Camposampiero tubeless percutaneous nephrolithotomy (tPCNL): Easy, quick, effective, safe.

OBJECTIVES: To describe our technique to perform tubeless percutaneous nephrolithotomy (tPCNL) using hemostatic matrix (i.e. Floseal®) for the closure of the percutaneous tract, developed through the experience gained in our endourology specialized center. To evaluate the procedure efficacy and safety. METHODS: tPCNL performed in our center with Floseal® application from February 2017 to December 2019 were retrospectively reviewed. Clinical and surgical data were collected in order to evaluate the success of the procedure and possible complications. Camposampiero technique is reported in detail. RESULTS: Sixty-nine patients (45 males, mean age 58 years old) were included. In all patients the procedure was completed successfully and in 88% of subjects no further treatments were necessary; a low complication rate (6.9%) was reported. CONCLUSION: In our experience, tPCNL with Floseal application is feasible, safe, and effective.

The role of bedside assistant during robot assisted radical prostatectomy: Is more experience better? Analysis on perioperative and clinical outcomes.

OBJECTIVES: To analyze the impact of the bedside assistant's experience during RARP. It is believed that the outcome of robotic surgery during Robot Assisted Radical Prostatectomy (RARP) for prostate cancer depends not only on the console surgeon's experience. MATERIALS AND METHODS: All consecutive RARPs from January 2017 to March 2018 were sourced from a prospectively maintained database. All cases were performed by the same surgeon. He was supported by three bedside assistants: one with bedside and console experience, one only with relevant bedside experience, one basically inexperienced. The patient's parameters analyzed: age, Body Mass Index (BMI), previous abdominal surgery, prostate volume (by TRUS), pre-operative PSA, bioptic grading. Surgical outcomes analyzed included skin-to-skin operative time and estimated blood loss; clinical outcomes included length of hospital stay and time to catheter removal; the oncological outcome was represented by positive surgical margin rate. RESULTS: A total of 116 RARPs were identified: 38 RARPs were performed with the console experienced bedside assistant, 38 with the experienced one, 40 with the novice one. The variables were similar between the three groups. As far as outcomes are concerned, there were no statistically significant differences between the three bedside assistants in terms of operative time, estimated blood loss, length of stay, days of catheterization, positive surgical margin rate.

"Endourological closure of a malformative vascular source of bleeding using the VortX 0.018" coil®".

AIMS: Renal vascular malformations, congenital or acquired, are sometimes challenging for urologists and interventional radiologists to resolve. Arterovenous fistulas and pseudoaneuryms are usually embolized by interventional radiologists, with a low rate of complications. We propose a new endourological/interventional radiology technique to treat a source of arterovenous bleeding coming from a renal calyx in a minimally invasive way. METHODS: A combined endourological and interventional radiology procedure is described, using a Flexible Fiberoptic Ureteroscopes to undertake a retrograde intrarenal surgery (RIRS) to identify the source of bleeding; subsequently the VortX Coil® is inserted through a microcatheter to stop the bleeding and the correct position of the VortX coil is evaluated. Furthermore, we made a literature research on Pubmed and Medline to look for similar procedures. RESULTS: In case of a renal bleeding that could not be treated by endovascular way, a combined urological and interventional radiology procedure can be undertaken. We did not find similar endourological and interventional radiology procedure on Pubmed and Medline, so this is the first tecnique of endourological closure of a bleeding point using a coil. CONCLUSION: From our experience this could be a mininvasive technique to solve renal bleedings coming from a calyx that are not found by endovascular approach. Indeed, in our knowledge, the technique here described is the first that provides the use of an endovascular coil by endourological way in renal vascular malformations.

Testicular metastasis from renal cell carcinoma after nephrectomy and on tyrosine kinase inhibitors therapy: Case report and review.

Renal cell carcinoma has extremely heterogeneous presentation at the diagnosis: it may present as a confined organ disease, locally advanced, metastatic to locoregional lymph nodes or with single or multiple systemic metastases. Since chemotherapy and radiation therapy have not demonstrated efficacy either in primary therapy or in neo-adjuvant or adjuvant therapy for renal clear cell carcinoma, targeted agents like tirosine kinase inhibitors were developed and are largely used in locally advanced and metastatic renal cell carcinoma. Here, we present a rare case of ipsilateral renal cell carcinoma testicle metastasis, after radical nephrectomy and during tyrosine kinase inhibitors therapy. In addition, a retrospective search in PubMed, ScienceDirect, and Web of Science database on testicular metasteses from renal cell carcinoma under tyrosine kinase inhibitors therapy was performed.

Robot-assisted nerve-sparing radical prostatectomy using near-infrared fluorescence technology and indocyanine green: initial experience.

INTRODUCTION: Indocyanine green (ICG) is a fluorescent molecule that provokes detectable photon emission. The use of ICG with near-infrared (NIR) imaging system (Akorn, Lake Forest, IL) has been described during robotic partial nephrectomy (RAPN) as an adjunctive means of identifying renal artery and parenchymal perfusion. We propose the use of the ICG with NIR fluorescence during laparoscopic robot-assisted radical prostatectomy (RARP), to identify the benchmark artery improving the preservation of neurovascular bundle and to improve the visualization of the vascularization and then the hemostasis. METHODS: From April 2015 to February 2016, 62 patients underwent to RARP in our Urology Unit. In 26 consecutive patients, in the attempt to have a better visualization of neurovascular bundles, we used to inject ICG during the procedure. We evaluated the percentage of identification of neurovascular bundles using NIR fluorescence. Then, we evaluated complications related to injection of ICG and operative time differences between RARP with and without ICG injection performed by the same surgeons. RESULTS: We identified prostatic arteries and neurovascular bundles using NIR fluorescence technology in all patients (100%). There was not any increase in the operative time compared with RARP without ICG injection performed by the same surgeons. Complications related to injection of ICG did not occurred. CONCLUSIONS: In our experience, even if on a limited number of patients, the application of ICG with NIR fluorescence during RARP is helpful to identify the benchmark artery of neurovascular bundle.

Actinic cystitis: causes, treatment and experience of a single centre in the last five years.

INTRODUCTION: Actinic cystitis (AC) is the manifestation of symptoms and signs following pelvic radiotherapy. Pelvic radiotherapy produces both acute and chronic damage and such damage may have a devastating impact on the quality and on the amount of life of the patient. OBJECTIVES: To evaluate the number of radical cystectomies that have become necessary in the last five years in our department for AC after radiation treatment. MATERIALS AND METHODS: From February 2012 to February 2017, 11 patients underwent "open" cystectomy for AC. All patients were studied with radiographic examinations and endoscopy prior to surgery. We retrospectively evaluated the type of primitive cancer, the radiation dose administered, the time between radiation treatment and cystectomy. We also studied the related symptoms that required surgery. RESULTS: The mean age of patients at the time of cystectomy was 75 years. In six patients (54.4%) radiotherapy was performed for prostate cancer, for rectal cancer in two patients (18.1%), and for endometrial cancer in three patients (27.2%). Total radiant dose was different in different patients depending on the type and localization of cancer. The median time between radiotherapy and cystectomy was 111 months (24-256 months). All patients had symptoms before surgery. Seven patients (63.3%) with gross haematuria were treated with endoscopic clot evacuation and fulguration. DISCUSSION: The first approach to patients with AC is often supportive care. Surgery remains the most invasive treatment in the management of those patients who are not responsive to conservative treatments.

Surgery of locally advanced and metastatic kidney cancer after tyrosine kinase inhibitors therapy: single institute experience.

PURPOSE:: Renal cell carcinoma (RCC) is the most common tumor of the kidney. Considering the TNM classification of 2009, locally advanced and metastatic diseases are included in the groups stage III and IV. The surgical treatment of these tumors could be divided into 3 categories: (1) curative (nephrectomy and/or metastasectomy), (2) cytoreductive, and (3) palliative. Targeted agents showed impressive antitumor efficacy and prolongation of progression-free survival. The integration between target therapy and surgery in patients with locally advanced or metastatic RCC has sometimes facilitated surgery. We aimed to evaluate patients' response to tyrosine kinase inhibitor (TKI) therapy and the feasibility of surgery after that and to observe complications related to surgery. METHODS:: From February 2007 to September 2014 in the Istituto Tumori of Milan, IRCCS, we selected patients with locally advanced or metastatic diseases, treated with target therapy before surgery (which comprised nephrectomy or partial nephrectomy, cytoreductive surgery, and metastasectomy) and cryoablation. RESULTS:: We selected 33 patients who underwent surgery after TKI therapy. As for response to TKIs, 20 patients (60%) had stable disease, 9 patients (28%) had a partial response, and 4 patients (12%) had progressive disease. A total of 17 patients (51%) presented complications directly or indirectly related to surgery and most of those were classified as grade II Clavien-Dindo score. CONCLUSIONS:: The association between TKI and surgery seems to have no contraindications. Our dataset provides an example of how surgery after TKI is possible in locally advanced metastatic tumor and does not have an excessive rate of postoperative complications.

An unusual cystic presentation of ductal carcinoma of the prostate.

A 74-year-old male came to our clinic for rectal tenesmus, lower urinary tract symptoms and a previous episode of acute retention of urine. Computed tomography (CT) and magnetic resonance imaging (MRI) scan of abdomen showed a multiloculated, cystic formation of 12 cm in the pelvic cavity to the left, with compression of the prostate, bladder, sigmoid and rectum, and its extension imprinted the back of the pubis and back bladder. Saturation prostate biopsy was negative for carcinoma. The histology of transurethral resection of bladder formation revealed flogistic tissue. Cistoprostatectomy and ureteroileal pouch with Wallace anastomosis, removal of the rectum and colostomy with Hartmann pouch were performed. The histopatology showed a ductal carcinoma of the prostate.

Syphilis or cancer? A urological challenge.

A 31-year-old male came to our clinic for suspicious testicular masses. Frozen-section examination of an excisional biopsy revealed inflammatory tissue, so we did not perform orchifuniclectomy. Definitive hystopatology revealed mio-fibroblastic nodules, which were considered consistent with testicular localization of luetic lesions. The patient was tested for syphilis and was found to be positive. HIV and other sexually transmitted diseases (STDs) tests were negative. He underwent antibiotic treatment and is doing well.

The Value of Open Conversion Simulations During Robot-Assisted Radical Prostatectomy: Implications for Robotic Training Curricula.

INTRODUCTION: There is a lack of protocols, formal guidance, and procedural training regarding open conversions from robot-assisted radical prostatectomy (RARP) to open radical prostatectomy (ORP). An open conversion places complex demands on the healthcare team and has recently been shown to be associated with adverse perioperative outcomes. AIMS: To perform a root cause analysis of open conversion simulations from RARP to ORP to identify errors that may contribute to adverse events. METHODS: From May 2013 to December 2013, with a team of two surgeons, an anesthesiologist, and three nurses, we simulated 20 emergencies during RARP that require open conversion. A human simulation model was intubated and prepared in the Trendelenburg position; a robot da Vinci SI was locked to it. All simulations were timed, transcribed, and filmed to identify errors and areas for improvement. An institutional conversion protocol was developed at the end of the conversion training. RESULTS: The average conversion time was 130.9 (interquartile range [IQR] 90-201) seconds. Frequencies of the observed errors were as follows: lack of task sequence (70%), errors in robot movements (50%), loss of sterility (50%), space conflict (40%), communication errors (25%), lack of leadership (25%), and accidental fall of surgical devices (25%). Four main strategies were implemented to reduce errors: improving leadership, clearly defining roles, improving knowledge base, and surgical room reorganization. By the last simulation, conversions were performed without errors and using 55.2% less time compared with initial simulations. CONCLUSIONS: In this preliminary study, repeated simulations, increased leadership, improved role delineation, and surgical room reorganization enabled faster and less flawed conversions. Further studies are needed to identify if such protocols may translate to actual safety improvement during open conversions.

Residual prostatic tumour in the surgical bed following radical prostatectomy in organ-confined prostate cancer: possible prognostic significance.

INTRODUCTION AND OBJECTIVES: The aim of our study was to verify the impact of benign and malignant residual glandular tissue on surgical bed after radical prostatectomy, in terms of both biochemical and clinical disease progression, in a group of patients with pathologically organ-confined cancer of the prostate (PCa). MATERIAL AND METHODS: Files from 70 consecutive patients who undergone radical retropubic prostatectomy (RRP) for organ-confined PCa were retrospectively evaluated. During each intervention, after prostate removal, biopsies of the surgical bed were obtained from the following sites: urethral/periapical section margin, basal, left and right postero-lateral and under/retrotrigonal regions. No patient was been previously treated with either radiation or hormone therapy. We evaluated the relationship between the presence of either benign or malignant prostatic cells at surgical bed biopsies and the following parameters: postoperative serum PSA levels, definitive Gleason score, tumour staging, margin status. RESULTS: In all cases pathological stage was pT2NOMO, an immediate postoperative PSA zeroing occurred and surgical margins were negative. Surgical bed biopsies after prostate removal were positive for malignant cells in 5/70 cases (7.1%) and for benign prostatic cells in 16/70 patients (22.9%). Overall a biochemical disease progression was observed in 13/70 cases (18.6%): 1 case with surgical bed biopsies positive for cancer; 3 cases with biopsies positive for benign prostatic tissue; 9 patients with biopsies negative for prostatic tissue residuals. In this latter group 2 cases of disease progression were observed. Stratifying patients according to biopsy features, we did not find any significant difference between groups concerning preoperative PSA (p = 0.319), prostate weight (p = 0.158), pathological staging (p = 0.371), Gleason score (p = 0.457), follow-up (p = 0.144), biochemical progression rates (p = 0.553). At logistic regression model the only statistically significant association was between disease progression and preoperative PSA (p = 0.026). Stratifying patients with no malignant biopsies in two subgroups (presence and absence of residual benign prostate tissue) no statistically significant differences were detected in terms of disease relapse (p = 0.158). CONCLUSIONS: In patients with pathologically organ-confined PCa, minimal neoplastic tissue residuals might not significantly affect medium-long-term prognosis: 80% of patients with positive biopsy showed undetectable serum PSA levels after a median follow-up over 5 years. In contrast, surgical margins positive for benign prostatic glands was not significantly related to a possible disease relapse/progression.

Preoperative criteria to select patients for bilateral nerve-sparing robotic-assisted radical prostatectomy.

INTRODUCTION: To date, no study has analyzed the predictors of potency recovery in a robot-assisted laparoscopic radical prostatectomy (RALP) series. A novel risk stratification for erectile function recovery after retropubic radical prostatectomy (RRP) has been proposed recently by Briganti et al. from the University Vita-Salute San Raffaele in Milan, Italy. AIM: To evaluate the potency rate in a series of consecutive patients who underwent bilateral nerve-sparing RALP, to identify the preoperative predictors of erectile function recovery, and to validate the risk-group stratification of Briganti et al. METHODS: The clinical records of all patients who underwent RALP for clinically localized prostate cancer between April 2005 and April 2009 were prospectively collected in the Prostate Cancer Padua Database. For the present study, we extracted all consecutive cases receiving a bilateral nerve-sparing technique with a minimum follow-up > or =12 months. MAIN OUTCOME MEASURES: Twelve-month potency rate after RALP, defined as an International Index of Erectile Function 6 (IIEF-6) score > or =18. RESULTS: Data showed that 129 out of 208 enrolled patients (62%) were potent 12 months after surgery. Age (hazard ratio [HR]: 2.8; P < 0.001), Charlson score (HR: 2.9; P = 0.007), and baseline IIEF-6 score (HR: 0.8; P < 0.001) were independent predictors of potency recovery at multivariate analysis. According to Briganti et al.'s risk-group stratification, the 12-month potency rate following RALP was 81.9% in the low-risk group, 56.7% in the intermediate-risk group, and 28.6% in the high-risk group (P < 0.001). CONCLUSIONS: In the era of robotic surgery, the key point for the success of the nerve-sparing technique remains the accurate selection of patients. Age < or =65 years, absence of associated comorbidities, and good preoperative erectile function are the most important preoperative factors to select those patients for whom bilateral nerve-sparing RALP can achieve the best results.