A matched-analysis on short-term and long-term (up to 5 years of follow-up) urinary incontinence outcomes after robot-assisted radical prostatectomy with and without anterior and posterior reconstruction: data on 1358 patients.

PURPOSE: We report a comparative monocentric study with a short and long-term follow-up with the aim to assess differences about urinary continence outcomes in patients treated with Robot-Assisted Radical Prostatectomy (RARP) with two different techniques: with anterior and posterior reconstruction and without any kind of reconstruction. MATERIALS AND METHODS: From January 2016 to September 2021, at the Department of Urology of the "F. Miulli" Hospital of Acquaviva delle Fonti, in Italy, 850 eligible patients underwent extraperitoneal RARP with anterior and posterior reconstruction and 508 without reconstructions. RESULTS: In patients undergoing RARP with reconstructions 1 month after surgery the urinary continence was preserved in 287/850 patients (33.8%), 3 months after surgery in 688/850 (81%), 6 months in 721/850 (84.8%), 12 months in 734/850 (86.3%), 18 months in 671/754 (89%), 24 months in 696/754 (92.3%), 36 months in 596/662 (90%), 48 months in 394/421 (93.6%), 60 months in 207/212 (97.6%). In patients undergoing RARP without reconstruction 1 month after surgery urinary continence was preserved in 99/508 (19.4%), after 3 months in 276/508 (54.3%), 6 months in 305/508 (60%), 12 months in 329/508 (64.7%), 18 months in 300/456 (65.7%), 24 months in 295/456 (64.7%), 36 months in 268/371 (72.3%), 48 months in 181/224 (81%), 60 months in 93/103 (90.3%). CONCLUSION: In our case study, the RARP with anterior and posterior reconstruction technique is associated with a statistically significant higher rate (up to 48 months of follow-up) and a faster recovery of urinary continence compared to the technique without reconstructions.

Laparoscopic versus open radical retropubic prostatectomy: a case-control study at a single institution.

We retrospectively compared 50 patients treated with open retropubic prostatectomy (RRP) with 50 patients treated with laparoscopic extraperitoneal radical prostatectomy (LRP) at our institution, in the same time period, with a follow-up up to 7 years. We focused on operative data, complications, pathological outcome and mid-term outcome and follow-up in terms of oncological results. The same surgeons performed both operations. The 2 groups were similar with respect to mean patient age, mean prostate specific antigen value, median Gleason score. No previous transurethral resection of the prostate nor neoadjuvant treatment, had been undertaken in both groups of pts. Mean operating time was significantly shorter after open surgery (126 minutes, range 90-185 minutes) [p = 0.03] compared to the laparoscopic group (188 minutes, range 130-250) but it did not differ significantly from the last 20 laparoscopic procedures, in which the time of procedure was reduced to a mean of 155 minutes group (range 140-184 minutes) [p = 0.1]. Mean blood loss (1,150 versus 800 cc) and transfusion rates (55.7% versus 19.6%) in the 2 groups significantly favored the laparoscopic group. Number of lymphnodes dissected during the procedures favoured, but not significantly, the RRP group: for RRP a mean 11 lymphnodes right side, 13 left side (ranges 2-20 and 2-19 respectively), while for LRP a mean of 9 lymphnodes right side, 11 left side (ranges 2-15 and 2-13 respectively) were collected. The complication rate was almost the same in both groups, with no major adverse events nor deaths, (19.2% versus 14.7%) but the spectrum differed. The laparoscopic group had a higher incidence of fever (1.8% versus 3.2% respectively) and subcutaneous or scrotal emphysema, whereas more lymphoceles (6.9% versus 0%), wound infection (2.3% versus 0.5%), embolism/pneumonia (2.3% versus 0.5%) and anastomotic strictures (15.9% versus 4%) occurred after open surgery. Median catheter time was longer after open retropubic prostatectomy (22 versus 8.9 days, respectively) but the continence rates (intended as complete continence with no use of pads) were similar in both groups at 12 months (90.3% versus 91.7%). The rate of positive margins did not differ significantly in groups, and was in all cases very low (8.2% versus 7.0%), prostate specific antigen biochemical recurrence was equivalent (10% vs 10%). Data regarding postoperative sexual function favoured the laparoscopic group, even if no statistical significance was recorded (55% vs 67%). No statistical differences were observed in terms of oncological results, with a 24 months mean follow-up. Laparoscopic radical prostatectomy is technically demanding, with an initially longer operative time and learning curve. The overall outcome in our series favours the laparoscopic approach regarding catheterization time, recover of continence and impotence, hospital stay, transfusion rate. The open approach is favoured for the still shorter time necessitating for the procedure. Consequently, at our institution laparoscopic radical prostatectomy is becoming the method of choice.

Percutaneous treatment of staghorn stones: a retrospective case-control study with evaluation of single vs multiple access to the kidney.

Staghorn stones have been treated, up to 30 years ago, with open surgery. With the introduction of percutaneous procedure (PNL) and the use of shock wave lithotripsy (SWL) together with flexible instrumentation and Holmium Laser lithotripsy the indication for open surgery is actually very limited. On the other hand conservative treatment of staghorn calculi will result in a complete destruction of the kidney associated to a mortality rate up to 30%. The best results of surgical treatment have been obtained after anatrophic nephrolithotomy, with stone-free rates of 71 to 100%. In 1955 was first described the method of percutaneous nephrostomy insertion, and 20 years later was first reported on percutaneous nephrostolithotomy. Initially, only calculi no larger than the diameter of the nephrostomy tract were removed. Treatment of complex staghorn stones remained controversial because of the very high stone burden and it was also debated the choice between a single tract percutaneous approach, or a multiple tract approach in order to obtain a complete stone clearance. In our study we have compared the percutaneous approach with a single tract and the use of a flexible nephroscope in order to reach all the calices with the percutaneous approach with multiple accesses.

Bilateral same session ureteroscopy: safety and efficacy.

Actually ureteroscopy represents the therapy of choice for the treatment of ureteric stones. In the case of bilateral synchronous ureteric calculi the options are between a staged or a synchronous procedure; the last would potentially reduce costs and the need for a second anesthetic in comparison with a staged procedure. We reviewed our experience with bilateral same session ureteroscopy and compared with staged bilateral or unilateral procedure in the same series. The size and site of the stones were similar in all groups with a mean of 8.5 x 6.51 mm (15-7 x 10-5 mm). Symptoms were compared between the groups both before and after surgery, like painful urination, flank pain, urgency, nocturia, frequency, lower abdominal pain and urinary incontinence were assessed. A slight prevalence in the presence of hematuria was present in the bilateral same session URS group, probably due to the presence of the DJ stent. Urinary discomfort was more common in this group without reaching statistical significance (p>0.05). In no case differences between groups were statistically significant. No statistically significant differences were reported between the groups regarding postoperative pain (p>0.5). In our series, bilateral synchronous ureteroscopy is a safe procedure, with high stone free rate even compared with staged bilateral and monolateral treatment. It has the advantage of saving multiple procedures and the need of a second anesthesia and hospitalization. It can be performed safely with minimal risks. The positioning of a DJ stent at the end of the procedure adds little time, preventing post-operative complications with little discomfort for the patient.

A prospective randomized multicentric study comparing stented vs non-stented ureteroscopic lithotripsy.

OBJECTIVE: We compared postoperative pain, short and long-term complications after ureteroscopic (URS) treatment of stones followed or not by placement of a double J stent. MATERIALS AND METHODS: from July 2000 to September 2001 we recruited a total of 56 patients with ureteric stones amenable of endoscopic treatment by URS. Mean age was 48 years (22-70) average stone diam was 9.17 x 6.91 mm (15-7 x 10-5 mm). Patients were classified into obstructed or non obstructed on the basis of the intravenous pielography, and thereafter prospectively randomized in stented (6 ch DJ) or non-stented patients. 26 patients were classified as obstructed, whilst 30 as non obstructed. Therefore we have 13 patients in each branch (stented/non stented) of the obstructed group and 15 in each branch (stented/non stented) in the non obstructed group). Procedures were carried out with rigid or semirigid ureteroscopes up to 8.5 Ch and in all cases ballistic lithotripsy was used. Stented patients had the double J removed between postoperative day 3 and 10 (mean 7). By means of a visual analogic scale (VAS), postoperative pain was assessed. Patients underwent an ultrasound assessment a month 1-3 and 6 post operatively. Also early complications, if present, were recorded and analysed. RESULTS: No statistically significant differences were reported between the groups regarding postoperative pain (p > 0.5) or persisting or newly established hydronephrosis (p > 0.5) unregarding the preoperative presence of urinary tract obstruction. In 2 cases residual fragments were present necessitating in 1 case of a second URS. In 1 case, randomized as non stented, a double J was positioned in day 1 postoperative with the aim to reduce persisting pain. CONCLUSIONS: Ureteroscopy is a safe, minimally invasive procedure, actually the optimal treatment for ureteric stones. The positioning of a double J stent after the procedure does not have, with the actual ureteroscope size and lithotripsy devices, as is evident from our study, anymore indication.