Comparison of laparoscopic versus open simple nephrectomy in patients with xanthogranulomatous pyelonephritis: A singlecenter analysis of outcomes and predictors of surgical approaches and complications.

Background: The aim of this study was to compare the outcomes of open simple nephrectomy and laparoscopic simple nephrectomy in patients with xanthogranulomatous pyelonephritis (XGP) in a single-institutional retrospective study and to identify predictive factors of surgical approaches and complications. Materials and methods: We retrospectively analyzed the data of 67 consecutive patients with a histopathological diagnosis of XGP who underwent either open simple nephrectomy (ON) or laparoscopic simple nephrectomy (LN) from January 2014 to April 2020. The primary endpoint was the evaluation of perioperative outcomes and complications. Secondary endpoints were to define factors influencing the surgical approach and the likelihood of postoperative complications. Results: Overall, 44 out of 67 patients (65.67%) underwent ON, while 23 (34.33%) underwent LN. Patients in the ON group experienced more postoperative pain according to the visual analogic scale (p = 0.032). Moreover, time to deambulation and time to return to full daily activities, assessed according to the 12-Item Short Form Survey physical and mental component summary scores questionnaires, were significantly shorter in the LN group (p = 0.021, p < 0.001, and p < 0.001, respectively). Of note, there were no significant differences in intraoperative and postoperative complication rates among the groups (p = 0.258 and p = 0.317, respectively). No conversion to open surgery was described. Logistic regression analysis demonstrated that urgency (p = 0.025) was the only predictor associated with a higher risk of intraoperative complications. However, no independent factors associated with postoperative complications or with the surgical approach of choice were found. Conclusions: Based on our results, laparoscopic treatment of XGP represents a feasible alternative to ON, resulting in less postoperative pain and faster recovery. In skilled hands, LN should be considered as the treatment of choice for XGP.

Initial Experience and Evaluation of a Nomogram for Outcome Prediction in Management of Medium-sized (1-2 cm) Kidney Stones.

BACKGROUND: The gold standard treatment for solitary medium-sized (1-2 cm) renal stones is not defined by recent guidelines, since management modalities including shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotomy (PNL) are recommended. Improved ability to predict patient outcomes would aid in patients' counseling and decision-making. OBJECTIVE: To develop a nomogram predicting treatment failure, based on preoperative clinical variables, to be used in the preplanning setting. DESIGN, SETTING, AND PARTICIPANTS: We recruited 2605 patients from 14 centers and carried out a multicenter retrospective analysis of 699 SWL, 1290 RIRS, and 616 PN L procedures performed as first-line treatment for 1-2-cm kidney stones. The variables evaluated included age, gender, previous renal surgery, body mass index, stone size, location, stone density, skin-to-stone distance, presence of urinary tract infections (UTIs), and hydronephrosis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariate logistic regression was fitted to predict treatment failure, defined as the presence of residual fragments >4 mm. A nomogram was developed based on the coefficients of the logit function. RESULTS AND LIMITATIONS: A total of 2431 (93.3%) patients were stone free; 174 (6.7%) treatment failures were recorded and considered the event to be predicted. On univariate analysis, type of procedure, preoperative hydronephrosis, stone density, stone location, and laterality turned out to be statistically significant. Skin-to-stone distance, UTIs, and previous renal surgery were predictors of failure on multivariate analysis. Each variable was given a score based on statistical relevance. The main limitation of the current study is its retrospective nature. CONCLUSIONS: This nomogram provides a prediction of treatment failure and need of reintervention for medium-sized kidney stones. External validation is needed to determine its reproducibility and validity. PATIENT SUMMARY: We developed a preoperative model of treatment outcomes for 1-2-cm kidney stones. Its application may assist urologists to counsel patients with regard to stone management modality.

A Multicenter Study of 2-year Outcomes Following Hyperthermia Therapy with Mitomycin C in Treating Non-Muscle Invasive Bladder Cancer: HIVEC-E.

INTRODUCTION: High grade, non-muscle invasive bladder cancer (NMIBC) is usually treated with intravesical Bacillus Calmette-Guérin. Chemohyperthermia therapy (CHT) may be a novel alternative therapy for the treatment of NMIBC. OBJECTIVE: To evaluate the recurrence-free survival (RFS) of patients treated with CHT using the Combat bladder recirculation system (BRS) for NMIBC. METHODS: This was a prospective multi-institutional study of 1,028 consecutive patients with NMIBC undergoing CHT between 2012 and 2020. A total of 835 patients were treated with CHT with Mitomycin C (MMC). Disease was confirmed on transurethral resection of bladder tumor (TURBT) prior to starting CHT. Follow-up included cystoscopy and subsequent TURBT if recurrence/progression was suspected. The primary endpoint was RFS. Secondary endpoints were progression-free survival (PFS) and adverse events from CHT. RESULTS AND LIMITATIONS: Median follow up was 22.4 months (Interquartile range (IQR): 12.8 -35.8). Median age was 70.4 years (IQR: 62.1 -78.6). A total of 557 (66.7%), 172 (20.6) and 74 (8.9%) of patients were classified to BCG naïve, BCG unresponsive and BCG failure, respectively. The RFS at 12 months and 24 months for BCG naïve was 87.6% (95% CI 85.0% - 90.4%) and 75.0% (95% CI 71.3% - 78.8%), respectively. The RFS at 12 months and 24 months for BCG unresponsive cohort was 78.1% (95% CI 72.0% - 84.7%) and 57.4% (95% CI 49.7% - 66.3%), respectively. The RFS at 24 months for the BCG unresponsive cohort for CIS with/without papillary disease and papillary only disease were 43.6% (95% CI 31.4% -60.4%) and 64.5% (95% CI 55.4% - 75.1%), respectively. Minor adverse events occurred in 216 (25.6%) patients and severe events occurred in 17 (2.0%) patients. CONCLUSIONS: CHT with MMC using the Combat BRS is effective in the medium term and has a favorable adverse event profile.

Preoperative Assessment and Management of Cardiovascular Risk in Patients Undergoing Non-Cardiac Surgery: Implementing a Systematic Stepwise Approach during the COVID-19 Pandemic Era.

Major adverse cardiac events, defined as death or myocardial infarction, are common causes of perioperative mortality and major morbidity in patients undergoing non-cardiac surgery. Reduction of perioperative cardiovascular risk in relation to non-cardiac surgery requires a stepwise patient evaluation that integrates clinical risk factors, functional status and the estimated stress of the planned surgical procedure. Major guidelines on preoperative cardiovascular risk assessment recommend to establish, firstly, the risk of surgery per se (low, moderate, high) and the related timing (elective vs. urgent/emergent), evaluate the presence of unstable cardiac conditions or a recent coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting), assess the functional capacity of the patient (usually expressed in metabolic equivalents), determine the value of non-invasive and/or invasive cardiovascular testing and then combine these data in estimating perioperative risk for major cardiac adverse events using validated scores (Revised Cardiac Risk Index (RCRI) or National Surgical Quality Improvement Program (NSQIP)). This stepwise approach has the potential to guide clinicians in determining which patients could benefit from cardiovascular therapy and/or coronary artery revascularization before non-cardiac surgery towards decreasing the incidence of perioperative morbidity and mortality. Finally, it should be highlighted that there is a need to implement specific strategies in the 2019 Coronavirus disease (COVID-19) pandemic to minimize the risk of transmission of COVID-19 infection during the preoperative risk assessment process.

Impact of systemic inflammatory markers on the response to Hyperthermic IntraVEsical Chemotherapy (HIVEC) in patients with non-muscle-invasive bladder cancer after bacillus Calmette-Guérin failure.

Objectives: To evaluate the impact of pre- and post-treatment systemic inflammatory markers on the response to Hyperthermic IntraVEsical Chemotherapy (HIVEC) treatment in a cohort of patients with high-grade non-muscle-invasive bladder cancer with bacillus Calmette-Guérin (BCG) failure or intolerance who were unsuitable or unwilling to undergo early radical cystectomy. As a secondary endpoint, we assessed the influence of some demographic, clinical and pathological factors on the response to chemo-hyperthermia. Patients and methods: Between March 2017 and December 2019, 72 consecutive patients were retrospectively analysed. Patients with diseases or conditions that could interfere with systemic inflammatory status or full blood count were excluded. The HIVEC protocol consisted of six weekly intravesical treatments with 40 mg Mitomycin-C diluted in 50 mL distilled water. The drug was heated to a temperature of 43°C. Association of categorical variables with response to HIVEC was evaluated using Yates' chi-squared test and differences in continuous variable were analysed using the Mann-Whitney test. Logistic regression analysis was performed to define independent predictors of response to HIVEC. Results: Patients who failed HIVEC were more likely to have multiple tumours (P = 0.039) at transurethral resection of bladder and a recurrence rate of >1/year (P = 0.046). Lower post-HIVEC inflammatory indices [C-reactive protein (P = 0.021), erythrocyte sedimentation rate (P = 0.027)] and lower pre- (P = 0.014) and post-treatment (P = 0.004) neutrophil-to-lymphocyte ratio (NLR) values were significantly associated with the response to the HIVEC regimen (no bladder cancer recurrence or progression). In the multivariate analysis, patients with a recurrence rate of >1/year were eight-times more likely to experience failure of HIVEC (P = 0.007). Higher pre- (P = 0.023) and post-treatment NLR values (P = 0.046) were associated with a worse response to the HIVEC regimen. Conclusions: The recurrence rate and systemic inflammatory response markers could be useful tools to predict the likelihood of obtaining a response with the HIVEC regimen. These markers might help to guide patients about the behaviour of the tumour after BCG failure, predicting failure or success of a conservative treatment. Abbreviations: CHT: chemo-hyperthermia; CIS: carcinoma in situ; CRP: C-reactive protein; EAU: European Association of Urology; ESR: erythrocyte sedimentation rate; HG: high grade; HIVEC: Hyperthermic IntraVEsical Chemotherapy; ICD: immunogenic cell death; IL: interleukin; MMC: Mitomycin-C; NK: natural killer; NLR: neutrophil-to-lymphocyte ratio; NMIBC: non-muscle-invasive bladder cancer; PLR: platelet-to-lymphocyte ratio; RC: radical cystectomy; SIR: systemic inflammatory response; TURB: transurethral resection of bladder.

Laparoscopic versus open partial nephrectomy for the management of highly complex renal tumors with PADUA score ⩾10: A single center analysis.

INTRODUCTION: The aim of this study was to compare laparoscopic and open partial nephrectomy (PN) for renal tumors of high surgical complexity (PADUA score ⩾10). METHODS: We retrospectively evaluated 93 consecutive patients who underwent PN at our department from January 2015 to September 2019. 21 patients underwent open partial nephrectomy (OPN) (Group A) and 72 underwent laparoscopic partial nephrectomy (LPN) (Group B). All OPNs were performed with a retroperitoneal approach, while all LPNs were performed with a transperitoneal approach by a single surgical team. Post-operative complications were classified according to the Clavien-Dindo system. RESULTS: The two groups showed no difference in terms of patients' demographics as well as tumor characteristics in all variables. Group A was found to be similar to group B in terms of operation time (p = 0.781), conversion to radical nephrectomy (p = 0.3485), and positive surgical margins (p = 0.338) while estimated blood loss (p = 0.0205), intra-operative (p = 0.0104), and post-operative (p = 0.0081) transfusion rates, drainage time (p = 0.0012), pain score at post-operative day 1 (<0.0001) were significantly lower in Group B. The rate of enucleation and enucleoresection/polar resection was similar (p = 0.1821) among the groups. Logistic regression analysis indicated that preoperative factors were not independently associated with the surgical approach. There was a statistically significant difference in complication rate (<0.0001) between the two groups even if no significant difference in terms of grade ⩾3 post-operative complications (p = 0.3382) was detected. DISCUSSION: LPN represents a feasible and safe approach for high complex renal tumors if performed in highly experienced laparoscopic centers. This procedure offers good intraoperative outcomes and a low rate of post-operative complications.

Clinical implications of transversus abdominis plane block (TAP-block) for robot assisted laparoscopic radical prostatectomy: A single-institute analysis.

INTRODUCTION: The aim of this study was to evaluate the role of TAP block in improvement of anesthesiological management and perioperative surgical outcomes of robot-assisted laparoscopic radical prostatectomy (RALP). METHODS: We consecutive enrolled 93 patients with prostate cancer whose underwent RALP at our department from January 2019 to December 2019. Group A included 45 patients who received bilateral TAP block, and Group B included 48 patients who did not received TAP block. TAP blocks were always performed by a single anesthesia team. An elastomeric pump device was used in all patients for post-operative pain management. TAP block was performed according to Rafi's technique, with Ropivacaine 0.375% and dexamethasone 4 mg. Mean values with standard deviations (±SD) were computed and reported for all items. Statistical significance was achieved if p-value was ⩽0.05 (two-sides). RESULTS: The two groups showed no difference in the most important demographics and baseline characteristics (p > 0.05). Group A showed a significant longer time of anaesthesia. Moreover, Ketorolac doses (started dose plus continuous post-operative infusion via elastomeric pump) used in Group A were significantly lower than Group B. Despite this, Group B showed statistical significant higher value of NRS PACU and at 12, 24, 48, 72 h than Group A but not at 96 h. Rescue analgesic medication use was significantly higher in the Group B than Group A. Moreover, patency of the intestinal tract and time to ambulation was significantly lower in the Group A. DISCUSSION: The use of TAP block during a RALP is a safe procedure that can be applied more appropriately to achieve better pain control. A multimodal protocol that includes locoregional anesthesia, reduction of intra and postoperative use of strong opiates, correct placing of the patient and the use of low pneumoperitoneum pressures should be implemented in order to reach a faster and better post-operative full recovery of patients whose underwent RALP.

Massive intra-abdominal recurrence after robotic-assisted radical cystectomy: A case report and critical appraisal of literature.

INTRODUCTION: Over the years, the robotic surgery is gaining increasing importance in the treatment of bladder cancer. Some doubts remain about the oncological safety of robotic approach and alerts have been raised about the occurrence of atypical recurrences, including peritoneal carcinomatosis and port-site metastasis. CASE PRESENTATION: The patient referred to our Emergency Department because of acute confusional state probably due to severe anemia and sepsis. A left nephroureterectomy, left hemicolectomy with end colostomy and the surgical excision of the huge mass was performed through a xipho-pubic incision associated to another left peri-stomal incision. The histological specimen analysis showed a high-grade sarcoma, not otherwise specified (sarcoma, NOS-type), measuring 29 cm × 8 cm × 5 cm in diameters. The left kidney and ureter were not infiltrated by the neoplasm while serosa membranes and muscular layers of left colon were infiltrated by the mass. The patient died because of a cardiac arrest 4 days after surgery. DISCUSSION: RARC is a safe and feasible alternative to open radical cystectomy (ORC) with satisfactory operative time, little blood loss, and low transfusion rates. Despite this, RARC is associated with a low, but not neglectable, risk of atypical metastases like peritoneal implants and port-site metastasis. Although a small amount (7%) of RARC were performed in non-urothelial variants of bladder cancer, the sarcomatoid one can be related to a greater risk of atypical recurrence and special precaution should be taken to reduce potential causes of tumor seeding.

A rare case of spontaneous parenchymal kidney explosion in a patient with ureteral obstruction caused by a single stone.

INTRODUCTION: Spontaneous rupture of kidney may involve collecting system or parenchyma. Parenchymal rupture usually occurs in patients with renal cell carcinoma, angiomyolipoma, renal cysts, arteriovenous malformation or vascular diseases such as periarteritis nodosa. Collecting system rupture is usually a rare complication of obstructive urolithiasis. We describe the unusual cases of spontaneous kidney rupture in patients with acute urinary obstruction. CASE PRESENTATION: The case report describes the left parenchymal kidney explosion related to ipsilateral ureteral obstruction caused by a single ureteral stone. The patient reached our emergency department with acute left flank pain and massive haematuria. At the moment of admission, the patient was in stage III hypovolemic shock and had a lower haematocrit (haemoglobin = 4.9 g/dL). Despite blood transfusions, emergency surgical exploration, extrafascial nephrectomy and intensive support care, the patient died twelve hours after surgery. CONCLUSIONS: Parenchymal renal rupture can be a life-threatening emergency. Despite its rarity, in the differential diagnosis of acute abdomen, parenchymal renal rupture should always be considered in patients with abdominal pain and an anamnesis or history of urinary stones, pointing out the need of early diagnosis also in benign urological conditions.

Four dilation techniques in percutaneous nephrolithotomy: a single-institute comparative analysis.

BACKGROUND: The aim of this study was to compare four renal access techniques in percutaneous nephrolithotomy (PCNL). METHODS: A total of 437 patients who underwent PCNL at our center from January 2015 to December 2019 were included in the analysis. Telescopic metallic coaxial dilation (TMD) was used in 146 patients, single step balloon dilation (BD) in 98 patients, one-shot dilation with 30F Amplatz (OS 30F) in 106 patients, and one-shot dilation with 16F Amplatz (OS 16F) in 87 patients. Primary endpoints were perioperative outcomes and complications of the procedures. RESULTS: Similar baseline characteristics were observed in the four groups. Fluoroscopy time was significantly shorter in OS 30F and OS 16F groups (P<0.0001). The drop in hemoglobin level was not significantly different between TMD and BD groups, but it was significantly lower in OS 16F group versus the OS 30F group and lower in OS 30F group versus the BD Group (P<0.0001). Despite this, the rate of blood transfusion was similar across groups (P=0.837). Moreover, a smaller tract was associated with reduced postoperative morbidity including time to nephrostomy removal (P=0.001), hospital stay (P<0.0001), VAS scale (P<0.0001). There were no significant differences in postoperative complications (P=0.683), and Clavien-Dindo grade ≥3 complication rates (P=0.486) among the groups. Stone-free rates and number of auxiliary procedures required to achieve stone-free status were also similar among all groups (P=0.964 and 0.988, respectively). Multinomial logistic regression analysis showed that BMI (P=0.002), stone size (P=0.002) and previous PCNL (P=0.038) were predictive factors associated with the choice of OS 16 approach. CONCLUSIONS: Different dilation methods are equally effective and safe to use in a PCNL procedure for kidney stone treatment, allowing similar stone free rates and risk of complications. The OS dilation techniques seem to allow a shorter X-ray exposure time, which might be beneficial for both patients and operators. The use of a 16 F dilator can reduce the postoperative morbidity. Risk of sepsis should be always kept in mind.

Preliminary evidence of the impact of social distancing on psychological status and functional outcomes of patients who underwent robot-assisted radical prostatectomy.

INTRODUCTION: Social distancing is considered the best strategy to prevent the spread of COVID-19 (COronaVIrus Disease 19). We aimed to analyse the effect of 'social distancing' on the emotional state, post-operative pain and functional outcomes of patients undergoing robot-assisted radical prostatectomy (RARP). MATERIAL AND METHODS: We retrospectively reviewed data of male patients who underwent RARP within the study period (from March to April 2019 [Group A = 27 patients] and from March to April 2020 [Group B = 29 patients]). Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) results were collected on the first day of hospitalization. Post-operative pain was assessed using the numerical rating scale (NRS) and visual analogic scale (VAS) after surgery in the post-anesthesia care unit (PACU) and at 24 hours. Functional outcomes were evaluated at the one-month follow-up. Demographic, pathological and peri-operative data were collected for all patients. RESULTS: There were no significant differences in demographics and pathological characteristics amongst the groups. We observed that patients in Group A had a statistically lower value on the PHQ-9 and GAD-7 questionnaires than patients of Group B. Moreover, Group A showed statistically significant better post-operative pain control in PACU and at 24 hours. At one-month follow-up, patients in Group B required more diapers for incontinence than Group A, showing poor early continence. Patients in Group A showed interest in sexual rehabilitation after 1.11 ±.320 months while patients in Group B after 2.59 ±.712 months (p <.001). Moreover, 17 out of 29 patients (58.62%) in Group B were referred to an andrologist, compared to 100% of patients from Group A (p = 0.0006). CONCLUSIONS: Social distancing during the COVID-19 pandemic is associated with a poor pre-operative emotional state, as well as influencing post-operative pain, early urinary continence and desire for sexual rehabilitation.

Outcomes and complications of Hyperthermic IntraVesical Chemotherapy using mitomycin C or epirubicin for patients with non-muscle invasive bladder cancer after bacillus Calmette-Guérin treatment failure.

INTRODUCTION: Chemohyperthermia is a feasible option in BCG (bacillus Calmette-Guérin) failure patients who desire bladder preservation. We aimed to assess outcomes and complications of chemohyperthermia using mitomycin C (MMC) or epirubicin (EPI). MATERIAL AND METHODS: From March 2017 to February 2020, 103 BCG failure or intolerance patients with high-risk NMIBC (non-muscle invasive bladder cancer) underwent a hyperthermic intravesical chemotherapy (HIVEC) regimen. Five patients did not complete at least 5 instillations and were excluded from analysis. MMC was used in 72 out of 98 patients (Group A) while EPI was used in 26 patients (Group B). Response to HIVEC, predictive factors for treatment outcome and the disease-free survival (DFS) were defined as primary endpoints. The complications of chemohyperthermia were assessed as a secondary endpoint. RESULTS: No significant differences were found in recurrence and progression after induction course between Groups A and B. Kaplan-Meier disease-free survival was 22.61 months in Group A and 21.93 in Group B. The log-rank test showed no statistically significant difference between the two curves (p = .627). In the multivariate analysis, patients with tumor size ≥3 cm (p = .029), recurrence rate >1/year (p = .034), concomitant carcinoma in situ (CIS) during transurethral resection of bladder (TURB) (p = .039) and BCG-unresponsive status (p = .048) were associated with a worse response to chemohyperthermia. The use of MMC or EPI did not influence the response to treatment (p = .157). A slightly significant higher rate of overall complications (p = .0488) was observed in Group B. A significantly higher rate of Grade 3 frequency/urgency (p = .0064) contributed to this difference. The use of EPI was the only independent factor associated with severe urinary frequency/urgency (p = .017). No patients experienced Grade 4/5 adverse events. CONCLUSIONS: HIVEC can be considered a feasible option in BCG failure/intolerant NMIBC patients, avoiding or postponing radical cystectomy in some particular subclasses of patients.

The role of Protopine associated with Nuciferine in controlling adverse events during hyperthermic intravesical chemotherapy instillations. A nutraceutical approach to control adverse event during intravesical instillations.

OBJECTIVES: The aim of this study was to analyse the role of two alkaloid, Protopine and Nuciferine, in the prevention and the treatment of the low and mild grade adverse events related to the use of HIVEC® (Hyperthermic IntraVEsical Chemotherapy) instillations. MATERIALS AND METHODS: From September 2017 to September 2019, 100 patients were prospectively randomized into two groups: Group A = Protopine and Nuciferine syrup, 10 ml, once a day, for 8 weeks; Group B = placebo (flavoured coloured water), 10 ml, once a day, for 8 weeks. The primary endpoint was the evaluation of the efficacy of the therapy with Protopine and Nuciferine in controlling of the irritative symptoms. The secondary endpoint was the evaluation of the influences of the treatment on the uroflowmetric parameters. RESULTS: The patients of Group A showed a better International Prostatic Symptoms Score (IPSS) score, a better control of urgency symptoms (PPIUS) and tolerate well the pain (VAS score). The treatment doesn't modify Uroflow-Qmax and seems to improve the Uroflow-Voided Volume (ml) without influencing the Uroflow-Post Void Residual volume (PVR). Moreover, the treatment with Protopine and Nuciferine has been proven to be effective in the treatment of overactive bladder (OAB) symptoms. Patients' evaluation of the two different treatments assessed with Patient Global Impression of Improvement questionnaire (PGI-I), demonstrated improvements in the Group A, while the Group B showed a lower satisfaction. CONCLUSIONS: Protopine and Nuciferine can be interesting nutraceutical compounds useful to control irritative and pain related symptoms of intravesical chemo/immunotherapy.

Hyperbaric oxygen therapy reduces mortality in patients with Fournier's Gangrene. Results from a multi-institutional observational study.

BACKGROUND: Evidence about the clinical benefits of Hyperbaric Oxygen Therapy (HBOT) in patients with Fournier's Gangrene (FG) is controversial and inconclusive. We aimed to compare the mortality related to FG between patients undergoing surgical debridement and/or standard antibiotic therapy alone or in combination with HBOT. METHODS: We performed a retrospective multi-institutional observational case-control study. All patients admitted with diagnosis of FG from June 2009 to June 2019 were included into the study. Patients received surgical debridement and/or standard antibiotic therapy alone or in combination with HBOT. Factors associated with FG related mortality were assessed with uni-and multivariate analyses. The main outcome measure was FG related mortality. RESULTS: A total of 161 patients with diagnosis of FG were identified. Mean FG Severity Index was 8.6±4.5. All patients had broad-spectrum parenteral antibiotic therapy. An aggressive debridement was performed in 139 (86.3%) patients. A total of 72 patients (44.7%) underwent HBOT. Mortality due to FG was observed in 32 (36.0%) of patients who do not underwent HBOT and in 14 (19.4%) of patients who underwent HBOT (P=0.01). At the multivariate analysis, surgical debridement and HBOT were independent predictors of lower mortality while higher FG Severity Index was independent predictor of higher mortality. CONCLUSIONS: HBOT and surgical debridement are independent predictors of reduced FG related mortality.

The Use of a Combination of Vaccinium Macracarpon, Lycium barbarum L. and Probiotics (Bifiprost®) for the Prevention of Chronic Bacterial Prostatitis: A Double-Blind Randomized Study.

INTRODUCTION: To evaluate the efficacy of Bifiprost® + Serenoa Repens 320 mg versus Serenoa Repens 320 mg alone for the prevention of chronic bacterial prostatitis (CBP) due to enterobacteriaceae. METHODS: Between September 2016 and September 2018, 120 patients with CBP at the National Institutes of Health (NIH type II) with recurrent infections due to enterobacteriaceae (Escherichia Coli and Enterococcus faecalis) were enrolled and randomized into 2 groups each to receive Bifiprost® + Serenoa Repens 320 mg (Group A) or Serenoa Repens 320 mg alone (Group B) daily for 24 weeks (after receiving a proper antibiotic treatment with subsequent culture negativization). The primary endpoint was the reduction in the episodes of prostatitis. The secondary endpoint evaluated was the score of the NIH-Chronic Prostatitis Symptom Index (NIH-CPSI). Evaluation was performed at baseline and at 12, 24, and 36 weeks. RESULTS: The patients of the Group A experienced a significantly larger reduction in the prostatitis episodes than the Group B at 24 and 36 weeks, but they did not experience a significantly larger reduction at 12 weeks. After 12 weeks of treatment, the mean NIH-CPSI score was reduced in both groups compared with baselines, but no significant differences were seen between the Group A and Group B. On the contrary, we observed a significant difference in the mean NIH-CPSI score between the 2 groups at 24 and 36 weeks. CONCLUSION: The association of Bifiprost® and Serenoa Repens 320 mg improves the prevention of the episodes of CBP due to enterobacteriaceae and ameliorates prostatitis-related symptoms after 6 months of therapy. The long-term impact on the entero-urinary route was also seen 3 months after the end of the treatment.

A very large leiomyoma of the urethra: A case report.

INTRODUCTION: Leiomyomas are benign mesenchymal tumours of smooth muscle origin. They are the most common uterine masses in women of reproductive age group and may be related to the hormonal status. Urethral leiomyomas are very rare. According to the literature, the mean diameter of the urethral leiomyomas is 3.7 cm. CASE REPORT: We report a case of a very large leiomyoma of the urethra. A 40-year-old women woman was admitted to our department for a giant vaginal mass. She complained of haematuria, dysuria, recurrent urinary tract infections and dyspareunia. The physical evaluation demonstrated a 6 × 5.5 cm neoformation involving the distal tract of the urethra. The patient underwent an ultrasonography and then a magnetic resonance that suggested the diagnosis of leiomyoma. The neoformation was excised through a suburethral incision. CONCLUSIONS: The patient was discharged after 3 days and no intraoperative and postoperative complications occurred. The Foley catheter was removed after a week. The patient was continent to urine, and at 6 months follow-up, the patient was symptom free and no recurrences occurred.

Emergent Embolization of a Very Late Detected Pseudoaneurysm at a Lower Pole Subsegmental Artery of the Kidney after Clampless Laparoscopic Partial Nephrectomy.

Renal artery pseudoaneurysm is a rare but life-threatening condition. Its incidence is higher after minimally invasive partial nephrectomy (PN) than after the open approach. We reported a case of a renal artery pseudoaneurysm occurred about four months after a clampless laparoscopic PN. A 49-year-old female underwent a clampless laparoscopic PN for a right renal tumor with high surgical complexity. The patient experienced an intraoperative blood loss from renal bed and the surgeons performed a deep medullary absorbable suture. Three months after surgery the patient underwent a renal ultrasonography with good results. The patient came to our emergency department 115 days after surgery with a hypovolemic shock stage 3. Her CT scan showed a pseudoaneurysm of a lower pole vessel of the right kidney. She underwent a superselective embolization of the segmental renal artery. The surgical complexity of the tumor, the anatomical relationships with the renal sinus and the deep medullary suture could be responsible for the development of the pseudoaneurysm. The authors presented an unusual case of a very late detected pseudoaneurysm of a renal vessel, suggesting that all very complex renal tumors removed with a minimally invasive technique should be followed up closely at least during the first six-months in order to early detect this major complication.

Laparoscopic management of recurrent ureteropelvic junction obstruction following pyeloplasty: a single surgical team experience with 38 cases

ABSTRACT Purpose To describe and analyze our experience with Anderson-Hynes transperitoneal laparoscopic pyeloplasty (LP) in the treatment of recurrent ureteropelvic junction obstruction (UPJO). Materials and methods 38 consecutive patients who underwent transperitoneal laparoscopic redo-pyeloplasty between January 2007 and January 2015 at our department were included in the analysis. 36 patients were previously treated with dismembered pyeloplasty and 2 patients underwent a retrograde endopyelotomy. All patients were symptomatic and all patients had a T1/2>20 minutes at pre-operative DTPA (diethylene-triamine-pentaacetate) renal scan. All data were collected in a prospectively maintained database and retrospectively analyzed. Intraoperative and postoperative complications have been reported according to the Satava and the Clavien-Dindo system. Treatment success was evaluated by a 12 month-postoperative renal scan. Total success was defined as T1/2≤10 minutes while relative success was defined as T1/2between 10 to 20 minutes. Post-operative hydronephrosis and flank pain were also evaluated. Results Mean operating time was 103.16±30 minutes. The mean blood loss was 122.37±73.25mL. The mean postoperative hospital stay was 4.47±0.86 days. No intraoperative complications occurred. 6 out of 38 patients (15.8%) experienced postoperative complications. The success rate was 97.4% for flank pain and 97.4% for hydronephrosis. Post-operative renal scan showed radiological failure in one out of 38 (2.6%) patients, relative success in 2 out of 38 (5.3%) patients and total success in 35 out of 38 (92.1%) of patients. Conclusion Laparoscopic redo-pyeloplasty is a feasible procedure for the treatment of recurrent ureteropelvic junction obstruction (UPJO), with a low rate of post-operative complications and a high success rate in high laparoscopic volume centers.

Laparoscopic management of recurrent ureteropelvic junction obstruction following pyeloplasty: a single surgical team experience with 38 cases.

PURPOSE: To describe and analyze our experience with Anderson-Hynes transperitoneal laparoscopic pyeloplasty (LP) in the treatment of recurrent ureteropelvic junction obstruction (UPJO). MATERIALS AND METHODS: 38 consecutive patients who underwent transperitoneal laparoscopic redo-pyeloplasty between January 2007 and January 2015 at our department were included in the analysis. 36 patients were previously treated with dismembered pyeloplasty and 2 patients underwent a retrograde endopyelotomy. All patients were symptomatic and all patients had a T1/2>20 minutes at pre-operative DTPA (diethylene-triamine-pentaacetate) renal scan. All data were collected in a prospectively maintained database and retrospectively analyzed. Intraoperative and postoperative complications have been reported according to the Satava and the Clavien-Dindo system. Treatment success was evaluated by a 12 month-postoperative renal scan. Total success was defined as T1/2≤10 minutes while relative success was defined as T1/2between 10 to 20 minutes. Post-operative hydronephrosis and flank pain were also evaluated. RESULTS: Mean operating time was 103.16±30 minutes. The mean blood loss was 122.37±73.25mL. The mean postoperative hospital stay was 4.47±0.86 days. No intraoperative complications occurred. 6 out of 38 patients (15.8%) experienced postoperative complications. The success rate was 97.4% for flank pain and 97.4% for hydronephrosis. Post-operative renal scan showed radiological failure in one out of 38 (2.6%) patients, relative success in 2 out of 38 (5.3%) patients and total success in 35 out of 38 (92.1%) of patients. CONCLUSION: Laparoscopic redo-pyeloplasty is a feasible procedure for the treatment of recurrent ureteropelvic junction obstruction (UPJO), with a low rate of post-operative complications and a high success rate in high laparoscopic volume centers.