A right colon pouch with a novel efferent channel concept: long-term results of the Turin pouch.

PURPOSE: To report stoma stenosis rates and efferent channel (EC) complications at long term follow-up for Turin pouch (TP). METHODS: This is a retrospective analysis of the prospectively maintained database of patients who underwent TP between March 2006 and May 2018. The TP is a U-shaped right colon pouch. The EC was conceived by the tubularization of 5 cm of the colon wall with the use of a stapler and sutured to the skin (EC-cutaneostomy). The ureters are sutured separately to the last 10 cm of ileum before the ileocecal valve. In literature, catheterization problems have been described on average in 20.3% of patients and stoma stenosis in 19.5% of the patients with flap valve systems. RESULTS: Thirty-eight consecutive patients underwent a TP procedure. The median age was 55 years (IQR: 52-60). Median operative time was 201 min (IQR: 170-210), median reconstructive time was 61 min (IQR: 55-65) and the blood loss was 244 ml (IQR: 150-300) and 4 patients (10.5%) needed blood transfusions. The median follow-up was 52 months (IQR: 37-92). Complete 24h continence was achieved in 34 (89%) patients. Seven (18.4%) patients reported difficulties in EC catheterization and 4 (10.5%) patients had stoma stenosis. This study is limited by the relatively small number of patients. CONCLUSION: In relation to similar systems, the TP seems to offer comparatively good functional results but EC and stoma complications were lower than other pouch variants in literature.

Retroperitoneal ancient schwannoma: case report and analysis of clinico-radiological findings.

Ancient schwannoma is a rare subtype of typical schwannoma, with histological predominance of degenerative findings. We report the second case of retroperitoneal ancient schwannoma (occurred in a 45-year-old female referred to our institution for an unremitting right lumbar pain) and pinpoint clinical, radiological, prognosis and therapeutic aspects of this tumor.

Roach's mathematical equations in predicting pathological stage in men with clinically localized prostate cancer.

AIMS AND BACKGROUND: The therapeutic choice in patients with clinically localized prostate cancer depends on preoperative clinical stage. Diagnostic instruments currently available for such an evaluation--considered separately--have not shown enough efficacy. Roach has recently introduced three simple mathematical equations that--on the basis of prostate-specific antigen and the biopsy Gleason score--are aimed at calculating the definitive pathological stage. We retrospectively analyzed our radical prostatectomy data base to assess the accuracy of the equations in predicting the final stage in patients with clinically localized prostate cancer. METHODS STUDY DESIGN: The study included 173 patients who had undergone radical retropubic prostatectomy at our Institution. Patients were divided into 25 groups, depending on preoperative PSA and the biopsy Gleason score. The risk of extracapsular neoplastic growth, seminal vesicle involvement and lymph node involvement was calculated for each group by means of Roach's equations. On the basis of definitive histological examinations, we compared the expected risk to the observed risk. RESULTS: The observed risk fell within the interval of expected risk in 16 of 17 groups (94%) regarding the evaluation of extracapsular growth, in 15 of 17 (88%) regarding the analysis of seminal vesicle involvement, and in 14 of 17 (82%) regarding the evaluation of lymph node involvement. Therefore, the observed event was in agreement with the expected event in 45 of 51 groups (88%). CONCLUSIONS: The equations represent a practical and effective instrument for preoperative clinical staging in patients with localized prostate cancer. By means of these mathematical formulas, one can assess the correct prognosis and--above all--plan the best therapeutic approach.

[Endourologic treatment of benign uretero-intestinal stenosis in patients with definitive urinary diversion: 10-year experience]. / Trattamento endourologico delle stenosi uretero-intestinali benigne in pazienti con derivazione urinaria definitiva: esperienza di 10 anni.

OBJECTIVE: Ureterointestinal (U-I) anastomotic stricture is one of the most important complications after radical cystectomy, occurring in 4% to 8% of patients. We report our ten years experience in the endourological treatment of this condition. MATERIALS AND METHODS: 32 patients with U-I strictures were endourologically treated at our Institution. The endoscopic procedure provides for a percutaneous nephrostomy, the passage of the stenosis with a guide-wire, the incision and balloon dilation of the stricture and, finally, a ureteral double J stenting. Of the 28 successfully treated patients, 10 underwent balloon dilation alone and 18 both ureteral incision (with cold knife in 11 and hot knife in 7) and dilation. RESULTS: The endourological approach failed in 4/32 (12.5%) patients: 3 failures were due to the inability to pass a guide-wire across the stricture, whilst in the remaining patient a serious intraoperative hemorrhage occurred. In 28/32 (87.5%) patients the endoscopic treatment was successful (a ureteral stent was positioned across the stenosis). However, long term results are less promising: at 6-90 month follow up, only 16 patients (57.1%) are free of strictures without ureteral stent, 10 (35.7%) need a permanent ureteral stent, 2 (7.2%) a percutaneous nephrostomy. CONCLUSION: Due to the low morbidity of endoscopic procedures and to the high risks associated with open surgery, we believe that endourology should represent the first choice in the treatment of U-I strictures, reserving open surgery for endoscopic failures or complications. Moreover, endourological treatment with both incision and dilation is more effective than dilation alone (which should be performed only in very short and recent strictures).

Adult testicular pure yolk sac tumor.

Here we describe the clinical, ultrasonographic and histological features of a rare pure adult yolk sac tumor detected in the right testis of a 44-year-old male. Due to the rarity of this neoplasm (less than 10 cases have been reported), there is no unanimous consensus for therapy following inguinal orchiectomy. We believe that nerve-sparing retroperitoneal lymph node dissection could be potentially curative and useful for future interpretations of this tumor's potential evolution.

Scrotal extraperitoneal hernia of the ureter: case report and literature review.

Ureteral herniation is a rare, often misdiagnosed event and serious surgical complications are possible. Until 1992, 128 cases of ureteral herniation were reported and in 54 (42%) the inguino-scrotal region was involved. From an anatomical and pathogenic standpoint, two types of uretero-inguinal hernias can be identified: paraperitoneal (more frequent, acquired, always presenting a peritoneal hernia sac, frequently associated with other herniated abdominal structures) and extraperitoneal (very uncommon, congenital, never associated with a true peritoneal sac, always composed only of the ureter). We describe a new case of scrotal extraperitoneal ureteral hernia and review the current urological, surgical and radiological literature to analyze the main clinical characteristics of this pathology and its ideal treatment.

[Experimental microsurgical gastrocystoplasty] . / La gastrocistoplastica sperimentale microchirurgica.

BACKGROUND: Stomach tract used for bladder augmentation decreases urinary pH and produces the syndrome of dysuria and hematuria; gastric mucosa in contact with urine may develop prominent histopathological changes including proliferative lesions. The aim of this study was to investigate in an experimental model the possibility of detecting the factors involved in the mucosal damage. METHODS: Thirty-five Sprague Dawley rats randomly underwent microsurgical gastrocystoplasty or sham operation (5 controls). During operation elliptical gastric patch was isolated with its gastroepiploic vascular pedicle, bladder was opened with midline incision and anastomosis performed. Urine was aspirated from the bladder for culture, pH and electrolytes evaluation; venous blood was samples for electrolytes, BUN and creatinine. Mean follow-up time was 6 months. RESULTS: Of the 30 rats subjected to gastrocystoplasty 23 survived (77%). All of cultures were negative, the urinary pH decreased after operation and increased gradually two months later. Urinary sodium and potassium ions concentrations increased significantly in gastrocystoplasty (p < 0.05). There were no significant changes in serum electrolytes or renal function. CONCLUSIONS: This experimental model was useful to investigate the effects related to the presence of gastric mucosa in the urinary tract.

Obstetric and gynaecological ureteric injuries: treatment and results.

OBJECTIVE: To compare endourological techniques and open surgery in the treatment of ureteric injuries following obstetric and gynaecological surgery. PATIENTS AND METHODS: From January 1982 to February 1994, 63 women (mean age 51 years, range 22-70) were treated for 72 ureteric lesions consequent upon obstetric or gynaecological surgery. In nine patients, 10 ureteric lesions were detected intra-operatively and repaired immediately. In the remaining 54 patients, the 62 ureteric injuries were diagnosed and treated after a delay; 29 patients with 37 ureteric injuries underwent repair by open surgery while 25 patients with a unilateral ureteric lesion underwent elective primary endourological treatment. RESULTS: The results of repair were not related to the type of treatment; the cure rate was 87, 88 and 90% for delayed open surgical, endourological and immediate intra-operative repair, respectively. The site (vesico-ureteric junction, uterine artery or infundibulopelvic ligament) and the type (fistula or stenosis) of ureteric lesion had no influence on the results, regardless of the type of treatment. The results of ureteric repair were related to the surgery that caused the lesion; 88% of the poor results occurred in the patients who underwent radical hysterectomy alone or combined with radiotherapy and approximately half of the irradiated patients required major surgery. CONCLUSION: When the patients are correctly selected, endourological treatment plays an equally important role in the treatment of gynaecologically-related ureteric injuries when compared to open surgery. Special attention should be paid to the treatment of lesions caused by radical hysterectomy alone or associated with radiotherapy, as these may lead to poor results.

Tatamento endourologico da estenose ureterointestinal / Endourologic treatment of ureterointestinal

Dez pacientes com estenose ureteroiintestinal foram tratados por tecnica endourologica endoscopoco compreendeu dilataçao endoscopica com balao (5 casos), incisao com faca fria (2 casos) e dilataçao precedida por incisao com eletrodo (2 casos). Os autores discutem a indicaçao, evoluçao e as tecnicas endoscopicas para tratamento da afecçao.

[Exploration of the intra-renal collecting system using flexible fibroscopy]. / Exploración del sistema colector intrarrenal a través de fibroscopia flexible.

23 cases of flexible retrograde nephroscopy system for undiagnosed hematuria or filling defect are reviewed. The introduction was carried out by combining hydraulic dilation, rigid ureterorenoscopy and a working sheath. The indications were merely diagnostic (filling defects and/or haematuria). The success rate was very high (22 of 23). 9 cases of papillary tumors, 4 cases of small radiolucent stones and 1 case of papillary necrosis were diagnosed. In 8 cases no pathology was found. The complication rate was extremely low and the postoperative course was uneventful. Flexible instruments offer a very good chance to explore the intrarenal collecting system and transureteral nephroscopy through a 10.8 F flexible scope is a feasible and effective procedure.

[Extracorporeal lithotripsy using the Lithoring multi-one, a third generation lithotripter]. / Litotrissia extracorporea con il lithoring multi-one, litotritore di terza generazione.

The Lithoring multi-one is a lithotripter recently developed in Italy. Its main features are: (1) spark gap generator with large ellipsoid with tunable power for treatments with or without analgesia (2) localization by fluoroscopy and ultrasounds without moving the patient (3) isocentric variation of shock wave window (4) multi-functional table. It can treat both urinary and biliary stones. Herein we described (1) the experimental in vitro studies, including those carried out by intentionally changing the direction of the blast path during the treatment (2) the experimental in vivo studies on pigs which demonstrated a rate of side effects favourably comparable with that of other spark gap lithotripters (3) the clinical experience on urinary stones which started in May, 1989. The first 50 patients were treated without anaesthesia with an average of 1700 shock waves at 19.2 Kv. 37 patients had stones larger than 1 cm. 13 patients had ureteral stones. Two patients had complete staghorn stones. The disintegration rate was 97.9 percent, the overall stone-free rate at 3 months follow-up was 83.3 percent and the retreatment rate was 1.29 treatments for patients. No complication occurred.

Percutaneous transcatheter renal angioplasty: an endourological experience.

A series of 56 percutaneous transcatheter renal angioplasties, carried out in an endourological unit, is reviewed and compared with radiological series. The results were inferior for fibrosclerotic lesions (77 vs. 90%) and nonostial atherosclerosis (67.8 vs. 75%), but slightly superior for ostial lesions (33 vs. 20-30%) in the endourological series as compared with the radiological series. Conversely, morbidity was significantly inferior (8.9 vs. 18.6%). The endourological series compares well with the radiological series in the literature. Percutaneous transcatheter renal angioplasty should be considered a procedure belonging both to interventional radiology and to endourology. Owing to the technical difficulties and the complication rate, it should not be performed in outpatients and a surgical support team should be available in the event of a threatening renal complication.

Flexible antegrade and retrograde nephroscopy: review of 50 cases.

50 cases of flexible instrumentation of the intrarenal collecting system are reviewed. 28 were performed by retrograde flexible ureterorenoscopy. The introduction was carried out by combining hydraulic dilation, rigid ureterorenoscopy and a working sheath. 22 cases were performed through a percutaneous route. The indications were both diagnostic (filling defects and/or hematuria) and therapeutic (caliceal stone and/or fragments). The success rate was high in the diagnostic cases (20 of 24), but lower in the therapeutic cases (13 of 26). The complication rate was extremely low and the postoperative course was always uneventful. Flexible instruments offer a very good chance to explore the intrarenal collecting system. Both transureteral and percutaneous flexible nephroscopies are feasible and effective procedures. A laser can be used well in this area.

First experience with the Lithoring in the management of urinary stones.

The Lithoring Multi-One is a lithotripter recently developed in Italy. Its main features are (1) spark gap generator with large ellipsoid, with tunable power for treatments with or without analgesia; (2) localization by fluoroscopy and ultrasounds without moving the patient; (3) isocentric variation of shock wave window, and (4) multifunctional table. It can treat both urinary and biliary stones. The first 50 patients were treated without anesthesia with an average of 1,700 shock waves at 19.2 kV. 37 patients had stones larger than 1 cm. 13 patients had ureteral stones. Two patients had complete staghorn stones. The disintegration rate was 97.9%, the overall stone-free rate at 3 months' follow-up was 83.3%, and the retreatment rate was 1.29 treatments for patients. No complication occurred.

In situ or retrograde manipulation of ureteral stones: still a controversy?

A series of 365 patients with ureteral stones is reviewed. ESWL, ureterorenoscopy, basket extraction and open surgery were alternatively used according to the stone and to the increasing experience in minimally invasive techniques. The overall success rate of in situ ESWL varied between 79 and 90% according to the localization of the stone and no difference was noted between patients treated with the original HM III Dornier lithotriptor and patients treated with the upgraded HM III with low pressure and large ellipsoid for painfree ESWL. Also the retreatment rate did not differ significantly (38 vs 42%). Ureterorenoscopy, carried out as first approach or after ESWL failure, was successful in 80.4% of the cases. Basket extraction was successful only in 32.3% of the cases. In situ ESWL, in one or two sessions, without anaesthesia and without hospital stay, is a good solution for roughly 80% of ureteral stones. Retrograde manipulation with or without ureterorenoscopy, requiring anaesthesia and hospitalization, should be reserved to failures of in situ ESWL.

[Aztreonam vs norfloxacin: a comparative study of the treatment of urinary tract infections in ambulatory and hospitalized patients]. / Aztreonam vs norfloxacina: studio comparativo nel trattamento delle infezioni delle vie urinarie in pazienti ambulatoriali ed ospedalizzati.

Eighty-two evaluable patients suffering from UTI were randomly treated with parenteral Aztreonam (1 g OD in cystitis and 1 g BID in pyelonephritis) or oral Norfloxacin (400 mg BID). Predisposing urological conditions were present in 75% and 78.5% respectively. Microbiological cultures at the end of treatment and at a follow-up visit after 4 weeks showed significantly better results among Aztreonam treated patients (microbiological cure: 97.5% vs 71.4%-p less than or equal to 0.005). Clinical cure was achieved in 97.5% and 71.4% respectively (p less than or equal to 0.001). A statistically significant difference was present only in patients treated for pyelonephritis (microbiological cure-AZT: 100%; NOR: 50%-p less than or equal to 0.0005) and not in those with cystitis (AZT: 95.0%; NOR: 83.3%). Side effects were rare in both treatments. Aztreonam seems to offer major advantages, when compared to Norfloxacin, in the treatment of UTI, especially when upper urinary tract is involved.

[Monodose aztreonam in the prevention of infection after extracorporeal shockwave lithotripsy. Theoretical premises]. / L'aztreonam in monodose nella profilassi delle infezioni dopo ESWL. Premesse teoriche.

A series of 905 patients suffering from renal calculosis and treated with ESWL is considered and the indications for antibiotic treatment with prophylactic or prolonged aztreonam reviewed: 1) for calculi with sterile urine or occasionally infected with I.S.T. less than 200, monodose prophylaxis is certainly advantageous; 2) for calculi with sterile urine or occasionally infected with I.S.T. between 200 and 500, prolonged antibiotic cover is useful; 3) for calculi with chronic infection or with I.S.T. greater than 500, prolonged target antibiotic therapy is necessary; 4) aztreonam is an effective drug for both monodose prophylaxis and for cover treatment. In more complex cases, an antibiogram indication is necessary.

Painless extracorporeal shock wave lithotripsy for outpatients: a new option.

Extracorporeal shock wave lithotripsy is becoming the most common procedure for the treatment of renal and ureteral stones. The introduction of a new generator and a new hemi-ellipsoid for the Dornier HM-III lithotripter improves patient comfort and requires no general or peridural anesthesia, thus making it easier to perform this procedure on an outpatient basis.

Extracorporeal shock wave lithotripsy in the prone position for stones situated anteriorly.

Stones situated anteriorly cannot be satisfactorily reached with extracorporeal shock wave lithotripsy (ESWL) in the supine position. By assuming the prone position, patients with stones in horseshoe or ectopic kidneys or in the iliac ureter can be treated by ESWL with the same success rate as patients with posterior stones. This new technique has been used in 30 patients with iliac ureteral stones, 5 patients with caliceal stones in horseshoe kidneys and 1 patient with a pyelic stone in a sacral kidney.