Cost-effectiveness analysis of a single-use digital flexible cystoscope for double J removal.

INTRODUCTION AND OBJECTIVE: The novel single-use digital flexible cystoscope Isiris™ has been developed to perform in-office JJ stent removal, without the need of special equipment nor limitations linked to the disinfection of a reusable device. The aim of our study was to perform a cost-effectiveness analysis of Isiris™ in our institution. PATIENTS AND METHODS: A total of 127 consecutive patients undergoing in-office stent removal with Isiris™ were prospectively included in study. After each procedure, the urologist filled a questionnaire specifically developed to evaluate the efficiency of the device and the invasiveness of the procedure. We performed a cost analysis of the main variables involved in JJ removal using Isiris™ versus the traditional Storz™ reusable flexible cystoscope used for all our previous patients. RESULTS: The procedure was successful in all cases except for one, where the device did not work due to the failure of the grasper and had to be replaced. Overall, the performance of Isiris™ was judged by the physician "very good" and "good" in 90.6% of the cases. Both median pain and invasiveness felt by the patient were 0 (range = 0-8). The mean cost of procedure was estimated at €361 for in-office stent removal with Isiris™, and €1.126.8 for stent removal in operatory room with a reusable flexible cystoscope. Considering the 127 procedures performed in office, 64 h of operatory room time was saved. CONCLUSION: In institutions where JJ removal is performed in the operatory room, Isiris™ leads to a significant advantage in terms of money saved per procedure, operatory room time gained and patient satisfaction.

Allium stent for the treatment of a malignant ureteral stenosis: A paradigmatic case.

OBJECTIVE: The aim of this study was to present a paradigmatic case where the new-generation Allium URS stent was the optimal choice to treat a malignant ureteral stenosis. METHODS: We describe in detail all the steps of our surgery, performed on a 69-year-old patient with left hydronephrosis caused by lumbo-aortic nodal metastases compressing the ureter. The patient was intolerant to double-J stent due to strong irritative urinary symptoms. Allium URS stent was positioned under fluoroscopy in replacement of pre-existing double-J stent. RESULTS: Our approach was successful and irritative urinary symptoms disappeared. At 6 months, the Allium URS was correctly positioned and no hydronephrosis was detected on ultrasound. The stent can be left in place for a maximum of 3 years. CONCLUSIONS: In complicated scenarios of chronic ureteral stenosis, the new-generation Allium URS can be an interesting option to treat the obstruction while sparing the patient the irritative urinary symptoms and periodic replacements typical of a double-J stent.

Therapeutic ureteral occlusion with Ifabond cyanoacrylate glue: an interesting solution.

OBJECTIVE: The aim of this study was to present a novel approach for complete and permanent ureteral occlusion using a percutaneous injection of Ifabond cyanoacrylate glue. METHODS: We describe in detail all the steps of our surgery, performed on a 79-year-old patient with urinary leakage from ureteral stump following radical cystectomy. N-hexyl-cyanoacrylate glue (Ifabond) was used to occlude the distal ureter and solve the leakage. RESULTS: Our approach was successful, sparing our already frail patient further surgical procedures. Six months pyelography confirmed the complete ureteral blockage with absence of extravasation. CONCLUSIONS: In complicated scenarios with urinary leakages and frail patients, synthetic glues such as Ifabond might represent an interesting therapeutic option to solve the fistulas, leading to durable success with a minimally invasive approach.

[Use of frozen sections to assess surgical margins during radical prostatectomy]. / Impiego dell'esame estemporaneo al congelatore per la valutazione dei margini chirurgici in corso di prostatectomia radicale

INTRODUCTION: At present there is no consensus on the use of frozen sections (FS) during radical prostatectomy. Several groups have proposed the benefit of FS although the studies differ widely in sampling methods and sites where FS were taken. This study aims to evaluate the usefulness and reliability of standard assessment of FS in multiple sites during radical prostatectomy. METHODS: During open radical prostatectomy in all patients we sampled tissue from the urethral stump, the neurovascular bundles, the Denonvillier fascia and the bladder neck after removing the prostate. Where FS showed positive margins, further periprostatic tissue was resected from the prostatic bed until negative margins were achieved. The results of FS were compared with margin status of final pathology. RESULTS: From 1998 to 2004 we performed FS during 250 consecutive open radical prostatectomies (104 nerve sparing procedures). 66 patients had positive FS (26.4%) and 53 patients had positive surgical margins at final pathology (21.2%). All patients with positive FS had negative margins when further tissue was resected in the prostatic bed. During nerve sparing procedures positive FS were found in 14 patients. In these cases the procedure was converted into standard prostatectomy by resecting the neurovascular bundles. Sensibility and specificity were both 90%. Positive and negative predictive values were respectively 72% and 97%. CONCLUSIONS: Standard assessment of FS in multiple sites during radical prostatectomy achieved sensibility and specificity as high as 90%. Although the resection of urethral stump and tissue close to the neurovascular bundles could compromise functional results, standard assessment of FS in multiple sites could help the surgeon to reduce the positive surgical margins, to monitor the oncological safety of a nerve sparing procedure and to improve the pathological staging.

Periprostatic tissues intraoperative frozen section during retrograde radical retropubic prostatectomy.

OBJECTIVE: To evaluate usefulness of periprostatic tissues intraoperative frozen sections (PTs IFSs) during RRP for prostate cancer, in order to find local extraprostatic neoplastic spreading and to eventually modify intervention and resection limits during surgery. MATERIAL AND METHODS: From January 1998 to June 2004, 259 consecutive patients underwent RRP at our department for clinically organ-confined prostate cancer; PTs IFSs were prospectively performed in all cases at membranous urethra after removal of prostatic apex, at whole neurovascular bundle (NVB) or at fibroadipose tissue subtended between prostatic capsule and NVB during extrafascial or nerve sparing (NS) RRP respectively, at middle portion of Denonvillier's fascia, at detrusor ring after removal of the prostate. IFSs positivity was followed by further excision at the corresponding site during intervention. RRP pathological specimen was handled and examined according to European Association of Urology (EAU) guidelines. Student's t-test and chi-square test were used for statistic analysis, matching patients with or without positive PTs IFSs for bioptic Gleason sum, preoperative serum PSA, clinical stage and lymph nodal involvement. RESULTS: PTs IFSs were positive 75 times in 63 patients out of 259. Pathological stage considering PTs IFSs overlapped 2002 TNM definitive pathological stage in 228 patients. The remaining 31 cases showed PTs neoplastic involvement at IFSs. These latter patients did not show prostatic capsular infiltration at definitive pathology. We demostrated intraoperative extraprostatic cancer spreading that was unrecognizable at definitive pathology. PTs neoplastic spreading changed NS RRP in extrafascial procedure in 17 patients out of 121 with preoperative planned NS RRP There were no significant statistic differences between patients with or without positive periprostatic margins (PMs), regarding preoperative serum PSA, bioptic Gleason sum and clinical stage (Student's t-test); lymph nodal involvement rate was not significantly different in both groups (chi-square test). CONCLUSIONS: PTs IFSs during RRP were feasible and effective in order to achieve better local pathological staging in 12% of patients, to modify planned nerve sparing RRP in extrafascial procedure in 14% of cases and to wide intraoperatively surgical resection margins in 24% of patients.

Skewing towards neuroendocrine phenotype in high grade or high stage androgen-responsive primary prostate cancer.

OBJECTIVE: The prognostic influence of neuroendocrine (NE) differentiation in prostate cancer patients is not yet properly established. In a series of primary hormone-naive prostate cancers from a patient population that underwent radical prostatectomy, we wanted to determine the relationship between NE phenotype expression and Gleason sum, disease stage, and serum PSA concentration. METHODS: Chromogranin A (CgA) expression was scored and compared in 105 consecutive primary prostate cancers with their homologous preoperative tumor prostate biopsies. RESULTS: High grade or high stage prostate cancers expressed a significantly higher CgA score than low grade or localized diseases (p < 0.005). Both the CgA score of the surgical specimens and the PSA level in the serum increased linearly (p = 0.001). In the samples of many corresponding tumor biopsies no significant CgA staining was found. CONCLUSION: NE differentiation in primary untreated prostate cancer is closely associated with the major prognostic parameters of survival. This association cannot be shown by evaluating the CgA staining in tumor biopsies.

Color Doppler sonography in the intratesticular varicocele.

OBJECTIVE: We describe and discuss clinical and color Doppler ultrasound findings of intratesticular varicocele. MATERIAL AND METHODS: Since 1998 we evaluated 295 patients diagnosed with varicocele by scrotal color Doppler sonography Routine andrological assessment has entailed grading the varicocele (Dubin-Amelar scale and Dubin Doppler scale) and the assessment of testicular size. Intratesticular varicocele is defined as venous reflux detected into anechoic lesions of the testis with or without ypsilateral varicocele. RESULTS: We detected 4 intratesticular varicoceles (1.3%), in all cases left sided with ypsilateral extratesticular varicocele. Three patients had a large varicocele, one patient had a small varicocele and bylateral testicular hypotrophy. All patients had a slight to severe worsening of sperm quality. CONCLUSIONS: Intratesticular varicocele is an uncommon lesion, first described only after the color Doppler ultrasound studies have been a wide diffusion in the 1990s. A few cases are reported in literature and its incidence is unknown. Data about fertility in males with intratesticular varicocele are still anecdotic. Moreover, the knowledge of intratesticular varicocele may rule out patients for sclerotherapy procedures, or the awarness of potential gonadal damage by aetoxysclerol spread into the testis, may suggest some technical tricks. Since the simple detection of this lesion, further investigations are needed to clarify its clinical and pathophysiological significances. Color Doppler Sonography appears to be the only tool able to identify intratesticular varicocele in order to learn more about this rare condition.

Inflammatory fibrosarcoma of the urachus: a case report.

The Authors reported a case of inflammatory fibrosarcoma of the urachus in a 27-year old woman. Differential diagnosis, surgical therapy and prognosis were discussed.