Live surgery: highly educational or harmful?

PURPOSE: Live surgery (LS) is considered a useful teaching opportunity. The benefits must be balanced with patient safety concerns. To evaluate the rate of complications of a series of urologic LS performed by experts during the Congress Challenge in Laparoscopy and Robotics (CILR). METHODS: We present a large, multi-institution, multi-surgeon database that derives from 12 CILR events, from 2004 to 2015 with a total of 224 cases. Radical prostatectomy (RP) was the most common procedure and a selection of complex cases was noted. The primary measure was postoperative complications and use of a Postoperative Morbidity Index (PMI) to allow quantitative weighing of postoperative complications. RESULTS: From 12 events, the number of cases increased from 11 in 2004 to 27 in 2015 and a total of 27 surgeons. Of 224 cases (164 laparoscopic and 60 robotic), there were 26 (11.6%) complications: 5 grade I, 5 grade II, 3 grade IIIa, 12 grade IIIb and 1 grade V, the latter from laparoscopic cystectomy. Analysis of PMI was 23 times higher from cystectomy compared to RP. CONCLUSIONS: In the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries. The PMI is not higher in more complex procedures, whereas RP seems very safe.

Increased accuracy of biopsy Gleason score obtained by extended needle biopsy.

PURPOSE: Accurate tumor grading is critical for adequate prostate cancer treatment. Nonetheless, the Gleason score of standard sextant biopsy correctly predicts the Gleason score of the radical prostatectomy specimen in about 50% of cases. We investigated if extended needle biopsy could improve biopsy Gleason score accuracy. MATERIALS AND METHODS: Laparoscopic transperitoneal radical prostatectomy was performed in 135 patients. Prostate cancer was diagnosed in 89 cases by standard sextant transrectal (6 to 8 cores) biopsy and in 46 by extended needle (12 core transperineal under transrectal guidance) biopsy. Preoperative evaluation included digital rectal examination, prostatic specific antigen measurement, transrectal ultrasonography and endorectal coil magnetic resonance imaging in all patients. All biopsy and prostatectomy specimens were reviewed by a single pathologist. RESULTS: Clinical characteristics were similar in the 2 groups. The concordance between prostate biopsy and radical prostatectomy Gleason score was 32 of 46 cases (70%) and 44 of 89 (49%) for 12 core and standard transrectal biopsy, respectively (z test p = 0.0127). Biopsy under grading was found in 11 of 46 cases (24%) and 35 of 89 (39%) (z test p = 0.0366), and biopsy over grading was found in 3 of 46 (6%) and 10 of 89 (11%) (z test p = 0.1894) with 12 core and standard transrectal biopsy, respectively. Primary Gleason pattern was predicted exactly by biopsy in 40 of 46 cases (87%) and 56 of 89 (63%) with 12 core and standard sextant biopsy, respectively (z test p = 0.0018). CONCLUSIONS: Extended needle biopsy significantly increases the accuracy of biopsy Gleason score for assessing final prostate cancer grade.

Buccal mucosa urethroplasty for bulbar urethral strictures

Objectives: Urethroplasty with the buccal mucosa graft is an excellent option for the treatment of urethral stricture disease. The authors report their 10-year experience with buccal mucosa graft urethroplasty by the dorsal and ventral approach. Patients and Methods: From June 1994 to May 2003; 67 patients with bulbar urethral stricture underwent buccal mucosa urethroplasty. A free graft of buccal mucosa was used as an onlay; ten patients were operated by the ventral approach and the remaining 57 by the dorsal approach. After the bulbar urethra is exposed; we perform a dorsal endoscopic cold knife urethrotomy until the urethra is fully opened. After measurement of the defect; the graft is harvested from the lower lip and sutured to the urethra and to the corpora cavernosa. A transurethral grooved catheter and suprapubic drainage are left for 7 and 14 days; respectively. Results: The median follow-up was 58 months (range 12 - 110). Recurrence of the stricture occurred in 4(3/67) of the patients with a recurrence rate of 2/10 (20) and 1/57 (2) for the ventral and dorsal onlay patients; respectively. The overall complication rate was 9/67 (13). Conclusions: Buccal mucosa urethroplasty provides a high long-term success rate for the treatment of bulbar urethral strictures. The dorsal onlay may be superior to the ventral onlay approach

Best approach for prostate cancer detection: a prospective study on transperineal versus transrectal six-core prostate biopsy.

OBJECTIVES: To compare the efficacy of transperineal versus transrectal six-core prostate biopsy. Transrectal sextant biopsy is the most common method for prostate cancer detection. However, the cancer detection rate with this technique is increasingly considered inadequate. Different prostate biopsy procedures, mainly based on addition of additional transrectal cores to traditional sextant biopsy, have been proposed to increase the cancer diagnosis rate. The efficacy of the transperineal approach has not yet been fully established. METHODS: In a prospective study, 107 patients with elevated prostate-specific antigen levels (greater than 4.0 ng/mL) underwent prostate biopsy with six transperineal cores, using a "fan" scheme, plus six transrectal cores, according to the sextant technique. The median prostate-specific antigen level was 8.2 ng/mL (range 4.1 to 240). RESULTS: The overall cancer detection rate was 40% (43 of 107); prostate cancer was found in 38% (41 of 107) of patients with the transperineal approach and in 32% (34 of 107) of patients with the transrectal approach. Of 43 diagnosed cancers, 41 (95%) were found with the transperineal approach and 34 (79%) with the transrectal approach (P = 0.012). No patient had low-grade cancer (Gleason score 2 to 4), 25 patients had intermediate-grade cancer (Gleason score 5 to 6), and 18 patients had high-grade cancer (Gleason score 7 to 10). CONCLUSIONS: This is the first report comparing in vivo two different approaches to prostate biopsy. Transperineal biopsy seems superior to transrectal biopsy to detect prostate cancer. Both the transperineal and the transrectal approach should be familiar to the urologist who needs to obtain an adequate cancer detection rate. Transrectal sextant biopsy cannot be considered the standard technique for prostate cancer detection.

High grade superficial (G3t1) transitional cell carcinoma of the bladder treated with intravesical Bacillus Calmette-Guerin (BCG).

OBJECTIVES: Immunotherapy with Bacillus Calmette Guerin (BCG) has been widely used recently as primary option for treatment of high grade superficial (G3T1) carcinoma of the bladder. We describe our long term experience of therapy of G3T1 bladder cancer. METHODS: From January 1982 to December 2000, 785 patients were diagnosed with superficial bladder cancer. All patients underwent preoperative CT scan and transurethral resection of the bladder. Eighty-six patients (11%) had histological high grade superficial bladder cancer infiltrating the lamina propria. This group was treated with the following schedule of BCG Pasteur strain plus maintenance. Four cycles BCG, 6 instillations per cycle, first cycle weekly x 6, second cycle every 2 weeks x 6, third cycle monthly x 6, fourth cycle (maintenance) every 3 months x 6 instillations. RESULTS: The median follow-up is 91 months (30-197 months). The overall recurrence rate was 35% (30/86). The median time to recurrence was 29 months (5-128 months). Of these patients, 12 (14%) had progression at a median follow-up of 16 months (range 8-58 months). Cystectomy was needed in 8 (9%) patients. Death due to disease occurred in 5/86 (6%) patients. One patient died due to adenocarcinoma at the ureterosigmoidostomy site. Sixty-four (74%) patients are alive at a median follow-up of 71 months (range 28-197 months). Sixty patients (70%) are alive with an intact bladder. CONCLUSIONS: Treatment with BCG is a feasible conservative therapy for patients with primary G3T1 transitional bladder cancer. Long term results of BCG treatment are excellent. Cystectomy shouldn't be considered first line treatment for high grade superficial carcinoma of the bladder.

The value of a single biopsy with 12 transperineal cores for detecting prostate cancer in patients with elevated prostate specific antigen.

PURPOSE: Prostate cancer detection on standard sextant biopsy is considered inadequate. Various biopsy protocols have been introduced to improve cancer diagnosis. We report our experience with transperineal 12-core prostate biopsy. MATERIALS AND METHODS: In a prospective study 650 patients underwent prostate specific antigen (PSA) measurement during a 15-month period, of whom 141 with PSA greater than 4 ng./ml. also underwent transperineal 12-core prostate biopsy using the fan technique. Median PSA was 8 ng./ml. (range 4.1 to 5,000). RESULTS: Prostate cancer was detected in 72 of the 141 patients (51%), including 44 of the 97 (45%) with PSA between 4.1 and 10 ng./ml. This incidence is higher than previously reported in the literature using other biopsy techniques. Disease was low grade Gleason 2 to 4 in 4 cases (5%), intermediate grade Gleason 5 to 6 in 26 (35%) and high grade Gleason 7 to 10 in the remaining 42 (60%). CONCLUSIONS: A high cancer detection rate is achieved by 12-core transperineal prostate biopsy. Most tumors represent clinically significant cancer. Further randomized trials are required to confirm these data.

Buccal mucosa urethroplasty for the treatment of bulbar urethral strictures.

PURPOSE: We report the results of urethroplasty with a free graft of buccal mucosa as a dorsal onlay for the treatment of bulbar urethral strictures. MATERIALS AND METHODS: Since June 1994, 30 patients with bulbar urethral strictures have been treated with buccal mucosa urethroplasty. Urethroplasty was performed with a free graft of buccal mucosa using a ventral onlay in the first 7 patients and a dorsal onlay in 23. Dorsal urethrotomy was performed with a Sachse urethrotome after the bulbar urethra was separated from the corpora. The buccal mucosa onlay was sutured to the urethra and corpora cavernosa to ensure a patent urethra. RESULTS: At 20-month followup (range 3 to 50) the success rate was 96% (29 of 30 patients). Urethral stricture recurred in only 1 of 7 patients in the ventral onlay and none of 23 in the dorsal onlay group. CONCLUSIONS: Preliminary results of urethroplasty for bulbar urethral strictures with a dorsal onlay graft of buccal mucosa are excellent. Longer followup is needed to evaluate definitive results.

Iatrogenic prostatic urethral strictures: classification and endoscopic treatment.

OBJECTIVES: The treatment of posterior urethral strictures is a controversial subject. For proper treatment, it is important to differentiate between iatrogenic prostatic urethral strictures and post-traumatic membranous urethral strictures. METHODS: Iatrogenic strictures of the prostatic urethra have been classified according to location and etiology into three categories: type I, located exclusively at the bladder neck; type II, located in the midportion of the prostatic fossa; and type III, when the whole prostatic fossa is replaced by stricture. From 1970 to 1996, 163 patients with postoperative strictures of the prostatic urethra were treated endoscopically. RESULTS: The results obtained in 122 patients are reported; 41 patients are not evaluable. The median follow-up was 63 months (range 12 to 239). Seven patients required a second endoscopic procedure to attain cure. Good results were achieved in 54 (91%) of 59 patients with type I strictures, in 45 (98%) of 46 patients with type II strictures, and in 13 (76%) of 17 patients with type III strictures. The overall success rate was 92% (112 of 122). Complications occurred in 21 patients (17%), including postoperative urinary tract infection (11%), incontinence (4%), stress incontinence (1%), and severe bleeding (1%). CONCLUSIONS: Postoperative strictures of the prostatic urethra must be recognized and can be easily treated with endoscopic therapy.

[Retroperitoneal liposarcoma]. / Liposarcoma del retroperitoneo.

Retroperitoneal soft-tissue sarcomas are a heterogeneous group of rare and peculiar mesenchymal tumors. They are locally invasive and have a peak incidence in the fifth decade of life. They account for 0.1-0.2% of all solid tumors and 15% of all soft-tissue tumors. Liposarcomas are usually large and occur most frequently in the lower extremities, in the retroperitoneal, perineal and mesenteric region. In the retroperitoneum they grow slowly due to the ability of the abdominal cavity to accommodate these slowly expanding masses. They don't produce symptoms until they are very large and have invaded local tissues. The case of a 61-year old man with a retroperitoneal liposarcoma is reported. The tumor was discovered due to the association of abdominal mass, weight loss and persistent fever. The fever, especially, is present due to a wide tumor necrosis. The diagnosis was suggested by computed tomography. Normally, the interval between start of symptoms and diagnosis is included within three weeks and one year. Surgical complete resection of the mass with splenectomy and local postoperative radiotherapy were performed. The weight of the mass was 8.56 kilograms and the pathological evaluation showed a pleomorphic highly undifferentiated liposarcoma. This histological type normally presents many tumor giant cells, some of which have the features of lipoblasts. The single most important prognostic factor in patients with soft-tissue sarcomas is the histologic grade of the primary lesion. In the last AJCC Staging System the grades are assigned from grade 1 (well differentiated) to grade 3 (poorly differentiated). The present case is grade 3. In the treatment of sarcoma of the retroperitoneum or genitourinary tract, the conventional chemotherapy does not seem effective, while radiotherapy has a little improvement on survival. Local recurrences are frequent, especially in the first three years, often in the absence of distant metastases. When the tumor recurs locally, the best therapy is still to remove the mass. Sometimes, two or more operations may be necessary for the patient. Generally, the prognosis is poor with overall 5-year survival of 15-50%. The patient was admitted in our division 4 months after the first operation with poor medical condition. The patient died nine months after surgery.

[Internal urethrotomy]. / Die Urethrotomia interna.

Urethral dilatation and urethrotomy can be effective treatments of the stricture disease in selected patients when the spongy tissue is not severely damaged. In the few reports comparing urethrotomy and dilatation, results are not significantly different. A long term followup is mandatory in assessing the outcome of treatment of urethral strictures. Characteristics of the stricture as location, length, caliber, number, and previous failed treatments allow to select the best therapeutical option. After the failure of the first instrumentation, repeated procedures are not curative.

Internal urethrotomy in the management of anterior urethral strictures: long-term followup.

PURPOSE: We evaluated the long-term results of internal urethrotomy for anterior urethral strictures. MATERIALS AND METHODS: Between 1975 and 1990, 224 patients underwent internal urethrotomy for anterior urethral strictures. Median followup was 98 months (range 60 to 216). RESULTS: The recurrence rate after 1 urethrotomy was 68% overall, and 58% for bulbar, 84% for penile and 89% for penile bulbar urethral strictures. Repeated urethrotomies did not improve the success rate. Prognostic characteristics of bulbar urethral strictures associated with good results included single or primary strictures, length shorter than 10 mm. and caliber wider than 15F. Preoperative infection and etiology of the strictures did not correlate with results. Multiple urethrotomies achieve only temporary improvement and can be compared to repeated dilations. CONCLUSIONS: Alternative treatments should be considered for penile strictures and after failure of initial urethrotomy.

Prostate-specific antigen and prostatitis in men under fifty.

OBJECTIVE: To evaluate the occurrence of increased prostate-specific antigen (PSA) serum concentration in patients with prostatitis and low incidence of benign prostatic hyperplasia and prostatic cancer, PSA was measured in a selected population. METHODS: PSA levels were evaluated in 72 patients with prostatitis under 50 years of age. RESULTS: An increased PSA (> 4 ng/ml) was found in 5/7 (71%) patients with acute prostatitis, and in 2/13 (15%) and 2/32 (6%) patients with chronic bacterial and abacterial prostatitis, respectively. No patient with prostatodynia had an increased PSA. In patients with bacterial prostatitis PSA level decreased to normal value after effective antibiotic therapy in most cases. CONCLUSION: Prostatitis must be considered when using PSA as tumor marker.

Bacillus Calmette-Guerin in the treatment of stage T1 grade 3 transitional cell carcinoma of the bladder: long-term results.

PURPOSE: We performed a retrospective long-term study to evaluate the results of immunotherapy in the treatment of high grade superficial bladder tumors. MATERIALS AND METHODS: Between 1981 and 1993, 593 patients with superficial transitional cell carcinoma of the bladder underwent transurethral resection. Of 64 patients with stage T1 grade 3 disease 50 received intravesical bacillus Calmette-Guerin after transurethral resection of all visible tumor. RESULTS: At a median followup of 42 months (range 12 to 112) 36 patients (72%) are disease-free and have not required further treatment. Superficial recurrence was noted in 8 patients (16%). Disease progressed in 6 patients (12%), including 5 with locally invasive and 1 with metastatic disease. Cystectomy was performed for progression in 4 patients and for recurrent stage T1 grade 3 disease in 1. There was 1 disease related death (2%). The overall survival rate is 94%. CONCLUSIONS: Intravesical bacillus Calmette-Guerin appears to be the most effective conservative treatment for patients with stage T1 grade 3 bladder cancer.

Treatment of a recurrent penobulbar urethral stricture after wallstent implantation with a second inner wallstent.

The wallstent has been proved to be effective for the treatment of bulbar urethral strictures. Only a few failures are reported in the literature. We present a case of a patient with a recurrent stricture after wallstent implantation. The recurrence has been managed successfully with gradual dilation and with the insertion of an inner stent inside the first one, with a twenty-nine-month follow-up.

Urethral stricture following transurethral resection of the prostate. The role of local anaesthetics.

In a multicentre prospective study, 261 patients undergoing transurethral resection of the prostate (TURP) in 17 urology departments were randomised to receive lubricating jelly containing either 3% tetracaine hydrochloride, 1% lignocaine hydrochloride, or no local anaesthetic. No patient had a history of urethral instrumentation or a previous urethral stricture. After 6 months' follow-up, 25/79 patients (32%) treated with 3% tetracaine jelly developed urethral strictures, as did 4/92 patients (4%) who received 1% lignocaine and 2/90 (2%) who received the jelly without anaesthetic. It was concluded that the use of 3% tetracaine jelly is associated with a high incidence of post-TURP urethral strictures.

Subdermal liposuction.

Liposuction is a widely used technique today and indications are that it is becoming even more popular due to new technical refinements. The use of cannulae with a smaller diameter allows suction of the fat immediately under the dermis. The cannula we use to perform this new kind of fat suction is straight and has an external diameter of less than 2 mm. This cannula, the so-called Mercedes cannula, has a bullet tip and a three-hole head. Moreover, the holes are not round but are slit-shaped and oriented in the same plane at 120 degrees. This cannula is specifically designed to produce less trauma. The cannula with one downward-facing orifice is not suitable for suction of the subdermal layer and an upward-facing orifice would be too traumatic. The advantage of this new technique, apart from the possibility of treating patients with very slight adiposity, is to allow an effective skin retraction. When a large amount of fat has already been aspirated, residual deformities can occur. These skin irregularities represent the lack of an effective cutaneous retraction mostly due to the permanence of the subdermal fat. In fact, the presence of a thick subdermal adipose layer decreases the possibility of skin retraction. Therefore, indications for liposuction of the subdermal fat are mainly the slight adiposities and the remnant deformities of a previous liposuction operation. Moreover, this technique is applied to every lipoplasty whenever better skin retraction is needed.