How-I-do-it: minimally invasive repair of ileal conduit parastomal hernias.

BACKGROUND: Parastomal hernia after radical cystectomy and ileal conduit urinary diversion is an underestimated and undertreated condition with significant impact on quality of life. However, its surgical treatment is challenging and prone to complications and the optimal surgical treatment of this condition remains to be determined. METHODS: In this article, we describe our surgical techniques in the minimally invasive treatment of ileal conduit parastomal hernia and present our preliminary results. In a retrospective single-center design, a prospectively maintained database was screened. Data from all patients undergoing surgical treatment for a parastomal hernia after cystectomy and ileal conduit urinary diversion in our center were collected. RESULTS: Between May 2016 and June 2020, 15 patients underwent minimally invasive repair of a parastomal hernia of an ileal conduit. Details on the surgical approach are provided, along with a flow chart to standardize the choice of surgical technique, depending on the presence of a concomitant midline incisional hernia and perioperative findings. The majority of patients were treated with robotic-assisted laparoscopic surgery (10/15; 66.7%). Median postoperative hospital stay was 5 days. One-third of patients developed a postoperative urinary infection. Median follow-up was 366 days. One patient developed a local recurrence of her parastomal hernia on day 66 postoperatively, treated with intraperitoneal mesh. CONCLUSION: The minimally invasive surgical treatment of a parastomal hernia after ileal conduit urinary diversion poses specific perioperative challenges that require a broad surgical armamentarium and a tailored approach. Preliminary results confirm a significant morbidity after this type of surgery.

Concordance Between Biopsy and Radical Prostatectomy Gleason Scores: Evaluation of Determinants in a Large-Scale Study of Patients Undergoing RARP in Belgium.

To determine whether Gleason scores were concordant between prostate biopsies (bGS) and the definitive resection specimen (pGS) excised with robot-assisted radical prostatectomy (RARP); to identify clinical and pathological factors that might predict upgrading; and to evaluate how upgrading affected outcome. Between 2009 and 2016, 25 Belgian centers participated in collecting prospective data for patients that underwent RARP. We analyzed the concordance rate between the bGS and the pGS in 8021 patients with kappa statistics, and we compared concordance rates from different centers. We assessed the effect of several clinical and pathological factors on the concordance rate with logistic regression analysis. The concordance rate for the entire population was 62.9%. Upgrading from bGS to pGS occurred in 27.3% of patients. The number of biopsies was significantly associated with concordance. Older age (>60 y), a higher clinical T stage (≥cT2), a higher PSA value at the time of biopsy (>10 ng/ml), and more time between the biopsy and the radical prostatectomy were significantly associated with a higher risk of upgrading. Positive margins and PSA relapse occurred more frequently in upgraded patients. Center size did not significantly affect the concordance rate (p = 0.40).This prospective, nationwide analysis demonstrated a Gleason score concordance rate of 62.9%. Upgrading was most frequently observed in the non-concordant group. We identified clinical and pathological factors associated with (non)-concordance. Upgrading was associated with a worse oncological outcome. Center volume was not associated with pathological accuracy.

Impact of urinary tract infection and detrusor pressure on renal tubular function in patients with vesicoureteral reflux.

OBJECTIVE: The aim of this study was to evaluate prospectively the impact of bacteriuria with or without pyuria and/or detrusor pressure on renal tubular function in patients with secondary vesicoureteral reflux. METHODS: From October 1994 to December1998, we evaluated 54 patients with secondary vesicoureteral reflux (26 men and 28 women; age 30+/-24 years), of whom 28 had a neurogenic and 26 a nonneurogenic voiding dysfunction. In a reference population (n = 48; 28 men, 20 women; age 38+/-14 years), 43 had a neurogenic and 5 a nonneurogenic voiding dysfunction. Urinary alpha-1-microglobulin was measured immunonephelometrically. Statistical analysis was performed by multiple regression analysis. RESULTS: Patients with vesicoureteral reflux had a significantly higher urinary alpha-1-microglobulin/creatinine ratio. Urinary alpha-1-microglobulin excretion was related to the grade of vesicoureteral reflux, detrusor pressure and compliance, but not to bacteriuria or pyuria, and was diagnostic for vesicoureteral reflux with a sensitivity of 90%, a specificity of 70% and a negative predictive value of 97%. CONCLUSION: Urinary alpha-1-microglobulin excretion is diagnostically useful in patients with secondary vesicoureteral reflux. The use of urinary alpha-1-microglobulin excretion in the follow-up of patients with vesicoureteral reflux has yet to be established.