety outcomes of PCNL improve with the number of surgeries performed in a given center per year.

[Origin of motion in the human ureter: mechanics, energetics and kinetics of the myosin molecular motors]. / Motori molecolari miosinici nell'uretere prossimale umano.

BACKGROUND: Ureteral peristalsis is the result of coordinated mechanical motor performance of longitudinal and circular smooth muscle layer of the ureter wall. The main aim of this study was to characterize in smooth muscle of proximal segments of human ureter, the mechanical properties at level of muscle tissue and at level of myosin molecular motors. METHODS: Ureteral samples were collected from 15 patients, who underwent nephrectomy for renal cancer. Smooth muscle strips longitudinally and circularly oriented from proximal segments of human ureter were used for the in vitro experiments. Mechanical indices including the maximum unloaded shortening velocity (Vmax), and the maximum isometric tension (P0) normalized per cross-sectional area, were determined in vitro determined in electrically evoked contractions of longitudinal and circular smooth muscle strips. Myosin cross-bridge (CB) number per mm2 (Ψ) the elementary force per single CB (Ψ) and kinetic parameters were calculated in muscle strips, using Huxley's equations adapted to nonsarcomeric muscles. RESULTS: Longitudinal smooth muscle strips exhibited a significantly (p<0.05) faster Vmax (63%) and a higher P0 (40%), if compared to circular strips. Moreover, longitudinal muscle strips showed a significantly higher unitary force (Ψ) per CB. However, no significant differences were observed in CB number, the attachment (f1) and the detachment (g2) rate constants between longitudinal and circular muscle strips. CONCLUSIONS: The main result obtained in the present work documents that the mechanical, energetic and unitary forces per CB of longitudinal layer of proximal ureter are better compared to the circular one; these preliminary findings suggested, unlike intestinal smooth muscle, a major role of longitudinal smooth muscle layer in the ureter peristalsis.

[The Endovision technique in renal percutaneous lithotripsy]. / L'approccio Endovision nella litotrissia percutanea endorenale.

INTRODUCTION: In order to achieve a safer percutaneous access to the kidney, even if not systematically, it is possible to combine the use of eco-fluoro-guided puncture with the endoscopic retrograde vision through flexible ureteroscopy. Our experience has been conducted in order to standardize the technique and highlight advantages and limitations. 
 MATERIALS AND METHODS: 26 patients (15 M-11 F), mean age 46 years, underwent flexible ureterorenoscopy as first percutaneous access for pyelic or pyelocaliceal stones.
20 cases were conducted in the prone and 6 in the supine position. 
We proceeded with the study of the caliceal topography and the choice of the calyx suitable for puncture, studying the orientation of the main axis of the papilla of the lower or middle group. Leaving the endoscopic instrument in place, we proceeded with the contrast injection and the eco-fluoro-guided puncture. The retrograde instrument followed the puncture and access dilatation.
 RESULTS: In 16 cases we identified a papilla of the lower caliceal group with a correct orientation for the renal puncture; in the other 10, we chose a papilla of the middle group, because it was more favorable. In 10 cases the puncture was made at the center of the papilla with its axis in favor; in 16 it was necessary to correct the puncture because the needle had penetrated the fornix (no. 14) or had punctured the other side of the calyx (no. 2). 
In 10 cases the puncture correction caused some bleeding, which required a careful washing in order to clear the field of vision and repeat the procedure; in other 6 cases, this was not possible: the Endovision procedure was interrupted and completed according to the conventional method. There was no difference in technique between the supine and the prone position.
 DISCUSSION: It is not always likely to find a papilla of lower calyx suitable to correct puncture.
The Endovision technique is related to an inevitably blind moment linked to the displacement of the kidney, which is not followed by the flexible instrument, and to the limitations related to the visibility. The technique can be used both in the prone and supine position; chances are that it might not always be completed.

[Laparoscopic transmesocolic pyeloplasty: our technical notes on the application of intrasurgical ureteral DJ catheter]. / Pieloplastica laparoscopica transmesocolica: nostre note di tecnica nell'applicazione del catetere ureterale a dj intraoperatorio.

INTRODUCTION: The ureteral stent used for laparoscopic pyeloplasty can be placed pre-surgically, intra-surgically or post-surgically. The intra-surgical application can be carried out by anterograde or retrograde techniques. MATERIALS AND METHODS: 23 patients affected by pelviureteric junction disease (14 males, 9 females), aged between 10 and 55 years, underwent laparoscopic pyeloplasty with Anderson Hynes technique. No patient had a pre-surgery DJ ureteral catheter. Surgery was performed on lateral decubitus with external genitals. A sterile field including a flexible cystoscope was prepared to apply the ureteral catheter. Pyeloplasty was performed. After placing the first 4 ureteropelvic anastomosis stitches, flexible cystoscopy was performed by applying a leading probe 0.038 or 0.035 stiff Lubriglide flexible straight tip, depending on the ureter caliber. A ureteral catheter 6 or 4.8 Ch was used. The guide was followed by laparoscope until the renal pelvis or superior renal calices were reached. After extracting the cystoscope, the ureteral catheter was inserted with a suitable pusher up to the pelvis. After guide extraction, J modeling was performed. The time elapsed from the beginning of cystoscopy until the end of the procedure was calculated. RESULTS: The procedure was easily performed in all patients. The application time varied between 5 and 8 minutes for males, and from 6 to 10 minutes for females. The DJ catheter in laparoscopic pyeloplasty was applied by retrograde way. An alternative is the laparoscopic access or application in a previous moment with the need of two different surgical fields. This provides a reasonable execution time, the only difficulty being the finding of the external urethral meatus. CONCLUSIONS: The intra-surgical application of DJ ureteral stent is a good alternative to the supine anterograde or retrograde technique.

[Laparoscopic ureteral reimplantation surgery according to Lich-Gregoir]. / Reimpianto ureterale secondo Gregoir-Lich per via laparoscopica.

INTRODUCTION: Terminal ureteral stenosis can occur as a consequence of gynecological diseases or surgical treatment of simple or radical hysterectomy and pelvic endometriosis. MATERIALS AND METHODS: We evaluated 5 patients aged between 30 and 52 years, who underwent ureterocystoneostomy for ureteral stenosis due to several factors: 2 cases of pelvic endometriosis; 2 cases of surgery treatment of pelvic endometriosis, and 1 case of simple hysterectomy. Patients were placed supine in Trendelemburg position of about 30°. After pneumoperitoneum induction, the following equipment was introduced through four different laparoscopic accesses: the optic tool into the umbilicus access, 5-mm operative accesses on the lesion side, and one of 10-11 mm in the contralateral site. Once we incised the peritoneum and isolated the distal ureter until the stenotic tract, we proceeded with the dissection, performing a 2 cm serum-muscle incision of the bladder, showing the mucosa after previous distension with 200 mL of saline. A little operculum in the mucosa was created by a spatula. After applying a DJ ureteral catheter with the distal end introduced into the bladder, the direct ureteral-vesical anastomosis was made. The application of serum-detrusor sutures next to the ureter created the antireflux barrier. The peritoneum was closed. RESULTS: Surgery was performed by laparoscopy without conversion into open surgery. Average performing time was 205 min. Clinical stay was 5 days and DJ ureteral catheter was removed after 3 weeks following cystography and absence of spillage around the bladder. The ultrasound controls performed after three and six months did not show any complication. CONCLUSIONS: Laparoscopy is a valid alternative to open surgery, also yielding better esthetic results, particularly in cases where the classical approach is difficult to perform, as for example in obese patients.

[Endoscopic prostate resection by bipolar gyrus resector for prostates over 80 ml: our experience after a 12-month follow-up]. / La resezione endoscopica con resettore bipolare gyrus nelle ghiandole di volume superiore a 80 ml: nostra esperienza a 12 mesi di follow-up.

INTRODUCTION: The open surgery approach is the gold standard for the treatment of prostatic adenoma with a volume over 80 mL. PATIENTS AND METHODS: We studied 180 patients from June 2004 to June 2011, affected by prostatic adenoma >80 mL, and who underwent endoscopic resection performed with bipolar technique by a single operator. We considered the following data: surgery duration, bleeding, absorption of irrigating fluids, resected tissue quantity, clinical stay, and catheterization time. Resections up to the surgical capsule were performed with bipolar Gyrus resector and the fragments were collected with prostate Ellik-type conveyor. Next step was the positioning of the bladder catheter with cystoclysis. We evaluated early and late complications and performed clinical reassessment of the patients at 1, 3, 6 and 12 months. RESULTS: Surgery average time was 118 min. The average resected tissue volume was 92 g. The post-surgery hemoglobin was 13.2 g/dL. In 15 patients a revision of the lodge was performed within 24 hours after resection; no blood transfusions were performed. The catheter was removed after 3.2 days and the average recovery time was 4 days. There were eight cases of cicatricial stenosis of the bladder neck treated with endoscopic laparotomy. There were no cases of post-TURP syndrome. The IPSS parameters varied from 20.7 to 3.8, the IIEF5 from 19.3 to 21.2. The average QoL decreased from 4 to 1.5, Qmax from 22.2 7.7 mL/sec. The total PSA values decreased from 6.39 ng/mL to 1.0 ng/mL. CONCLUSIONS: TURP for prostatic adenomas greater than 80 mL in volume, is a valid alternative in terms of efficacy and safety to open surgery, considered the gold standard treatment.