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.

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

ABSTRACT Introduction: The Lithocatch™ 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™ 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™ 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™ 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.

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.

Massive migration of embolization coils inside the renal pelvis. A rare complication that can be approached through percutaneous surgery.

Percutaneous nephrolithotripsy (PCNL) has become a common procedure performed in patients with large renal calculi. Hemorrhage is the most frequent complication of this procedure. Transcatheter renal artery embolization is an effective and minimally invasive treatment option for acute renal bleeding but it is not without risks. In the case we describe, a big stone originated on embolization coils which migrated inside the renal pelvis after a previous PCNL and transcatheter artery embolization. We show that a new percutaneous approach is feasible and allows for the fragmentation of the stone and full clearance of fragments and coils.

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.