The role of bedside assistant during robot assisted radical prostatectomy: Is more experience better? Analysis on perioperative and clinical outcomes.

OBJECTIVES: To analyze the impact of the bedside assistant's experience during RARP. It is believed that the outcome of robotic surgery during Robot Assisted Radical Prostatectomy (RARP) for prostate cancer depends not only on the console surgeon's experience. MATERIALS AND METHODS: All consecutive RARPs from January 2017 to March 2018 were sourced from a prospectively maintained database. All cases were performed by the same surgeon. He was supported by three bedside assistants: one with bedside and console experience, one only with relevant bedside experience, one basically inexperienced. The patient's parameters analyzed: age, Body Mass Index (BMI), previous abdominal surgery, prostate volume (by TRUS), pre-operative PSA, bioptic grading. Surgical outcomes analyzed included skin-to-skin operative time and estimated blood loss; clinical outcomes included length of hospital stay and time to catheter removal; the oncological outcome was represented by positive surgical margin rate. RESULTS: A total of 116 RARPs were identified: 38 RARPs were performed with the console experienced bedside assistant, 38 with the experienced one, 40 with the novice one. The variables were similar between the three groups. As far as outcomes are concerned, there were no statistically significant differences between the three bedside assistants in terms of operative time, estimated blood loss, length of stay, days of catheterization, positive surgical margin rate.

"Endourological closure of a malformative vascular source of bleeding using the VortX 0.018" coil®".

AIMS: Renal vascular malformations, congenital or acquired, are sometimes challenging for urologists and interventional radiologists to resolve. Arterovenous fistulas and pseudoaneuryms are usually embolized by interventional radiologists, with a low rate of complications. We propose a new endourological/interventional radiology technique to treat a source of arterovenous bleeding coming from a renal calyx in a minimally invasive way. METHODS: A combined endourological and interventional radiology procedure is described, using a Flexible Fiberoptic Ureteroscopes to undertake a retrograde intrarenal surgery (RIRS) to identify the source of bleeding; subsequently the VortX Coil® is inserted through a microcatheter to stop the bleeding and the correct position of the VortX coil is evaluated. Furthermore, we made a literature research on Pubmed and Medline to look for similar procedures. RESULTS: In case of a renal bleeding that could not be treated by endovascular way, a combined urological and interventional radiology procedure can be undertaken. We did not find similar endourological and interventional radiology procedure on Pubmed and Medline, so this is the first tecnique of endourological closure of a bleeding point using a coil. CONCLUSION: From our experience this could be a mininvasive technique to solve renal bleedings coming from a calyx that are not found by endovascular approach. Indeed, in our knowledge, the technique here described is the first that provides the use of an endovascular coil by endourological way in renal vascular malformations.

Testicular metastasis from renal cell carcinoma after nephrectomy and on tyrosine kinase inhibitors therapy: Case report and review.

Renal cell carcinoma has extremely heterogeneous presentation at the diagnosis: it may present as a confined organ disease, locally advanced, metastatic to locoregional lymph nodes or with single or multiple systemic metastases. Since chemotherapy and radiation therapy have not demonstrated efficacy either in primary therapy or in neo-adjuvant or adjuvant therapy for renal clear cell carcinoma, targeted agents like tirosine kinase inhibitors were developed and are largely used in locally advanced and metastatic renal cell carcinoma. Here, we present a rare case of ipsilateral renal cell carcinoma testicle metastasis, after radical nephrectomy and during tyrosine kinase inhibitors therapy. In addition, a retrospective search in PubMed, ScienceDirect, and Web of Science database on testicular metasteses from renal cell carcinoma under tyrosine kinase inhibitors therapy was performed.

Robot-assisted nerve-sparing radical prostatectomy using near-infrared fluorescence technology and indocyanine green: initial experience.

INTRODUCTION: Indocyanine green (ICG) is a fluorescent molecule that provokes detectable photon emission. The use of ICG with near-infrared (NIR) imaging system (Akorn, Lake Forest, IL) has been described during robotic partial nephrectomy (RAPN) as an adjunctive means of identifying renal artery and parenchymal perfusion. We propose the use of the ICG with NIR fluorescence during laparoscopic robot-assisted radical prostatectomy (RARP), to identify the benchmark artery improving the preservation of neurovascular bundle and to improve the visualization of the vascularization and then the hemostasis. METHODS: From April 2015 to February 2016, 62 patients underwent to RARP in our Urology Unit. In 26 consecutive patients, in the attempt to have a better visualization of neurovascular bundles, we used to inject ICG during the procedure. We evaluated the percentage of identification of neurovascular bundles using NIR fluorescence. Then, we evaluated complications related to injection of ICG and operative time differences between RARP with and without ICG injection performed by the same surgeons. RESULTS: We identified prostatic arteries and neurovascular bundles using NIR fluorescence technology in all patients (100%). There was not any increase in the operative time compared with RARP without ICG injection performed by the same surgeons. Complications related to injection of ICG did not occurred. CONCLUSIONS: In our experience, even if on a limited number of patients, the application of ICG with NIR fluorescence during RARP is helpful to identify the benchmark artery of neurovascular bundle.

Actinic cystitis: causes, treatment and experience of a single centre in the last five years.

INTRODUCTION: Actinic cystitis (AC) is the manifestation of symptoms and signs following pelvic radiotherapy. Pelvic radiotherapy produces both acute and chronic damage and such damage may have a devastating impact on the quality and on the amount of life of the patient. OBJECTIVES: To evaluate the number of radical cystectomies that have become necessary in the last five years in our department for AC after radiation treatment. MATERIALS AND METHODS: From February 2012 to February 2017, 11 patients underwent "open" cystectomy for AC. All patients were studied with radiographic examinations and endoscopy prior to surgery. We retrospectively evaluated the type of primitive cancer, the radiation dose administered, the time between radiation treatment and cystectomy. We also studied the related symptoms that required surgery. RESULTS: The mean age of patients at the time of cystectomy was 75 years. In six patients (54.4%) radiotherapy was performed for prostate cancer, for rectal cancer in two patients (18.1%), and for endometrial cancer in three patients (27.2%). Total radiant dose was different in different patients depending on the type and localization of cancer. The median time between radiotherapy and cystectomy was 111 months (24-256 months). All patients had symptoms before surgery. Seven patients (63.3%) with gross haematuria were treated with endoscopic clot evacuation and fulguration. DISCUSSION: The first approach to patients with AC is often supportive care. Surgery remains the most invasive treatment in the management of those patients who are not responsive to conservative treatments.

[Biopsy findings of low-risk prostate disease: are they real? Single centre experience]. / Il riscontro bioptico di malattia prostatica "low risk" è reale? single centre experience.

Clinically insignificant prostate cancer is characterized by limited biologic malignancy and, possibly, it is suitable for non-radical treatment. We performed a retrospective analysis of 1028 patients who underwent radical prostatectomy (118 of them with clinically insignificant prostate cancer), in order to assess the predictors of cancer-related outcome. Only 19% of the patients undergoing radical prostatectomy for clinically insignificant prostate cancer had clinically insignificant cancer in the prostatectomy specimen, whereas in 19% of the cases we found a high-risk disease. The risk of overtreatment is present but currently counterbalanced by the risk of undertreatment.

[Prostatic tumor: how many biopsies?]. / Tumore prostatico: quante biopsie?

INTRODUCTION: Ultrasound-guided prostatic biopsy is usually performed by sextants according to Hodge, but the authors feel that 6 biopsies are insufficient. It has been suggested that the number of prostatic biopsies be increased and the mapped areas extended, but this causes discomfort to patients and increases effective costs. The authors suggest repetition of biopsies in "risk" cases, routinely selecting patients taking into account the best cost-benefit ratio. MATERIALS AND METHODS: From January 2000 to December 2001, 682 first series biopsies were performed on as many patients. A Stamey modified sextant technique was used: 6 biopsies, 3 on each side carried out more posterolaterally than the original technique. The biopsy procedure was repeated within 4 months in 11 patients with high risk clinical parameters (PSA > 10 or high PSA and prostatic nodule). During the period of observation, 25 patients had over 0.75 ng/year increase in their PSA and so biopsies were repeated. RESULTS: After the first biopsy series, 277 were positive. Of the 11 repeated biopsies, 3 were positive. Of the 25 patients with altered PSA velocity, 9 were positive. DISCUSSION AND CONCLUSIONS: It has been shown that only 10-12% of biopsies are false negative in the sextant biopsy series when taken posterolaterally. The techniques that increase the number of biopsies have around 3-5% false negatives, but this involves more discomfort for the patient, local anaesthesia and a possible increase in complications. The procedure whereby biopsies were only repeated in patients with high risk clinical elements, saved 3852 biopsies from being carried out, with an economic saving (just on the histological exam that was not carried out) assessed at 59.681,80 Euro (115,560,000 Lire) for our Local Health Service.