[Salvage laparoscopic pyeloplasty in the worst case scenario: after failed open repair and endoscopic salvage]. / Pieloplastica laparoscopica di salvataggio "in the worst case scenario": dopo fallimento sia di pieloplastica open che di endopielotomia.

OBJECTIVES: We present the video of a laparoscopic correction of a left ureteropelvic junction obstruction in a patient who has already undergone previous surgical open pyeloplasty and subsequent acucise for failure of the first surgery. At 8 years after the second surgery, the patient showed a recurrence of the obstruction of the left ureteropelvic junction.
 It was decided to perform the retroperitoneal laparoscopic correction of the obstruction.
 MATERIALS AND METHODS: With the patient placed in a 90° flank position, 4 trocars are placed in the retroperitoneum space by the Hasson tecnique.
 After the creation of the retroperitoneum space, the Gerota's fascia is opened. The posterior layer of the Gerota's fascia appears very thickened at the level of the lower pole of the kidney and is very adherent with the surrounding structures, in particular the psoas muscle.
 Gerota's fascia is incised and removed from the previous surgery and the psoas muscle is identified. The distal lumbar ureter is tenaciously anchored to the psoas muscle. The lower pole of the kidney is freed from the adhesions of the previous surgery. The proximal ureter is hardly isolable for the presence of fibrosis. The renal pelvis is fixed to the psoas due to fibrotic tissue that is cut with scissors. Once the pelvis and the ureter are separated from the psoas, the surgery proceeds with the liberation of the pelvis from the adipose tissue and fibrosis that surround it. The pieloureteral obstruction is not easily identifiable. The renal pelvis is opened at the level of the ureteral junction, the ureter is spatulated on its medial side. The scar tissue is removed until well vascularized tissue is seen. The anastomosis between the ureter and pelvis is performed with 2 semicontinuous running sutures. Once the anterior plate of the anastomosis is completed a cystoscopic retrograde DJ ureteral stent insertion is performed. The procedure ends with the packaging of the posterior plate of the anastomosis with the second running suture.
 RESULTS: The operation lasted 180 minutes. The postoperative course was uneventful, the drain was removed on the second day and the bladder catheter on the 4th. The patient was discharged on the 5th day and the DJ ureteral stent was removed on the 21st post-operative day. 
 DISCUSSION: The laparoscopic reoperation in patients with previous open surgery interventions is definitely difficult. This kind of surgery has to be carried out after having gained considerable laparoscopy experience. Specifically, the reoperation of laparoscopic pyeloplasty after 2 previous intervention poses the following difficulties: the creation of appropriate space, dissection of the ureter and pelvis from the psoas muscle, appropriate mobilization of the lower pole of the kidney to get a "tension free" anastomosis, liberation of the pelvis and ureter from the tenaciously adherent fibrotic tissue, identification of the stenotic ureteropelvic junction.
 CONCLUSIONS: Laparoscopic pyeloplasty after failure of past interventions remains a difficult procedure that should only be performed after major laparoscopic experience. In experienced hands, redo laparoscopic pyeloplasty provides high success rates.

Dorsal free graft urethroplasty according to Barbagli. Minimum follow-up of 2 years.

Series of free graft methroplasties for structure of the urethra according to Barbagli. Fifteen men underwent dorsal free graft methroplasty for structures situated in the penile urethra in 6 cases, in the bulbous urethra in 7 and in the urethra geno bulbous in 2. The length of the structures ranged from 1.5 to 13 cm. In all the patients but one uroflow was satisfactory at a mean follow-up of 40 months. In one patient a reument structure occurred 8 months after treatment and was successfully treated with cold urethrotomy. In conclusion, dorsal free graft urethroplasty is a safe and fairly simple procedure in long bulbous stenosis and penile multi stenosis.

Interstitial cystitis.

Interstitial cystitis (IC) is still considered a rare disease, but in the future its incidence will probably be revised if tendency is that of considering interstitial cystitis on the basis of clinical rather than endoscopic-histological criteria. According to some urologists, cystodistension and vesical biopsy, even if not pathognomonic, are still effective up till now, at least for their prognostic-therapeutic value as well. If on one hand in the diagnosis of this condition symptoms tend to be of more and more value unlike instrumental investigations, on the other hand little has changed in therapy.

Pubo-vaginal sling.

The Authors discuss their experience in the use of pubo-vaginal sling in the treatment of female urinary stress incontinence. In the last 5 years (1997-2002) 35 patients with type 3 incontinence underwent pubo-vaginal sling with rectus fascia or porcine skin. Healing was obtained in 74.2%, de novo urgency in 5.7%, obstruction in 8.5% and persisting incontinence in 11.4% of cases. The developments of the technique have recently turned pubo-vaginal sling into a minimally invasive procedure with low morbidity. Its indications have therefore been extended to the point that it is now considered by many authors as the treatment of choice in any type of incontinence, whether associated with genital prolapse or not.

[Complications of urinary diversion after radiotherapy]. / Complications of urinary diversion after radiotherapy.

Primary radiation therapy may be recommended for patients with invasive bladder cancer, gynecological or prostatic cancer. When complications occur or in case of malignant recurrence, urinary diversion may be the best chance to restore an acceptable quality of life. The complication rate after this surgery is doubled. We report our experience in 32 patients submitted to urinary diversion after radiotherapy from 1985 to 2000: 2 enteric fistulas; 2 urinary fistulas; 5 stenosis of uretero-intestinal anastomosis were our complications. Radical cystectomy (24 cases) or anterior pelvic exenteration (8 females) preceded urinary diversion. Preoperative high-dose radiotherapy contributes to increased postoperative morbidity rates, particularly entero-enteric fistulas, uro-intestinal fistulas and stenosis of the uretero-intestinal anastomosis. In our experience, in most of the major urinary or enteric complications non surgical management was inefficient and surgical management was necessary.

[Pathology of the gynecologic ureter: our experience]. / Patologia dell'uretere ginecologico: nostra esperienza.

UNLABELLED: Endometriosis, surgery and radiotherapy are the main causes of ureteral injuries in gynaecologic pathology. MATERIALS AND METHODS: In this paper we present our experience about ureteral injuries. We treated 31 patients; 6 cases of endometriosis, 13 cases of pelvic radiotherapy for gynecologic tumors, 12 cases of ureteral injuries after gynecologic surgery. The treatments were different depending on the cause of the lesion and on the site of the lesion. In 3 cases we performed an ureteral-bladder implant with bladder psoas hitch, in 2 cases an end to end anastomosis was made. In 2 cases we made an ureteric substitution with Boari bladder flap. In 8 cases the ureteral stenting with DJ or a percutaneous nephrostomy was the solution. RESULTS AND CONCLUSIONS: In our experience good results can be obtained with ureteral implant and bladder psoas hitch. The end to end ureteral anastomosis had disappointing results in our hands. In case of ureteral fistula it would be better repair it as soon as possible. If the ureteral lesion is recognised during surgery and the loss of substance is not complete, the suture on stent can be performed.