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#297: Analysis of regional weather parameters in 2016, 2017, and 2018 and correlation with early ureteral whole stent encrustation

Inviato da: maranoale@tiscali.it

Argomenti: 

A. Marano1, M. Bottalico1, A.G. Saracino1, S.V. Impedovo1, M. Erinnio1, V.D. Ricapito1
  • 1 Ospedale San Giacomo, Unità Operativa di Urologia (Monopoli)

Objective

Early Whole Ureteral Stent Encrustation (EWUSE) is an uncommon adverse event.(1) Since we observed 5 EWUSE cases occurring all in a very short period after a scorching heat summer in year 2017, we considered weather condition as a possible external risk factor.

Materials and Methods

We indwelled a JJ ureteral stent (4.7 or 6 Fr), because of stone related hydronephrosis, in 51, 73 and 64 patients respectively in year 2016, 2017 and 2018. None EWUSE cases occurred in 2016, 5 in 2017 (6.8%), and 1 in year 2018 (1.5%). All the EWUSE cases brought the JJ during one or more summer months. All stents were removed before the limit of 180 days suggested by the producer. Stent material was Percuflex with HydroPlus™ coating produced by Boston Scientific. We did not consider patients with encrustation only on distal J that could be simply removed in the endoscopic office. Patients’ characteristics (age, sepsis, stone size and position, date of stent indwelling, number of weeks with stent) were considered and regional weather data of year 2016, 2017, and 2018 (obtained from archives available on weather’s internet sites) were analyzed.(2)
Common weather factors, that may interfere with human hydration, such as Temperature (maxim, medium and minimum) (Tmx, Tmd, Tmn) in Celsius (°C), Dew Point (DP) in °C, Relative Humidity (RH) in percent, Wind Velocity (WV) in km/h and Atmospheric Pressure (AP) in mbar were considered. RH is the ratio between amount of moisture in air to the maximum amount of water the air can absorb. DP is the temperature at which liquid first forms from a vapor. DP changes linearly for every given RH level.
Since in 2016 we did not register any EWUSE cases, we fixed as thresholds the average highest temperatures and the average lowest DP and RH, that were all happening in July 2016. We counted the days in each month with DP, RH inferior and Tmx, Tmd, Tmn superior to the thresholds.

Results

Summer weather condition of year 2016 and 2018 were similar. Interesting differences were found in summer 2017 for DP, RH, Tmx, Tmd, and Tmn showing that it was warmer and drier, and warmer and drier for a longer period.
Furthermore on August 2017 the temperature went on increasing and RH and DP decreasing comparing to the already hot and dry July 2017, while generally the apex of temperatures happens on July. Average Tmx in August 2017 was 3.5°C more than August 2016 and even 1.2°C more than July 2017).
In year 2017 the number of days with Tmx, Tmd, Tmn superior to our thresholds (31, 26, 21°C) were respectively: 8|9|9 days in June; 17|19|18 July; 15|21|20 August; 1|2|5 September. Which means that July and August 2017 had together 40 days with temperature higher than the thresholds and in those months for 13 days Tmx was over 35°C.
The number of days in 2017 with DP, RH inferior to our thresholds (16°C, 55%) were: 26|14 in June; 26|27 July; 26|27 August; 25|8 September. Which means that almost all July and August 2017 were under the thresholds for DP and RH, and almost all June and all September were with DP under the threshold.
While the analysis of WV, AP and patients’ characteristics did not show any interesting result.
The 5 EWUSE patients occurred in year 2017 had no metabolic factor causing stone formation, while the only EWUSE case of year 2018 had hyperuricemia has metabolic factor. Only 3 encrustation from the EWUSE cases were analyzed and all of them were brushite (Calcium hydrogen phosphate; CaHPO4.2H2O).

Discussions

In the recent years many articles are trying to correlate weather parameters to the incidence and prevalence of human diseases. Stone formation has a known multifactor etiology, an important role it has always been given do the income of daily water intake and the hydration status of the patient because highly concentrated salts and slow flow of urine in the collecting system facilitate precipitation of crystals and stone formation.(3)
“Stifling heat” is when both Temperature and RH are high. In this condition people suffer the heat and the sweat cannot evaporate easily from the body, because of the amount of moisture already present in the air.
“Scorching heat” is when, at a generally low RH, the Temperature is high and the DP is low. In this condition, in order to decrease the body temperature, the thermoregulation system induce sweating that immediately evaporate facilitating fast dehydration.

Conclusion

The 5 EWUSE patients (6.8% of the indwelled stent in year 2017, but also 28% of the indwelled stent in summer 2017) brought the stent during August and September 2017, and 3 of them also during July 2017, which were the months with the highest number of days with DP, RH and temperatures over the thresholds.
Results show that the “Scorching Heat” (high temperatures united with low RH and low DP) registered for so many days during summer 2017 acted as an external risk factor facilitating dehydration due to increased perspiration for thermoregulation.
Patients carrying stent should be advice to avoid condition that facilitate dehydration and increase water daily intake.

Reference

1) Long-term complications of JJ stent and its management: A 5 years review. Ray RP, Mahapatra RS, Mondal PP, Pal DK. Urol Ann. 2015 Jan-Mar;7(1):41-5.
2) https://www.ilmeteo.it/portale/archivio-meteo
3) Seasonal Variation in the Frequency of Presentation with Acute Ureteral Colic and Its Association with Meteorologic Factors. Roche EC, Redmond EJ, Yap LC, Manecksha RP.J Endourol. 2019 Nov 21.

#301: PREDICTIVE FACTORS OF RENAL FUNCTION IMPAIRMENT AFTER 18 MONTHS IN PATIENTS UNDERGOING LAPAROSCOPIC PARTIAL NEPHRECTOMY

Inviato da: gc.rocca@ausl.fe.it

Argomenti: 

A. Gobbo1, G.C. Rocca1, G. Capparelli1, S. Papa1, G.P. Daniele1, G. Rossin1, L. Fornasari1, G. Ughi1, C. Ippolito1
  • 1 Azienda Ospedaliera Universitaria di Ferrara (Ferrara)

Objective

Currently there are no indications about nephrologic consult in patients undergoing partial nephrectomy (PN) at risk of chronic kidney disease. The present study has the purpose of identifying the predictive factors of significant fall in eGFR below 60 mL/min after 18 months (eGFR18) in patients undergoing laparoscopic partial nephrectomy. The analyzed variables are: preoperative creatinine, age at the time of surgery, Padua score, RENAL nephrometry score, gender and the percentage change in perioperative creatinine (from before the surgery to 72h after).

Discussions

According to EAU guidelines, the choice therapy for T1a and T2b tumors is PN due to the lower morbidity compared to radical nephrectomy (RN)1,2. Despite the fact that PN preserve renal function more than RN, the former procedure still exposes the patient to the risk of renal filtration’s fall. In fact, many studies in the last years had the purpose of disclosing the risk factors for renal function impairment after PN3–8.
Preoperative creatinine, as said before, was found not significant at univariate analysis (p=0,0792) but, at multivariate, using 0,95 mg/dl as threshold it was the only significant variable (p=0,0205, OR=18,2). We speculated that because creatinine values, in our sample, were not pathological as one inclusive criterion was preoperative eGFR>=60 mL/min, it was necessary to split our population to better perform the multivariate analysis. The creatinine threshold was found building the ROC curve, comparing creatinine values to eGFR18, and it resulted that creatinine >0,95 mg/dl had sensitivity of 66,7% and specificity of 73% to identify patients at risk of eGFR18<60 mL/min. The analysis demonstrates that creatinine level is a prominent risk factor for significant renal function impairment also in normal functioning kidneys. We believe that this result is important and reliable, since our population preoperative eGFR is above 60 mL/min and thus with normal renal function.
Padua score demonstrated significant at univariate (p=0,0242) but not significant at multivariate (p=0,404, OR=1,52). RENAL proved to be not significant to both univariate (p=0,0942) and multivariate (p=0,6653, OR=1,21). Despite the results we believe that both scores are important, and the small population played a major role for the outcome as other papers showed a correlation between nephrometric scores and late eGFR9,8. In support of our hypothesis, we highlight that group 1 had higher values in both mean and median for both scores.
Gender proved to be a risk factor at multivariate but without statistical significance, nevertheless it agrees with literature 7,8(p=0,1779, OR=5,85).
Age did not demonstrate any correlation with eGFR18, neither at univariate nor at multivariate analysis (p=0,6831, OR=1,01). Even if group 1 had higher mean and median age the values between the groups were too close to identify any significant difference, and this is likely to be the reason for the result as other studies had a different outcome3,4,8.
Percentage change in creatinine from pre-surgery to 72h after-surgery was not associated with eGFR18 (p=0,6855; OR=1,01). This is still a relevant result because, as said previously, we incurred in only 5 AKI stage 1, and therefore the role of AKI in our sample can be considered marginal. For this reason, we speculated that variation in perioperative creatinine, in the absence of AKI, doesn’t represent a risk factor and should not alarm the physician, but other investigation should be performed.

Conclusion

The present study, despite the small sample and therefore the lack of significance in most statistical analysis, still highlights preoperative creatinine, Padua score, RENAL score and gender as risk factors for significant eGFR18 fall. Furthermore, it seems that percentage change in perioperative eGFR in the absence of AKI is not a risk factor and therefore should not alarm the physician. The age between the two groups is comparable so it was not possible to find any correlation with eGFR18.

Reference

1. Klatte T, Ficarra V, Gratzke C, et al. A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy. Eur Urol. 2015. doi:10.1016/j.eururo.2015.04.010
2. Weight CJ, Larson BT, Fergany AF, et al. Nephrectomy Induced Chronic Renal Insufficiency is Associated With Increased Risk of Cardiovascular Death and Death From Any Cause in Patients With Localized cT1b Renal Masses. J Urol. 2010. doi:10.1016/j.juro.2009.12.030
3. Choi YS, Park YH, Kim YJ, Kang SH, Byun SS, Hong SH. Predictive factors for the development of chronic renal insufficiency after renal surgery: A multicenter study. Int Urol Nephrol. 2014. doi:10.1007/s11255-013-0534-8
4. Lee KS, Kim DK, Kim KH, et al. Predictive factors for the development of renal insufficiency following partial nephrectomy and subsequent renal function recovery: A multicenter retrospective study. Medicine (Baltimore). 2019. doi:10.1097/MD.0000000000015516
5. Mukkamala A, He C, Weizer AZ, et al. Long-term renal functional outcomes of minimally invasive partial nephrectomy for renal cell carcinoma. Urol Oncol Semin Orig Investig. 2014. doi:10.1016/j.urolonc.2014.04.012
6. Barlow LJ, Korets R, Laudano M, Benson M, McKiernan J. Predicting renal functional outcomes after surgery for renal cortical tumours: A multifactorial analysis. BJU Int. 2010. doi:10.1111/j.1464-410X.2009.09147.x
7. Lane BR, Babineau DC, Poggio ED, et al. Factors Predicting Renal Functional Outcome After Partial Nephrectomy. J Urol. 2008. doi:10.1016/j.juro.2008.08.036
8. Martini A, Cumarasamy S, Beksac AT, et al. A Nomogram to Predict Significant Estimated Glomerular Filtration Rate Reduction After Robotic Partial Nephrectomy. Eur Urol. 2018. doi:10.1016/j.eururo.2018.08.037
9. Marconi L, Desai MM, Ficarra V, Porpiglia F, Van Poppel H. Renal Preservation and Partial Nephrectomy: Patient and Surgical Factors. Eur Urol Focus. 2016. doi:10.1016/j.euf.2017.02.012

#304: THE ROLE OF MULTIPARAMETRIC RISONANCE AND FUSION BIOPSY IN PROSTATE CANCER DETECTION: THE “NEW ERA” OF MINIMALLY INVASIVE APPROACH WITH HIGH DIAGNOSTIC ACCURACY COMPARED WITH DEFINITIVE HISTOPATHOLOGICAL SPECIMEN AFTER LAPAROSCOPIC/ROBOTIC RADICAL PROSTATECTOMY

Inviato da: sebadoc22@gmail.com

S. Rapisarda1, A. Polara1, M. Bada1, G. Grosso1
  • 1 Ospedale Pederzoli (Peschiera del Garda)

Objective

The diagnosis of PCa is determined by histopathology of the biopsy taken in case of clinical suspicion, high PSA level and abnormal digital rectal examination (DRE). The current standard technique for PCa detection is transrectal and trans perineal ultrasound-guided biopsy (TRUS-GB/ TRUS-TP) and many strategies for prostate biopsy have been described, but the gold standard remains to be the 10-12 core format under transrectal ultrasound (TRUS) guidance. Developments of multiparametric MRI (mpMRI) techniques have increased the sensitivity of imaging for PCa8. Clinical guidelines advise performing an mpMRI when initial TRUS biopsy results are negative but the suspicion of PCa persists9. Usage of a 3 Tesla (3-T) magnet has further enhanced resolution and quality of imaging compared with 1.5-T 10. The Prostate Imaging-Reporting and Data System (PI-RADS) classification was introduced in 2012 by the ESUR, and has recently been updated to version 2.0.The aim of the study is to evaluate the diagnostic accuracy of mpMRI side of lesion and MRI/US fusion biopsy compared to final hystopatologic after the radical prostatectomy.
The main endpoint is to evaluate the correlation between mpMRI suspicious area, fusion/standard biopsy and histopathological definite specimens after radical prostatectomy.

Materials and Methods

We collected data about 65 patients with suspicious PCa undergoing targeted Biopsy prostatic transrectal Fusion from March 2018 to September 2019 at the Hospital Pederzoli, Peschiera del Garda (Vr) Italy. We analyzed the following information:
– Anagraphical: age, informed consent
– PSA before the mpMRI
– Urological examination: DRE
– Prostate volume at MRI (ml)
– Number of previous biopsies
– mpMRI: PIRADS score, lesion(s) position(s)
– Histological examination of the prostate biopsies: number of cores, Gleason score or ASAP, total involvement by cancer and the side of positive core (right or left sides).
– Definitive histopathological examination on the surgical specimen: T stage and localization. The correspondence between Gleason score at the fusion and/or random biopsy and at the definitive examination was assessed.
We created an excel database (named DB FUSION PEDERZOLI) and used the same sheet for collecting the data of patients who underwent radical prostatectomy after positive biopsy.
All statistical analysed were conducted using SPSS software (version 25, SPSS Inc.,Chicago, IL). Chi-square tests were used to calculate the relations between respectively: laterality of target lesion at MRI and at biopsy; laterality of target lesion at MRI and at definitive histologic report; laterality at biopsy and definitive histologic report; laterality of biopsy and definitive histologic report; PIRADS score and definitive histologic report; Gleason score at biopsy and definitive histologic report; PIRADS score and Gleason score at biopsy. Relation between variables was considered significant for p&lt;0.05. All results were also reported as bar charts. All data were analyzed with chi square test and were statistical significant with p&lt;0.05.

1. Multiparametric magnetic resonance (mpMRI) and type of machine.
We used a Ultrasound Hitachi Arietta V70 and Stereotactic Navigated Biopsy Biopsee for fusion of MRI. All patients underwent MP-MRI on a 1.5-T and 3.0-T MRI. Prior to biopsy, an MP-MRI was interpreted by the radiologists; the images were segmented, and lesion locations were recorded. Patients with lesions identified on MP-MRI underwent a targeted biopsy performed by one operator.
All biopsies were carried out at the Urology Clinic –Pederzoli Hospital following a standardized protocol. T2-weighted axial, sagittal and coronal sequences of the mpMRI were uploaded into a MRI/US fusion device (Hitachi Arietta v70 with integrated real-time ultrasonography) and the suspicious lesions were marked in the 3 planes using the RVS software. The targeted biopsy was performed with the previously identified MP-MRI lesions overlap using the T2-weighted sequence on the real-time TRUS images. Each lesion was sampled both in axial and sagittal planes by an Bi-Convex TRUS probe (Fig.8-9-10).
The standard biopsy was typically 16 cores collected in an extended-sextant template of biopsies from the lateral and medial aspects of the base, mid, and apical prostate on the left and right side14.

Results

A total of 60 patients underwent mpMRI fusion biopsy and radical prostatectomy during the study period. 65% patients with suspicious area on the right side on mpMRI had a concordance with the positive core biopsy. In the 70% of cases with suspicious area on the left side, had a concordance with the positive core biopsy: in patients with bilateral lesions on mpMRI there were a concordance of 100% with the positive core biopsy (p &lt;0.000). However, mpMRI missing respectively 35% and 30% cases of bilateral cancer, confirmed at biopsy cores but described as unilateral on mpMRI. The laterality to the definitive histology was confirmed in 50% of the patients who showed a right laterality to prostatic biopsy and in 35.7% of the patients who showed a left laterality to the prostatic biopsy. Furthermore, the concordance is 100% in patients who showed the presence of suspected bilaterally lesions (p 7. PIRADS score 5 was associated with a total GS of 7 in 53.3%, while in 26.7% of cases was 8 and only in 10% of cases was &gt;7. Moreover in another 10% of cases was negative or associated with ASAP (p=0.015).

Discussions

MpMRI is increasingly used as a tool to improve the diagnostic pathway for prostate cancer. Recently more studies have provide evidence to support a large use of mpMRI, the detection and characterization of PCa is more accurate when the lesion was previously identified using mpMRI specially in biopsy-naïve patients, thus reducing the number of unnecessary biopsies. PRECISION trial randomized biopsy-naïve patients with clinical suspicion of PCa to undergo mpMRI followed or not by target biopsy or upfront standard biopsy. In this study, despite an improved detection rate with mpMRI and fusion biopsy, there is a small number of patients in whom negative target biopsy was revealed to be a false negative on saturation biopsy or showed upgrade at saturation biopsy when compared to target biopsy19. PROMIS study proposed the use of mpMRI as a ‘triage’ test, therefore avoiding prostate biopsy in 27% of the patients and the diagnosis of non-CSPCa clinically-significant PCa in 5%. However, any mpMRI suspicious lesion needs to be confirmed by biopsy prior to any further therapeutic decision20. Another study by Siddiqui et al. showed that target biopsy is able to detect PCa with a higher GS compared to standard biopsy or to upgrade the GS of a cancer already detected at standard biopsy15. This study have a led a fraction of patients with CSPCa is still missed by target biopsy, in fact Muthigi et al 16 hypothesized four different mechanisms explaining why a CSPCa could be missed or downgraded at target biopsy; Failing to identify the lesion at a first exam with detection in a second exam, failing to identify a suspicious area at mpMRI, failing to biopsy accurately the lesion detected at mpMRI for technical problem during registration, heterogeneity of the intralesional Gleason score. This can be true especially for large tumors where an larger intralesional heterogeneity can be expected; target sampling and random sampling could therefore give a different representation of the various grading areas present in the same tumor 17. From the result of the study, we learned that the Fusion biopsy is a complex procedure influenced by various factors, experience of the operator, contouring of prostate in first step of procedure, by the eye-hand coordination of the operator during navigation, the adjustment of the image coupling in case of patient’s movement or deformation of the prostate during the procedure. We show target and standard saturation biopsy are complementary in the diagnosis of PCa in setting of biopsy-naïve patient. In this moment the guidelines do not support the execution of exclusively target biopsies because the risk of missing a CSPCa and our experience support this idea. In case of patients with previous negative biopsy the fusion technique improve the diagnostic accuracy of standard biopsy, with similar result of patients under Active surveillance. Several different studies have evaluated the ability of mpMRI to detect CSPCa comparing the imaging results with the definitive histopathology at RP. A work by Turkbey et al 18 aimed to evaluate the detection rate of cancer for 3T mpMRI, with sensitivity and specificity evaluate the influence of tumor volume and GS on the sensitivity of mpMRI. The results showed that mpMRI was more sensitive in cancers &gt; 5 mm and GS &gt; 7, thus confirming the adequacy of the imaging study for CSPCa detection. Moreover, the correlation analysis between mpMRI, fusion biopsy and GS at RP histopathology represents a further tool for evaluating the diagnostic accuracy of mpMRI. A study by Siddiqui et al 14 showed that target biopsy significantly improved the prediction of Gleason grade and risk group at definitive RP pathology. Of 170 included patients, 17 were positive at standard.
LIMITATIONS
The main limitation of the present study is the reduced number of patients in each subgroup. Therefore, the observations drawn from the analysis do not have statistical significance and should be regarded as trends rather than as conclusions. Another possible limitation could be seen in the fact that not all the mpMRI were carried out in our hospital: 145/267 patients of the general database and 60 in the RP subgroup. To overcome this limitation, all the external scan were assessed for quality (and, if minimal standard not met, excluded from the analysis) and the reviewed by dedicated uro-radiologists. Another problem in studies dealing with fusion biopsy is how to define CSPCa: in the absence of an universally-supported definition, the comparison between different studies is very difficult. Finally, another technical limitation is the difference between the maps used by the radiologist and the pathologist for reporting. The 39 regions sector map provided PIRADSv2 and used by the radiologist did not show concordance with the macro-sections used by the pathologists and there is a risk for mismatch when comparing the position of lesions in mpMRI and pathology. In the future this will need to be improved through the use of a shared map allowing radiologist and pathologist to speak the same language.

Conclusion

Regarding the ability of mpMRI-targeted sampling to identify cancer compared to random biopsy according to the current literature show improve on detection rate of PCa. Our analysis showed that the most frequent PCa patients have bilateral tumors, despite resonance and biopsy report homolateral lesions. Data suggest the existence of a positive correlation among PIRADS score at mpMRI and Gleason score at definitive histological examination. The multidisciplinary approach with radiologist and urologist is important to obtain an analysis very close to reality.

Reference

1. Ferlay, J. et al. Reprint of: Cancer incidence and mortality patterns in Europe: Estimates for 40 countries in 2012. Eur. J. Cancer (2015). doi:10.1016/j.ejca.2015.05.004
2. Siegel RL, Miller KD, J. a. Cancer Statistics,2015. CA Cancer J Clin (2015).
3. T., R. et al. PSA screening of black veterans before, during, and after implementation of the 2012 us preventative services task force recommendations. J. Urol. (2018).
4. Brierley, J. D., Gospodarowicz, M. K. &amp; Wittekind, C. TNM classification of malignant tumours – 8th edition. Union for International Cancer Control (2017). doi:10.1002/ejoc.201200111
5. Epstein, J. I. et al. The 2005 International Society of Urological Pathology (ISUP) consensus conference on Gleason grading of prostatic carcinoma. in American Journal of Surgical Pathology (2005). doi:10.1097/01.pas.0000173646.99337.b1

#305: THE COST OF ROBOT-ASSISTED LAPAROSCOPIC PROSTATECTOMY. ECONOMIC EVALUATIONS AT A REFERRAL CENTRE

Inviato da: mogorovich@hotmail.it

A. Mogorovich1, M. Cecchi1, C.A. Sepich1, D. Summonti1, A. Di Benedetto1, M. Catastini1, L. Lunardini1, S. Pampaloni1, I. Bardelli1
  • 1 USL Toscana Nord-Ovest Ospedale Versilia (Lido di Camaiore)

Objective

Since the introduction of robotic surgery for radical prostatectomy, the cost-benefit of this technology has been under scrutiny (1, 2). While robotic surgery has shown to offer multiple advantages, including reduced blood loss, reduced length of stay, and expedient recovery, the associated costs tend to be significantly higher, secondary to the fixed cost of the robot as well as the variable costs associated with instrumentation. This study analyzes the cost of robotic prostatectomy in a referral center and compares it to the DRG reimbursement amount.

Materials and Methods

Our experienced surgical team performed robotic assisted laparoscopic prostatectomy (RALP) at the Multidisciplinary Centre for Robotic Surgery of Pisa Hospital. A retrospective analysis of patients who underwent RALP for prostate cancer was performed: preoperative, operative and post-operative costs were evaluated.

Results

According to our analysis, preoperative assessment cost € 111.0. The total amount of the operative phase was € 5693,0, including € 801,0 for surgical team, € 1110,4 for surgical room and € 3781,8 for medical devices and drugs. Post-operative period was estimated to cost € 739.0. Hence, a total amount of € 7852,0 per patient submitted to RALP was estimated.

Discussions

While potential benefits of robotic technology include decreased morbidity and improved recovery, some have suggested a prohibitively high cost. According to a recent revision of the Regional Government of Tuscany, the DRG reimbursement amount has been raised from € 4234.0 to € 9677.0 leading to a positive financial balance for the hospital of € 1824.9. Before this modification took place, considering the DRG reimbursement of € 4234.0, the financial loss per patient was € 3618,0.

Conclusion

Robotic technology in prostate cancer surgery has shown to offer several advantages in comparison to open procedure; however the higher cost of robotic surgery has been matter of debate in the recent years. The recent modification of the DRG reimbursement allows the hospital to offer patients an excellent treatment avoiding the loss of a significative amount of money

Reference

1. Ramsay C, Pickard R, Soomro N et al. Systematic review and economic modelling of the relative clinical benefit and cost‐effectiveness of laparoscopic surgery and robotic surgery for removal of the prostate in men with localised prostate cancer. Health Technol Assess 2012; 16: 1– 313

2. Hughes D, Camp C, O'Hara J, Adshead J. Health resource use after robot‐assisted surgery vs open and conventional laparoscopic techniques in oncology: analysis of English secondary care data for radical prostatectomy and partial nephrectomy. BJU Int 2016; 117: 940– 7

#308: Primary transrectal random prostate biopsy: is still actual?

Inviato da: giorgio.napodano@gmail.com

G. Napodano1, A. Campitelli1, T. Realfonso1, G. Molisso1, R. Baio1, M. Addesso2, R. Sanseverino1
  • 1 Ospedale Umberto I - Asl Salerno, UOC Urologia (Nocera Inferiore)
  • 2 Ospedale Umberto I - Asl Salerno, UOC Patologia (Nocera Inferiore)

Objective

Random prostate biopsy is still the gold standard procedure to detect prostate cancer. Multiparametric MRI has been introduced to guide target prostate biopsy to improve detection of clinically significant prostate cancer. Today is debated whether primary biopsy should be performed with random or target approach. We evaluated outcomes of patients undergone first transrectal random prostate biopsy. We also evaluated predictive factors of prostate cancer diagnosis.

Materials and Methods

Patients with suspicious of prostate cancer based on PSA, DRE, ultrasound findings underwent a TRUS guided transrectal biopsy. Procedure were performed under local anaesthesia or intravenous sedation as indicated. Clinical and pathological data were prospectively collected from May 2010 to September 2019 in our database. We calcolated cacer detection rate and we identified predicitve factors of cancer. Statistical analysis was performed using Chi square test, Mann Whitney, logistic regression test, as appropriate (SPSS 19).

Results

Data on 1974 patients were available. Patients characteristics are reported in table 1. Indications for biopsy are reported in table 2. Prostate cancer has been diagnosed in 46.4% of the patients (table 3). Positive patients presented ≥3 positive cores or Gleason ≥3+4 in 78,5% and 86,7%, respectively. At multivariate analysis, age, PSA, DRE, prostate volume, number of cores, and year of biopsy are predictive of cancer diagnosis (tab 4).

Discussions

Random prostate biopsy is still the gold standard procedure to detect prostate cancer. Multiparametric MRI has been introduced to guide target prostate biopsy to improve detection of clinically significant prostate cancer. Today is debated whether primary biopsy should be performed with random or target approach

Conclusion

Random transrectal prostate biopsy identified cancer in 46% of all patients. In the last three years, cancer detection rate is more than half of the patients. More than three quarters of patients presented a clinically significant cancer. Age, PSA, positive DRE, prostate volume and number of cores are correlated with presence of cancer

#313: Pelvic floor Muscle Training after Radical Prostatectomy: is there any differences when we compare retropubic radical prostatectomy with laparoscopic radical prostatectomy?

Inviato da: lucia.mastroserio@hotmail.it

L.A. Mastroserio1, P.A. Mastrangelo1, D. Di Prima1, I. Veneziano1, B. Mazzoccoli1, U. Locunto1, F. Boezio1, B. Zaccaro2, G. Disabato1
  • 1 Ospedale "Madonna delle Grazie", ASM Matera (Matera)
  • 2 Università degli Studi di Foggia (Foggia)

Objective

To evaluate the effectiveness of pelvic floor muscle training (PFMT) for treating urinary incontinence (UI) after radical prostatectomy (RP), both retropubic radical prostatectomy (RRP) and videolaparoscopic radical prostatectomy (VLRP).

Discussions

Open retropubic radical prostatectomy has been the "gold standard" treatment for locally confined prostate cancer (PCa) but in recent years minimal invasive techniques as laparoscopy and robot-assisted prostatectomy have become widely available. The trifecta of the surgical treatment of PCa is cancer control, the preservation of continence, and erectile potency (1). Incontinence after RP (P-RP-I) varies widely (2% to &lt;60%) according to the definition and quantification of incontinence, timing of evaluation, and who evaluates (physician or patient) (2). Conservative treatments, including pelvic floor muscle training (PFMT), anal electrical stimulation (AES), lifestyle adjustment, or combination are usually recommended at first for P-RP-I (3). In our study we compare the benefits of PFMT on P-RP-I after retropubic radical prostatectomy and after laparoscopic radical prostatectomy. We found an earlier (after 1 month) recovery of continence in patients underwent retropubic radical prostatectomy vs laparoscopic approach but, after 6 months the results were the same. Just one patient in RRP group and one patient in VLRP group manifested a high grade UI at six months, but they both had adjuvant radiotherapy.

Conclusion

As is known, PFMT is an effective treatment for urinary incontinence in men after radical prostatectomy (4). There were no differences between RRP group patients and VLRP group patients in terms of long-term results.

Reference

(1). Van Poppel H et al. Asian J Urol 2019 Apr;6(2):125-128. (2). O’Callaghan ME et al. Prostate Cancer Prostatic Dis. 2017 Dec;20(4):378-388. (3). EAU Guidelines 2019. (4). MacDonald R et al. BJU Int. 2007 Jul;100(1):76-81.

#315: Focal high-intensity focused ultrasound (HIFU) for clinically localized prostate cancer: disease control or definitive treatment?

Inviato da: f.m.mele@gmail.com

A. Rocca1, F. Mele1, M. Barale1, R. Migliari1
  • 1 AO Ordine Mauriziano, S.C. Urologia (Torino)

Objective

To report our intermediate results on the use of focal ablation for the treatment of clinically localized prostate cancer.
Thanks to the improvement of the diagnostic tools (MRI and prostatic biopsy) which has occurred in the last 10 years, the possibility of carrying out ablative treatments with high intensity focused ultrasound (HIFU) has been the natural step in the concept of precision therapy.
The HIFU technique allows to treat prostate cancer lesions effectively and with a low profile of side effects.

Materials and Methods

Consecutive patients with PCa treated with primary focal HIFU at our centre since 2015 were assessed. Patients were submitted to either focal ablation or zonal-ablation using HIFU (Focal One®). The primary objective of the study was to assess medium-term oncological outcomes, defined as overall survival, freedom from biopsy failure, freedom from radical treatment after focal HIFU. The secondary objective was to evaluate the changes in functional outcome referred by patients treated with focal HIFU, through validated questionnaires (IPSS, IIEF-5).

Results

A total of 92 focal HIFU treatment between February 2015 and May 2019 were assessed. 79 (85.9%) patients underwent to a primary treatment, 9 (9.8%) patients a second controlateral treatment (for a new lesion discovered during follow-up), 4 (4.3%) patients a re-HIFU (for disease persistence). The median age was 66 years and median prostate-specific antigen level was 6.8 ng/mL.
A total of 41% (38) had high volume Gleason 6 disease, 46% had Gleason 3+4 disease, and 13% had Gleason ≥ 4+3 disease.
The median (interquartile range) follow-up was 25 (14-40) months. The overall survival rates were 100% up to 48 months. Freedom from biopsy failure, defined as absence of prostate cancer in the treated area, was 95%. Of those that underwent a second HIFU treatment (4 re-HIFU for persistence and 9 new-HIFU for a metachronous lesion) all of them are free from disease.
Freedom from radical treatment was 96,7%, 93,4% and 91,3% at 12, 24 and 48 months.
No significant changes were recorded in the IPSS and IIEF-5 questionnaires. Postoperative complications included 1% urethral stricture, 3.2% post-HIFU THULEP, and new onset ED of 5.4%.

Conclusion

New therapeutic methods have emerged in recent years as "focal" treatment alternatives greatly reducing the side effects associated with radical treatment. HIFU appears to have short or medium term cancer control, with a low complication rate comparable to that of standard treatment. Longer-term follow-up studies are needed to assess overall and specific cancer survival. If our promising results will be confirmed in future prospective studies, focal therapy could begin to challenge the current standard of care.

Reference

J Endourol. 2017 Apr;31(S1):S30-S37. High-Intensity Focused Ultrasound for the Treatment of Prostate Cancer: A Review. Chaussy CG, Thüroff S.
J Urol. 2018 Sep;200(3):512-519. Prostate Ablation Using High Intensity Focused Ultrasound: A Literature Review of the Potential Role for Patient Preference Information. Babalola O, Lee TJ, Viviano CJ.
Curr Opin Urol. 2017 Mar;27(2):138-148. High-intensity focused ultrasound for focal therapy: reality or pitfall?
Schulman AA, Tay KJ, Robertson CN, Polascik TJ.

#248: A rare case of a well-differentiated neuroendocrine tumor of the kidney in a young patient: a diagnostic challenge and surgical management

Inviato da: mogorovich@hotmail.it

Argomenti: 

A. Mogorovich1, M. Cecchi1, C.A.. Sepich1, D. Summonti1, A. Di Benedetto1, I. Bardelli1, S. Pampaloni1, M. Catastini1, L. Lunardini1
  • 1 USL Toscana Nord-Ovest Ospedale Versilia (Lido di Camaiore)

Objective

Neuroendocrine tumors (NETs) are uncommon tumors that exhibit a wide range of differentiation and biological behavior. NETs can arise from any tissue or organ, including organs that do not normally contain neuroendocrine cells.[1] NETs embrace a large spectrum of diseases rarely originating from the kidney (2); they include well-differentiated NET (carcinoid), well-differentiated neuroendocrine carcinoma, poorly differentiated neuroendocrine carcinoma and small cell carcinoma. Renal carcinoids are typically slow-growing tumors with a variable clinical course. We herein report a rare case of well-differentiated NET (carcinoid) in a 17-year-old male along with the immunohistochemical features and a review of the literature.

Materials and Methods

A 18-year-old male presented with dull pain in the left flank since 9 months. The abdominal examination revealed a big palpable mass in the left abdomen; CT scan showed a huge cystic tumor occupying the entire left part of the abdominal cavity arising from the left kidney with maximum diameter &gt; 30 cm without regional node involvement and distant metastasis.

Results

US-guided percutaneous biopsy of the neoplasm was inconclusive and the patient underwent surgical removal of a large renal tumor displacing all the surrounding organs in absence of infiltrative growth pattern. The mass was excised by blunt dissection from the kidney allowing to preserve a large amount of healthy renal parenchyma.
Gross examination revealed a brown coloured cystic mass with large haemorragic areas, apparently surrounded by a fibrous capsule.
On microscopic examination there was absence of necrosis and mitotic figures were scant (&lt;2/10 HPF). Immunohistochemically, these tumor cells were diffusely positive for chromogranin, synaptophysin, vimentine, CK8/18 and negative for GFAP, pS100, RCC, PAX-8, WT-1 and CK-7. Ki-67 index was nearly 2%. Thus, a diagnosis of well-differentiated NET was given.

Discussions

NETs are most commonly seen in the gastrointestinal tract, less frequently in the respiratory system and sporadically in parenchymal organs such as the liver. Primary NETs of the kidney are extremely rare.[2] They can occur in both the renal parenchyma and the renal pelvis.[3]
The pathogenesis of primary NETs of the kidney is still controversial. Neuroendocrine cells have been identified in the renal pelvis but not in the normal renal parenchyma.[4] Different theories support the fact that NETs arise from primitive totipotential stem cells that subsequently differentiate in a neuroendocrine direction. Several mechanisms have been used to explain the origin of such tumors, including metastasis from an occult primary tumor site to the kidney, activation of aberrant gene sequences in a totipotential stem cell line that differentiates into aberrant NET cells, and concurrent renal congenital abnormalities. Some authors think that the tumors arise from neuroendocrine cells occurring in the mucosa of the renal pelvis in intestinal metaplasia.[5]
In 2010, the WHO has proposed a classification system for renal carcinoid tumors that is similar to that of the carcinoid tumors of other organs.[6] They classified neuroendocrine neoplasms into NET-well differentiated grade 1, NET-well differentiated grade 2, NEC-poorly differentiated grade 3 (small and large cell type), mixed adenoneuroendocrine carcinoma, hyperplastic, and preneoplastic lesions. This classification differentiates between NETs and neuroendocrine carcinomas. The proliferation index (Ki-67, MIB-1), angioinvasion, and mitoses are important factors in this classification.
Well-differentiated NET (carcinoid) of the kidney are rare with 4 cm. This could be due to the vacuous nature of the retroperitoneal space as kidneys are essentially retroperitoneal organs.
There is no clear correlation between the histologic features of the disease and prognosis and tumor necrosis is not a predictor of prognosis. Metastatic workup must always be done to rule out the possibility of metastasis from an occult tumor elsewhere when a clinical diagnosis of renal carcinoid is made. Long-term follow-up care is essential because of the prolonged course of disease despite metastasis. The clinical course of renal carcinoid is difficult to predict because of the rarity of the condition; however, it is largely believed to have an indolent course

Conclusion

The current recommended management for primary renal carcinoid tumors includes radical nephrectomy with surveillance and surgical removal of any subsequent metastases.[6] Even partial nephrectomy is recommended. The average follow-up time is 20 months with 73.1% of patients without evidence of disease after surgical treatment which suggests that surgical treatment is curative.[8],[9] Liver metastasis can be treated with open resection or with minimally invasive ablative procedures. Metastatic renal carcinoid has been noted to be resistant to chemotherapy.

Reference

1.
DeLellis RA, Osamura RY. Neuroendocrine tumors: An overview. Pathol Case Rev 2006;11:229-34.

2.
Lane BR, Jour G, Zhou M. Renal neuroendocrine tumors. Indian J Urol 2009;25:155-60.
3.
Kuroda N, Katto K, Tamura M, Shiotsu T, Hes O, Michal M, et al. Carcinoid tumor of the renal pelvis: Consideration on the histogenesis. Pathol Int 2008;58:51-4.

4.
el-Naggar AK, Troncoso P, Ordonez NG. Primary renal carcinoid tumor with molecular abnormality characteristic of conventional renal cell neoplasms. Diagn Mol Pathol 1995;4:48-53.

5.
Romero FR, Rais-Bahrami S, Permpongkosol S, Fine SW, Kohanim S, Jarrett TW. Primary carcinoid tumors of the kidney. J Urol 2006;176 (6 Pt 1):2359-66.

6.
Eble JN, Sauter G, Epstein JL. World Health Organization Classification of Tumours. Pathology and Genetics of Tumors of the Urinary System and Male Genital Organs. Lyon: IARC Press; 2004. p. 81-2.

7.
Omiyale AO, Venyo AK. Primary carcinoid tumour of the kidney: A review of the literature. Adv Urol 2013;2013:579396.

8.
Raslan WF, Ro JY, Ordonez NG, Amin MB, Troncoso P, Sella A, et al. Primary carcinoid of the kidney. Immunohistochemical and ultrastructural studies of five patients. Cancer 1993;72:2660-6.

9.
Cabral Ribeiro J, Sousa L, Ribeiro Santos A. Primary neuroendocrine tumor of the kidney. Actas Urol Esp 2010;34:907-9.

#249: Penis strangulation caused by a steel ring: A Case Report

Inviato da: mogorovich@hotmail.it

Argomenti: 

A.. Mogorovich1, M. Cecchi1, C.A. Sepich1, D. Summonti1, A.. Di Benedetto1, M. Catastini1, I. Bardelli1, S.. Pampaloni1, L.. Lunardini1
  • 1 USL Toscana Nord-Ovest Ospedale Versilia (Lido di Camaiore)

Objective

To describe a man with penis strangulation caused by a steel ring and its successful removal.

Materials and Methods

A 33 year-old man presented to our emergency department with a 3-hour history of a grossly swollen and painful penis due to a stainless steel ring located at the base of the penis for erection enhancement during intercourse. After intercourse, he was unable to remove the ring and the penile pain and swelling progressively worsened.
At presentation, the patient also complained of pain in his lower abdomen and hypoesthesia in his genitalia. He had no comorbidities and no history of mental illness or substance abuse.
On examination, the patient was anxious and distressed. Abdominal bulging was absent, although guarding and tenderness were present in the lower abdomen. A 2.5-cm-diameter, 2-cm wide and 2-mm-thick ring was positioned tightly at the base of the penis.
The incarcerated penile shaft was grossly edematous and bluish with areas of exudation, cool and diminished in sensation.
The small diameter of the ring and edematous tissue made it impossible to pull out the ring from the shaft.
Hence, the fire department was contacted to obtain assistance; after consultation with them, the decision was made for the fire personnel to remove the steel ring using their hydraulic cable cutter. After disinfection, 1% lidocaine was injected at the base of the patient's penis. The ring was sheared in two places and successfully removed without injury to skin and other tissue. After removal of the ring, circulation and skin color of the penis and scrotum were restored. At follow-up 2 weeks later, the edema had resolved and the skin had completely healed. Urination, skin sensation, and erectile function had returned to normal after 1 week. Urinalysis results were normal. On examination, a discontinuous circumferential scar was evident at the base of the penis.

Results

The hydraulic cable cutter avoided thermal injury and shortened removal time compared with other procedures described. The patient's recovery was uneventful, with erectile function restored after 1 week.

Discussions

Ring-shaped objects are placed on the penis often to enhance sexual performance and for autoerotic purposes or curiosity.(1,2). The ring hinders venous return and leads to swelling, followed by arterial and lymphatic blockage and ischemia distal to the ring (3, 4) Timely removal of the offending object is paramount for full recovery of circulatory and urinary functions and in most cases further management is unwarranted. Delay in removal can lead to penile necrosis, urethrocutaneous fistula, and even septic shock and death (3, 4, 5, 6).
Management depends on the type and size of the constricting object, time after incarceration, degree of injury, available instruments, and experience of the physicians (2). The literature describes four approaches for removal of the object: string technique, aspiration, cutting, and surgery (2, 5, 7, 8). Special implements are often needed, which are not always available in the emergency and urology departments (1, 3, 4, 9, 10). Indeed, management delay is typically caused by locating an appropriate tool (2). However, their use introduces the risk of thermal burn or mechanical damage to genitalia tissue. Furthermore, a protective device needs to be inserted between the edematous genitalia and the ring, which can increase pressure and pain (5). The Winter procedure can be attempted, but the surgery is lengthy and poses a risk of injury (2).
We believe that ours is the second report of a hydraulic cable cutter being used to shear a constricting object. The cutter posed no risk of thermal injury and was capable of directional and power adjustments. We also did not need to insert a protective device between the ring and genitalia; thus, no ensuing injury occurred.

Conclusion

Genital incarceration is an urgent clinical situation requiring prompt treatment. However, suitable tools for removing the foreign object are not readily available in emergency and urology departments. Cooperation with other disciplines, even non-medical disciplines, can result in creative and timely measures for removal of the object.

Reference

1. Efthimiou I., Kazoulis S., Christoulakis I. Penile and scrotal strangulation caused by a steel ring: a case report. Cases J. 2008;1:45.

2. Wu X., Batra R., Al-Akraa M. Penoscrotal entrapment: a safe, innovative technique for removing metal constricting devices. BMJ Case Rep. 2012;2012

3. Kyei M.Y., Asante E.K., Mensah J.E. Penile strangulation by self-placement of metallic nut. Ghana Med J. 2015;49:57–59.

4. Sathesh-Kumar T., Hanna-Jumma S., De Zoysa N. Genitalia strangulation—fireman to the rescue! Ann R Coll Surg Engl. 2009;91:W15–W16.

5. Osman I., Muñoz A.M., Lozano J.M. Penile incarceration secondary to a ring. Urol Int. 2010;85:245–246.

6. Morentin B., Biritxinaga B., Crespo L. Penile strangulation: report of a fatal case. Am J Forensic Med Pathol. 2011;32:344–346.

7. Santucci R.A., Deng D., Carney J. Removal of metal penile foreign body with a widely available emergency medical-services-provided air driven grinder. Urology. 2004;63:1183–1184.

8. Yousef I., Ismail E., Gomaa M. A ring constriction of the penis: an emergency presentation of an aged man. J Sex Med. 2015;12(Suppl 1):62.

#277: Bipolar plasma TURP of prostate of 150 ml: The white resection

Inviato da: maranoale@tiscali.it

A. Marano1, M. Bottalico1, F. Palumbo1, S.V. Impedovo1, M. Erinnio1, G.A. Saracino1, V.D. Ricapito1
  • 1 Ospedale San Giacomo, Unità Operativa di Urologia (Monopoli)

Abstract

The video shows the synthesis of a 70 minutes TURP of a prostate with a volume of 150 ml performed using the bipolar plasma edge technology by Lamidey. TURP remains the gold standard and it is strongly recommended for the treatment of moderate-to-severe LUTS men with prostate size of 30-80 mL. Oversized prostates > 80-100 mL undergo to traditional open prostatectomy or to laser enucleation. The TURP shown is one of a group of 7 patients with prostate larger than 100 ml and up to 180 ml treated by bipolar plasma TURP since November 2018. The approach for those oversized prostate was posterior to remove first the large medium lobe. For the lateral lobes a tunnel between the lobe and the prostate capsule was made to allow a faster and less bleeding resection of each lobe from the lateral to the median part. Average operative time was 71 minutes (range 55-90); mean hospitalization time was 3.3 days (range 2-4); no patient had TUR syndrome; none required blood transfusion or iron intravenous implementation; no other adverse event were registered. The use of saline solution and the short operative time allow the procedure to be safe also for large size prostate. Larger studies are mandatory to confirm our results.

#298: Laparoscopic treatment of a big urinoma after RARP

Inviato da: dott.tpuglisi@gmail.com

F. Curto1, T. Puglisi2, G. Caldarella3
  • 1 Fondazione Istituto Giglio (Cefalù)
  • 2 Ospedale Sant'Antonio Abate (Trapani)
  • 3 Ospedale Giovanni Paolo II (Ragusa)

Abstract

Nowadays robotic prostatectomy (RARP) is performed increasingly with improved precision and fewer post -operative complications. Despite the miniinvasivilly technique, linfocele and urinoma remain the most complex and severe complications and the most challenging problem is to resolve and treat it. 
In this video we present a case of a 59-year-old man who underwent a RARP and after 15 Post – op days complained a left ureteral fistula and a big abscessualized urinoma (14 x 10 cm) between bladder and rectum and an homolateral perirenal extravasation of contrast.
We performed a laparoscopic complete drainage of the urinoma and irrigation of the cavity. Samples were obtained for bacterial culture and drug testing.
In literature urinoma and ureteral fistula rates are not widely reported, and it is usually reported with urinary leakage, at rates of 2.4%. The most cause is represented by anastomotic leakage and only in rare case it is necessary to perform a surgery revision.
In order to avoid this complication, and eventually treat it faster, maybe an accurate post- operative imaging is necessary to check the pelvis status following RARP.
In our case, the percutaneous aspiration of the urinoma was not a safe procedure for the presence of ileal adherence and laparoscopic drainage remained a safe and minimally invasive approach.

#317: Laparoscopic pyeloplasty: our experience

Inviato da: willygiannubilo@virgilio.it

W. Giannubilo1, G. Sortino1, M. Diambrini1, A. Marconi1, M. Di Biase1, V. Ferrara1
  • 1 "Carlo Urbani" Hospital (Jesi)

Abstract

in this video we show our experience with laparoscopic pyeloplasty in the treatment of pyeloureteral junction obstruction.
We describe the technique of laparoscopic dismembered Anderson-Hynes type pyeloplasty
Our technique always involves a trans peritoneal approach with 3 trocars. a mono J stent is always placed before surgery.
Laparoscopic pyeloplasty has become the operation of choice in cases of hydronephrosis secondary to crossing vessel, when there is great pyelic dilation, and for the treatment of failures of previous endopyelotomy.

#321: NEFRECTOMIA DESTRA LAPAROSCOPICA RETROPERITONEALE CON CAVOTOMIA

Inviato da: sebadoc22@gmail.com

Argomenti: 

A. Polara1, S. Rapisarda1, G. Grosso1
  • 1 Ospedale Pederzoli (Peschiera del Garda)

Abstract

Il video descrive il trattamento laparoscopico di una voluminosa neoformazione renale destra in paziente ZD di anni 55, che ha eseguito follow-up per pregresso Ca mammario, con riscontro TC di lesione espansiva di 8 cm al III medio inferiore del rene destro, determinante infiltrazione del sistema collettore ed espansione della vena renale per estesa colonizzazione di tessuto neoformato che protrude leggermente nel lume cavale.
TC torace negativa.
Il video mostra la preparazione dello spazio di lavoro retroperitoneale destro, isolamento e trattamento dell’arteria renale destra, clippaggio della vena surrenalica e dell’uretere destro; preparazione della cava ed isolamento della vena renale destra, imbottita dal trombo neoplastico. Viene descritto il posizionamento di Satinsky sulla cava, cavotomia, asportazione del trombo cavale, doppia sutura in prolene 3-0: declampaggio cavale, completamento dell’isolamento del rene ed asportazione in endobag attraverso minilaparotomia di servizio.
I tempi operatori sono stati di 100 minuti, le perdite ematiche intraoperatorie 400 ml.
Gli esami di laboratorio hanno evidenziato un calo dell’emoglobina in prima giornata postoperatoria: 13.1 g/dl (da 15.1 preoperatoria), mentre la creatininemia postoperatoria è stata 1.0 (preoperatoria 0.9).
Il drenaggio lombare è stato rimosso in II giornata post-operatoria, mentre la paziente è stata dimessa in IV giornata.

#310: CLAMPLESS LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR HILAR COMPLEX TUMORS

Inviato da: giorgio.napodano@gmail.com

Argomenti: 

R. Sanseverino1, T. Realfonso1, O. Intilla1, U. Di Mauro1, R. Baio1, U.. Pane1, G. Napodano1
  • 1 Ospedale Umberto I - Asl Salerno, UOC Urologia (Nocera Inferiore)

Abstract

Nephron sparing surgery is now reference standard for many T1 renal tumors. ”Zero ischemia” partial nephrectomy allows to eliminate ischemia during nephron sparing surgery. It is possible to realize a clampless LPN also for the treatment of hilar tumors. The video shows 3 cases of complex renal turmors.
The first case shows a transperitoneal clampless left PN for hilar tumor.Hilar vessels are prepared in event that bulldog clamping may subsequently be needed. Intreoperative laparoscopic ultrasound is performed to identify tumor borders. To induce hypotension, the doses of inhalational isoflurane is increased. The renal lesion is excised using Ligasure. Calyceal suture was performed with Monocryl. Renal parenchyma was repaired with Vicryl™ sutures arrested with absorbable clips. Hemopatch and Floseal were applied to resection bed. The second case is represented by a right hilar tumor; Padua score is 9h and C index 1.4. The renal artery and vein are isolated on vessel loop. We proceed with resection of tumor using Ligasure. The third tumor is a left hilar tumor with Padua score is 10h, C index 0.4; renal artery is isolated on vessel loop. In this case we proceed with selective clamping of tumor artery during resection of the lesion. After removing bulldog clamp, renorraphy is completed.

#203: robotic kidney transplationretroperitoneal graft placement, indocyanine green imaging

Inviato da: stefano.masciovecchio@hotmail.com

S. Masciovecchio1, B. Binda2, A.B. Di Pasquale1, F. Pisani2, L. Di Clemente1
  • 1 P.O. "San Salvatore", U.O.C. Urologia (L'Aquila)
  • 2 P.O. "San Salvatore", U.O.C. Trapianti (L' Aquila)

Abstract

The aim of this video is to report the first preliminary experience with intraoperative indocyanine green (ICG) fluorescence videography (IFV) to assess graft and ureteral reperfusion during robot-assisted kidney transplantation (RAKT). We prospectively collected data from consecutive patients undergoing RAKT and IFV from living-donors at our Institution. ICG was injected intravenously after vascular anastomoses to quantitate graft and ureteral fluorescence signal. The signal intensity within selected intraoperative snapshots was evaluated for renal parenchyma, ureter and vascular anastomoses. Three patients were included. Neither conversions to open surgery nor major intra- or postoperative complications were recorded. At a median follow-up of 9 months median estimated glomerular filtration rate was 61.2 mL/min/1.73 m2. Intraoperative quantitative assessment of ICG fluorescence was successful in all patients. IFV during RAKT is feasible and safe and provides a reliable assessment of graft reperfusion. Larger studies are needed to standardize the technique and to evaluate the association between fluorescence signal, ultrasound parameters and postoperative kidney function.

#274: Nefrectomia parziale laparoscopia transperitoneale 3D per neoplasie renali complesse

Inviato da: mattia.nidini@asst-mantova.it

Argomenti: 

P. Parma1, M. Nidini1, L. Cappellaro1, A. Samuelli1, S. Guatelli1, E. De Luise1, V. Galletta1, M. Luciano1, F. Croce1, B. Dall'Oglio1
  • 1 Ospedale Carlo Poma, Urologia (Mantova)

Abstract

In questo video vogliamo esporre il nostro approccio chirurgico abituale per le neoplasie renali T1b complesse.
Riteniamo infatti che la tecnica lapariscopica transperitoneale tridimensionale, possa essere un approccio standard per l'aggressione di masse renali voluminose, localizzate soprattutto sulla faccia anteriore e al polo superiore dell'organo.
Il video si compone di 2 casi clinici similari:
Caso 1: una Paziente di 37 anni normopeso che non presentava nessuna comorbidità di rilievo, ha avuto una diagnosi accidentale TC durante ricovero in ambiente internistico per polmonite, di neoformazione allocata al polo superiore del rene destro delle dimensioni di 71×46 cm, in stretta contiguità alla faccia inferiore del surrene omolaterale.
Caso 2: una Paziente di 66 anni obesa e con lievi comorbidità, ha avuto una diagnosi accidentale ecografica (successivamente approfondita con indagine TC) di neoformazione renale allocata alla faccia anteriore del rene sinistro, sul terzo medio-superiore verso il labbro mediale, del diametro di 3,9 cm.
Secondo la nostra esperienza, l’approccio chirurgico laparoscopico tridimensionale transperitoneale, risulta ideale nella gestione delle neoformazioni renali (fino a T1b) localizzate alla faccia anteriore del rene, di natura anche complessa e parzialmente endofitica. Tale evidenza corrobora inoltre le indicazioni delle linee guida EAU a tal riguardo.

#314: Bladder Pneumatosis: an inusual case report

Inviato da: diego.rosso@aslcn1.it

D. Rosso1, M.T. Filocamo1, P. Mondino1, G. Cordara1, R. Rossi1, R. Borsa1, P. Polledro1, P. Coppola1
  • 1 ASL CN1 Savigliano, SOC Urologia (Savigliano)

Objective

Emphysematous cystitis (EC) or bladder pneumatosis is a very rare condition characterized by air within the wall of the bladder as a result of infection by gas‐forming organisms. Predisposing factors include diabetes mellitus, a neurogenic bladder, bladder‐outlet obstruction, in‐dwelling urethral catheters and recurrent urinary tract infections The major risk factor is diabetes mellitus (1). There are reported cases in literature of bladder pneumatosis without urinary tract infection (2). The amassing of gas within the wall of the bladder in this cases is not clear, a similar process of intestinal pneumatosis was proposed (2,4). Here we present a case of Bladder pneumatosis in an elderly woman affected by diabetes.

Materials and Methods

A female patiste 75 years old presented with asthenia, hyporexia cachexia, was affected by lung cancer with metastasis, BPCO and 24 hour oxygen therapy, hearth failure, hyperthyroidism , DM, Bartolini’s gland abscess. The patients presented in acute urinary retention, so an indwelling catheter was placed with drainage of 800 cc of clear urine. A computed contrasted tomography scan of the abdomen and thorax showed the presence of a lung cancer with multiple liver and lymph nodal metastasis and multiple air‐filled cysts within the wall of the bladder.

Results

Work‐up failed to show an infectious etiology, results of the urine analysis did not show pyuria, hematuria or bacteriuria, and no organisms were isolated from urine and blood cultures carried out before the administration of antibiotics. Antibiotic therapy was administered for Bartolini’s gland infection. No therapy was administered ether for lung cancer nor metastasis, the patients was addressed to palliative therapies.

Discussions

EC is a rare disorder characterized by the amassing of gas in the wall of the bladder. The disease is most common in female than in male (64% vs 36%) and more frequent in middle‐aged diabetic women (mean age 66 years) (3,6,7). There are several theories on the pathogenesis of these gas‐forming infections, but the combination of the presence of gas‐producing organisms, high glucose concentration in tissues and impaired tissue perfusion all favor the development of emphysematous infections of the urinary tract (1). Clinical presentation varies with abdominal pain, outlet irritative symptoms, pneumaturia and acute abdomen are are the most frequent symptoms (3). This is not a typical emphysematous cystitis case. Bladder ischemia could allow bacterial to enter in the bladder wall as happens in intestinal ischemia (5). The most common bacterial etiology are Escherichia coli and Klebsiella pneumoniae (80%) (6). None of the theories proposed to explain EC can fully account for the characteristic features of this case.

Conclusion

Bladder penumatosis is a rare condition not fully understood not always associated to UTI. Il Conservative treatment, urinary tract decompression with indwelling catheter and antibiotic treatment are preferred.

Reference

1. M. Amano, T. Shimizu Emphysematous cystitis: a review of the literature. Intern Med, 53 (2014), pp. 79-82.
2. J. Medina-Polo, J.A. Nunez-Sobrino, R. Diaz-Gonzalez An unusual case of air within the bladder wall: bladder pneumatosis? Int J Urol, 18 (2011), pp. 375-377.
3. A.A. Thomas, B.R. Lane, A.Z. Thomas, et al. Emphysematous cystitis: a review of 135 cases. BJU Int, 100 (2007), pp. 17-20.
4. A.J. Aschoff, G. Stuber, B.W. Becker, et al. Evaluation of acute mesenteric ischemia: accuracy of biphasic mesenteric multi-detector CT angiography. Abdom Imaging, 34 (2009), pp. 345-357.
5. P. Renner, K. Kienle, M.H. Dahlke, et al. Intestinal ischemia: current treatment concepts. Langenbecks Arch Surg, 396 (2011), pp. 3-11.
6. E.P. Oñate, M.E. Sanhueza, R. Torres, E. Segovia. Emphysematous cystitis: report of one case. Rev Med Chil. 2014 Jan;142(1):114-7.
7. I.J. Cooke, L.M. Okorji, R.S. Matulewicz, D.T. Oberlin, B.T. Helfand. Bladder Pneumatosis From a Catastrophic Vascular Event. Urol Case Rep. 2016 Aug 4;8:58-60.

#307: 3D CLAMPLESS LAPAROSCOPIC PARTIAL NEPHRECTOMY

Inviato da: giorgio.napodano@gmail.com

Argomenti: 

G. Napodano1, T. Realfonso1, G. Molisso1, O. Intilla1, U. Di Mauro1, R. Baio1, M.. Addesso2, R. Sanseverino1
  • 1 Ospedale Umberto I - Asl Salerno, UOC Urologia (Nocera Inferiore)
  • 2 Ospedale Umberto I - Asl Salerno, UOC Patologia (Nocera Inferiore)

Objective

Nephron sparing surgery is now reference standard for many T1 renal tumors. Although hilar clamping creates bloodless operative field, it necessarily imposes kidney ischemic injury. ”Zero ischemia” partial nephrectomy allows to eliminate ischemia during nephron sparing surgery.We report our preliminary experience of “zero ischemia” laparoscopic partial nephrectomy realized by controlled hypotension.

Materials and Methods

Patients with a single, clinical T1 tumor were candidates for “zero ischemia” laparoscopic partial nephrectomy. High-risk patients with severe, preexisting, cardiopulmonary, cerebrovascular, or hepatorenal dysfunction were not eligible. The preoperative work-up comprised medical history, physical examination, routine laboratory tests and CT scan or MRI.A transperitoneal approach was performed in all patients; four or five laparoscopic ports are inserted. The hilar vessels are prepared in event that bulldog clamping may subsequently be needed.Intraoperative monitoring includes electrocardiogram, central venous pressure (CVP), electroencephalographic bispectral (BIS) index (BIS monitor™), NICOM (non invasive cardiac output monitoring), urinary Foley catheter. A controlled hypotension, to carefully lower the mean arterial pressure (MAP) while maintaining excellent systemic perfusion, is maintened at approximately 60 mmHg. To induce hypotension, the doses of inhalational isoflurane is increased. The renal lesion is excised using cold endoshears. Upon completion of tumor excision, blood pressure is restored to preoperative levels. Parenchyma is repaired withVicryl™ sutures arrested with absorbable clips and Hem-O-lok™. Biologic hemostatic agents and Surgicel™ are applied to the resection bed.

Results

101 patients affected by renal tumor underwent zero ischemia LPN. Mean age and mean BMI were 59.9 (±11.7) years and 28.0 (±4.9). ASA score was 1, 2 and 3 in 6.9%, 42.5%, 43.7% and 6.9%, respectively. Renal score was low (4-6) in 28.7%, moderate (7-9) in 61.4% and high (10-12) in 9.9% of the patients.
Mean tumor size was 43.7 mm (±15.8). Operative time, blood loss, ∆Hb were 149.6 min (±52.4), 371.2 ml (±328.8), 2.8 gr/dl (±1.5), respectively. In all cases the procedure was performed without clamping. Resection, first and second suture times were 8.3 (±5.7), 9.4 (±6.3) and 6.7 (±2.3) minutes, respectively. Hospital stay was 6.7 (±3.9) days. Postoperative complications were: 5 fever (Clavien I), 1 fever (Clavien II), 3 urine leakage managed conservatively (Clavien IIIa). Histological evaluation revealed benign lesion in 4 pts, Oncocytoma in 10 pts, AML in 4 pts, complex cyst in 1 pts, Papillary RCC in 14 pts, Cromophobe RCC in 5 pts, clear cell RCC in 47 pts [pT1a (31 pts), pT1b (25 pts), T2 (2 pts), T3a (7 pts)]. Preoperative and postoperative serum Creatinine was 0.8 ±0.24 and 0.9 ±0.22, respectively (Δ0.05±0.08; Δ% -6.2); Preoperative and postoperative GFR was 96.43 ±33.03 and 88.03 ±26.35, respectively (Δ-8.41 ±12.97 Δ% -8.7).

Discussions

Nephron sparing surgery is now reference standard for many T1 renal tumors. Although hilar clamping creates bloodless operative field, it necessarily imposes kidney ischemic injury. ”Zero ischemia” partial nephrectomy allows to eliminate ischemia during nephron sparing surgery.

Conclusion

Zero ischemia LPN represents a safe and reproducible technique that allow to sparing renal parenchyma and preserve renal function. However long-term results are needed.

#306: SURGICAL OUTCOMES AND PERIOPERATIVE MORBIDITY OF CLAMP vs OFF-CLAMP LAPAROSCOPIC PARTIAL NEPHRECTOMY

Inviato da: giorgio.napodano@gmail.com

Argomenti: 

G. Napodano1, T. Realfonso1, G. Molisso1, O. Intilla1, R. Baio1, U. Di Mauro1, M. Addesso2, R. Sanseverino1
  • 1 Ospedale Umberto I - Asl Salerno, UOC Urologia (Nocera Inferiore)
  • 2 Ospedale Umberto I - Asl Salerno, UOC Patologia (Nocera Inferiore)

Objective

Nephron sparing surgery (NSS) is now reference standard for many T1 renal tumors. To reduce renal damage several technique have been proposed; cold ischemia, artery clamping, selective artery clamping, zero ischemia. We retrospectively compared perioperative results of clamp vs no clamp procedure in patients affected by T1 renal cancer.

Materials and Methods

From database of our institution we reviewed patients affected by single, clinical T1 tumor who underwent a laparoscopic partial nephrectomy (LPN). A transperitoneal approach was performed in all patients. In Clamp LPN group renal artery was clamped using laparoscopic Bull dog. In off-clamp group, a controlled hypotension, to carefully lower the mean arterial pressure (MAP) while maintaining excellent systemic perfusion, was maintened at approximately 60 mmHg. To induce hypotension, the doses of inhalational isoflurane was increased. The renal lesion was excised using cold endoshears. Parenchyma was repaired with Vicryl™ sutures arrested with absorbable clips and Hem-O-lok™. In clamp group bulld dog was removed while in the off –clamp group blood pressure was restored to preoperative levels. Biologic hemostatic agents and Surgicel™ were applied to the resection bed when appropriated.

Results

We identified 65 patients in the clamp group and 101 in off-clamp group; baseline characteristic of the two groups are described in table 1. Patients of off clamp group presented significant less operative time, blood loss and transfusion rate than clamp group. Hospitalization and suture time were shorter for off-clamp group, also [table 2]. No significant differences were observed in terms of histological evaluation [table 3]. Postoperative complication were rare [table 4].

Discussions

Nephron sparing surgery (NSS) is now reference standard for many T1 renal tumors. To reduce renal damage several technique have been proposed; cold ischemia, artery clamping, selective artery clamping, zero ischemia.

Conclusion

Clamp and off-clamp laparoscopic partial nephrectomy are equally safe and reproducible technique in terms of perioperative outcomes and complications. However the appropriate procedure should be selected taking into account tumor complexity, patient comorbidity and surgeon experience

#316: Does laparoscopic surgery still play a role in urology?

Inviato da: willygiannubilo@virgilio.it

W. Giannubilo1, G. Sortino1, M. Diambrini1, M. Di Biase1, A. Marconi1, V. Ferrara1
  • 1 "Carlo Urbani" Hospital (Jesi)

Abstract

In this video we show some complex urological procedures treated with laparoscopic approach: radical prostatectomy in patients already undergoing major abdominal surgery, ureteral replantation, removal of large retroperitoneal masses, complex partial nephrectomies. Our goal is to demonstrate the effectiveness and safety of this method in the age of robotic surgery.

#303: DETRUSOR UNDERACTIVITY: ARE DIFFERENT DIAGNOSTIC CRITERIA OFTEN RELIABLE IN CLINICAL PRACTICE?

Inviato da: sebadoc22@gmail.com

S. Rapisarda1, A. Polara1, C. Scandura2, G. Grosso1
  • 1 Ospedale Pederzoli (Peschiera del Garda)
  • 2 Policlinico catania (Catania)

Objective

Detrusor underactivity (DU) is a common clinical problem in patient being referred with lower urinary tract symptoms (LUTS). DU is defined as a contraction of reduced strenght and/or duration, resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span (ICS in 2003). However, the majority of published criteria concentrate on detrusor strenght with the combinations of maximal flow rate (Qmax) and maximal detrusor pressure at Qmax (Pdet/Qmax) resulting incomplete consequence with regarde to definition perspective. Finally, many other tools have been proposed with the aim of chacterizing DU, but specific recommendations have been made on this regarding.
The aim of our study is to evaluate the diagnostic performance of different DU definitions in a large cohort of patients undergoing urodynamic study.

Materials and Methods

We prospectively collected data of patients receiving urodynamic examination from February 2010 to September 2018 according to EAU guidelines. Urodynamic exam has been performed on the basis of ICS recommendations. DU has been considered as the presence of a defined as detrusorial pressure (pDet)/Qmax &lt; 30 cmH20 and it has been considered as the reference variable. We also calculated different variables including: bladder contractility index (BCI), watt factor (WF) and bladder voiding efficiency (BVE). The following cut-offs have been considered as suggestive for DU according to previious literature data: BCI &lt; 100, BVE &lt; 100, WF80 &lt; 10

Results

In total, 792 patients have been included, 65.1% male and 34.9% female. The median age was 63.0 yrs (interquartile range: 47.0-71.0). 232 pts (29.29%) had a Pdet/Qmax &lt; 30 cmH20, 590 (74.49%) had a BVE &lt; 100, 370 (46.72%) had a BCI &lt; 100 while 540 (68.2%) had a WF80 &lt; 10. The agreements using the kappa Cohen’s coefficients between PdetQmax and the other parameters were as following: with BCI was 77.53% (p&lt;0.01), with BVE was 36.87% (p=0.98) and with WF80 was 48.66% (p&lt;0.01). At the univariate logistic regression analysis, BCI &lt; 100 (odds ratio [OR]: 26.96; p&lt;0.01), BVE &lt; 100 (OR: 1.44; p=0.03) and WF80 &lt; 10 (OR: 5.35; p&lt;0.01) were associated with PdetQmax &lt; 30 cmH20. We performed a bivariate logistic regression combining BCI &lt; 100 with the other parameters and we showed that BCI (OR 0.94; p&lt;0.01) and W80 (OR: 0.89; p=0.02) were both associated with DU. Finally, the decision curve analysis showed clinical benefit of BCI in predicting DU, with slightly increase in net benefit of BCI+WF80 over BCI.

Discussions

Finally, the decision curve analysis showed clinical benefit of BCI in predicting DU, with slightly increase in net benefit of BCI+WF80 over BCI. We found that BCI and WF80 exhibited agreement with PdetQmax for assessing DU and that combining both variables add clinical benefit in predicting DU.

Conclusion

We found that BCI and WF80 exhibited agreement with PdetQmax for assessing DU and that combining both variables add clinical benefit in predicting DU. We suggest in improving definition of DU by investigating the clinical benefits of other variables for assessing DU.

Reference

1: Zhang WY, Xia QX, Hu H, Chen JW, Sun YR, Xu KX, Zhang XP. [Analysis of
urodynamic study of female outpatients with lower urinary tract symptoms and
follow-up of the patients with detrusor underactive]. Beijing Da Xue Xue Bao Yi
Xue Ban. 2019 Oct 18;51(5):856-862

2: Matsukawa Y, Yoshida M, Yamaguchi O, Takai S, Majima T, Funahashi Y, Yono M,
Sekido N, Gotoh M. Clinical characteristics and useful signs to differentiate
detrusor underactivity from bladder outlet obstruction in men with non-neurogenic
lower urinary tract symptoms. Int J Urol. 2019 Sep 21

3:Hartigan SM, Reynolds WS, Dmochowski RR. Detrusor underactivity in women: A
current understanding. Neurourol Urodyn. 2019 Nov;38(8):2070-2076

#279: Treatment of large volume prostates with bipolar plasma TURP: preliminary results

Inviato da: maranoale@tiscali.it

A. Marano1, F. Palumbo1, M. Bottalico1, S.V. Impedovo1, M. Erinnio1, G.A. Saracino1, V.D. Ricapito1
  • 1 Ospedale San Giacomo, Unità Operativa di Urologia (Monopoli)

Objective

Trans Urethral Resection of Prostate (TURP) remains still the gold standard and it is strongly recommended for the treatment of patient with moderate to severe LUTS (Lower Urinary Tract Symptoms) with prostate size of 30-80 mL.(1) Patients with oversized prostates &gt; 80-100 mL undergo to traditional open prostatectomy or to a laser enucleation. Aim of our study is to analyze the surgical outcomes and the safety of bipolar plasma TURP extended to oversized prostate.

Materials and Methods

Since November 2018 we treated with bipolar plasma TURP seven patients with a prostate volume larger than 100 ml and up to 180 ml. The average age was 69 years (range 51-80); the average prostate size, measured before the procedure by ultrasound, was 137 mL (range 100-180); at the moment of the procedure 4 patients had a bladder catheter (1 suprapubic and 3 transurethral), 2 had history of acute urinary retention, and 1 had severe LUTS and Qmax of 8 ml/s at the uroflowmetry; all of them previously received pharmacological treatment for LUTS (1 only dutasteride, 1 only alpha blocker, and 5 combined therapy with alpha blocker and dutasteride).
The TURP was performed using the bipolar plasma edge technology by Lamidey Noury Medical, saline solution as medium, instrument for resection with continuous irrigation system, and high definition video camera and 16:9 high definition monitor. The approach for those oversized prostate was modified, mainly it was a posterior approach to remove first the large medium lobe and then the lateral lobes. The medium lobe was first isolated between 2 tunnels at 5 and 7 o’clock deep to the capsule and extended to apex preserving the veru montanum; the resection was than performed between the 2 tunnels going parallel to the posterior wall, from one side to the other, and upward to downward. For both the large lateral lobes a deep tunnel between the lobe and the prostate capsule (starting at 1 o’clock for the left lobe down to almost 4 o’clock; and at 11 o’clock for the right lobe down to almost 8 o’clock) was first made in order to allow the resection of each lobe from the lateral side to the median part.

Results

Average operative time was 71 minutes (range 55-90); mean hospitalization time was 3.3 days (range 2-4); no patient had TUR syndrome neither serum sodium level drop, neither serum sodium level drop; no one required blood transfusion or iron intravenous implementation; no other adverse events were registered. Catheter was removed after 9.6 days (range 3-18) and all of them could void again. After 2 months, one patient, who suffered also Parkinson’s disease preferred to have the catheter indwelled again to better manage, according to his opinion, the relapse of severe LUTS.

Discussions

The bipolar plasma TURP was performed using normal saline solution (NaCl 0.9%) as fluid for continuous irrigation, instead of a nonconductive solution, offering the advantage of minimal absorption by the open vessels and eliminating the risk of electrolytic disorders, both TUR syndrome and the serum sodium level drop.(2)
The resection with the bipolar plasma edge technology is faster with less bleeding because of the attitude of the instrument to cut, vaporize and coagulate smaller vessels at the same time. After the cutting the prostate tissue looks white, not carbonized and it is still soft for further cuttings.
We believe that the modified approach for the large lateral lobes gives 2 other important advantages. One is to set immediately the capsular limit of the resection. The second is to create a flap from the lateral lobe which is already ischemized and ready to be fast removed by lateral to median resection going from upward to downward.
We believe that both the ultimate plasma technology and the modified approach contributed to a faster and less bleeding resection, allowing a safe operative time for those oversized prostate with volume up to 180 mL.

Conclusion

According to other authors (3) the treatment of oversized prostate with bipolar plasma TURP is an effective endoscopic technique and seems to offer surgical results equivalent to those encountered for smaller prostate volumes.
The use of saline solution and short operative time confirm the safety of the procedure also for large size prostate. In our single center study bipolar plasma TURP represents a valid alternative to open prostatectomy in large benign prostatic hyperplasia &lt; 180 mL, up today. Because of the low cost comparable to standard TURP, it may be used in centers that do not have yet laser equipment. Larger studies and longer follow up are mandatory to confirm our results.

Reference

1) https://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts
2) Systematic review and meta-analysis of the clinical effectiveness of bipolar compared with monopolar transurethral resection of the prostate (TURP). Omar MI, Lam TB, Alexander CE, Graham J, Mamoulakis C, Imamura M, Maclennan S, Stewart F, N&#039;dow J. BJU Int. 2014 Jan;113(1):24-35. doi: 10.1111/bju.12281. Epub 2013 Oct 24. Review.
3) A Prospective Study of Bipolar Transurethral Resection of Prostate Comparing the Efficiency and Safety of the Method in Large and Small Adenomas.Mertziotis N, Kozyrakis D, Kyratsas C, Konandreas A. Adv Urol. 2015;2015:251879. doi: 10.1155/2015/251879. Epub 2015 Dec 7.

#293: A strange case of transverse testicular ectopia and testicular fusion due to iatrogenic cause

Inviato da: mogorovich@hotmail.it

Argomenti: 

A. Mogorovich1, M. Cecchi1, C.A. Sepich1, D. Summonti1, A. Di Benedetto1, L. Lunardini1, M. Catastini1, S. Pampaloni1, I. Bardelli1
  • 1 USL Toscana Nord-Ovest Ospedale Versilia (Lido di Camaiore)

Objective

Transverse testicular ectopia (TTE) is a rare anomaly in which both the testes descend through a single inguinal canal and lie in the same hemiscrotum or inguinal region. It is usually found incidentally in patients operated for inguinal hernia or undescended testicles. In the literature, less than 100 cases of TTE have been reported (1). Standard treatment of TTE is mainly surgery, including inguinal hernia repair, transseptal orchiopexy, and the repair of congenital anomalies (2). In this case study, we report the case of a iatrogenic transverse testicular ectopia in a 16 years-old r man who had previously undergone left orchiopexy for testicular torsion. After the procedure the patient complained the absence of the left testis and abnormal enlargement in the right hemiscrotum.

Materials and Methods

A 16 years-old male patient was admitted to our hospital complaining a left empty hemiscrotum and an enlarged right testis. On the physical examination it was noted the absence of the left testis whereas the right testis was enlarged, with normal texture and without sign of inflammation.
The urethral meatus was in normal localization, and there were no findings related to the hernia in both inguinal canals. Ultrasound scan revealed the presence of both testicles, apparently fused together, located in the right hemiscrotum; left hemiscrotum was empty. Surgical exploration was planned. Through a transverse scrotal incision right hemiscrotum was entered; both testes were located in the right side and partially fused together. The right vas and vascular elements had the conventional course from the right inguinal ring through the right hemiscrotum to the testis; the left cord originated from the ipsilateral inguinal ring going through the scrotal septum to reach the left testis.
The testicles were easily separated each other avoiding any lesion to the tunica albuginea; hence the scrotal septum was partially opened in order to move the left testicle to the proper side.
Bilateral orchiopexy was then performed by using an absorbable suture joining the caudal pole of the testis to the ipsilateral pouch of the scrotum and the septum rebuilt.

Results

Post-operative course was uneventful and the patient was discharged the day after the procedure. Follow-up with ultrasound at 6 months after surgery showed both testes properly placed in the scrotum with normal homogeneous granular echotexture and vascularity.

Discussions

TTE was first reported by von Lenhossek in 1886 (3). The various theories to suggest the etiopathogenesis are: dysfunction of the genitofemoral nerve, true crossover of the testis, both the testis arising from the same genital ridge or both lying in the same processus vaginalis before descent. Management is orchidopexy, either trans-septal or extraperitoneal transposition orchidopexy (4). Laparoscopy better delineates the anatomy and enables us to see the crossing over of the spermatic cord towards the opposite side. It helps assess the testis and its side, vas, and vessels for length. The management depends upon the length of the vas and vessels. If length is severely inadequate, both the testes are fixed in the same hemiscrotum and if the length is adequate, then transseptal orchidopexy is recommended. In cases, where there is inadequate or just adequate length, transseptal contralateral orchidopexy can be done (5).
In the case reported, the transverse testicular ectopia was not due to a congenital abnormal migration of the left testis through the contralateral inguinal canal, but it resulted from the unfortunate consequences of the surgical procedure the patient had been submitted some months earlier.
Scrotal orchiopexy had been performed for left testicular torsion; it is usually a simple procedure with few surgical steps. In this case, the surgeon probably accidentally damaged the scrotal septum so that the left testis could migrate contralaterally then adhering to the right testis in a diminished space available.
Our surgical procedure was simple and effective especially if you consider that the spermatic cords in this case originated from the ipsilateral inguinal ring as usual and did not have a common origin from one side only.

Conclusion

The transverse testicular ectopia should be considered as an extremely rare complication of scrotal surgery; the integrity of the scrotal septum should be respected in order to avoid this occurrence.

Reference

1. Fourcroy JL, Belman AB. Transverse testicular ectopia with persistent müllerian duct. Urology. 1982;19:536–8
2. M.W. Gauderer, E.R. Grisoni, T.A. Stellato, J.L. Ponsky, R.J. Izant Jr. Transverse testicular ectopia J. Pediatr. Surg., 17 (1982), pp. 43-47
3. Von Lenhossek MN. Ectopia testis transversa. Anat Anz. 1886;1:376–81.
4. Pandey A, Gupta DK, Gangopadhyay AN, Sharma SP. Misdiagnosed transverse testicular ectopia: A rare entity. Hernia. 2009;13:305–7.
5. Raj V, Redkar R, Krishna S, Tewari S. Rare case of transverse testicular ectopia – Case report and review of literature. Int J Surg Case Rep. 2017;41:407–10

#292: MEGAPENE ACQUISITO: corporoplastica riduttiva con rinforzo in pericardio bovino

Inviato da: info@andrologiapescatori.it

E.. Pescatori1, B. Drei1, S. Rabito2
  • 1 Hesperia Hospital, Servizio di Andrologia (Modena)
  • 2 Hesperia Hospital, U.O. Urologia (Modena)

Abstract

Si descrive correzione chirurgica di raro caso di cedimento strutturale dell’albuginea di entrambi i corpi cavernosi, esteso per pressochè tutta l’asta con risparmio di pochi centimetri alla base, con risultante incremento circumfereziale del pene tale da rendere fortemente disagevole l’ attività sessuale penetrativa.
Caso clinico: paziente di 55 anni con sviluppo senza causa apparente di deformazione simil-aneurismatica del pene con circonferenza massima di 21 cm. Rigidità conservata. Iter diagnostico: cavernosometria/-grafia dinamica e RNM basale e dinamica, con conferma di dilatazione aneurismatica di entrambi i corpi cavernosi.
Tecnica chirurgica: incisione circumferenziale e degloving dell’asta, estrusione dell’asta tramite incisione scrotale. Bilateralmente incisioni parauretrali a tutta lunghezza della fascia di Buck e completo scollamento della stessa – con nel suo contesto il fascio neurovascolare dorsale – dai corpi cavernosi. Erezione indotta: albuginea assottigliata nell’area di cedimento strutturale. Misurazioni circumferenziali seriate e calcolo della riduzione circumferenziale da ottenere. Conseguente asportazione bilaterale di losanghe di albuginea. Punti di ancoraggio introflettenti in Biosyn rinforzati da continua incavigliata in PDS. Confezionamento di patch in pericardio bovino (Supple Peri-Guard, Synovis) a coprire l’intera circonferenza dell’albuginea denudata, ad eccezione del corpo spongioso uretrale, fissata con punti di ancoraggio all’albuginea.
Ricostruzione di fascia di Buck. Reinserimento dell’asta nel proprio involucro cutaneo.
Circoncisione formale.

#291: MINI-JUPETTE nella climacturia dopo prostatectomia radicale: caveat dopo prima esperienza

Inviato da: info@andrologiapescatori.it

Argomenti: 

E. Pescatori1, B. Drei1, D.. Dell'Orco2
  • 1 Hesperia Hospital, Servizio di Andrologia (Modena)
  • 2 Tegea - Boston Scientific (Modena)

Abstract

Descrizione di sling uretrale “Mini-Jupette” eseguito in corso di impianto protesico penieno idraulico tricomponente per trattare incontinenza ad orgasmo (“climacturia”) e deficit erettile severo dopo prostatectomia radicale.
Caso clinico: paziente di 71 aa status/post prostatectomia radicale robotica e successiva radioterapia di salvataggio, fortemente motivato a ripresa attività coitale penetrativa, nonostante modica incontinenza e climacturia.
Si esegue intervento di Mini-Jupette sec. Andrianne. Incisione scrotale trasversa come da impianto protesico con accesso penoscrotale; esecuzione di corporotomie latero-caudalmente rispetto a impianto standard. Misurazione di distanza tra i margini mediali delle corporotomie e confezionamento di mesh in polipropilene (Pro-Lite, ATRIUM) di misure corrispondenti. Sutura dello stesso in continua alle due corporotomie (margini mediani) e verifica di appropriata tensione. Inserimento standard di protesi idraulica tricomponente. Chiusura corporotomie in continue. Protesi lasciata disattivata.
In prima giornata: rimozione catetere e drenaggio, e dimissione.
Follow-up precoce: completa risoluzione di incontinenza, e ripresa di attività coitale senza climacturia.
A termine video vengono illustrati i principali caveat di questa procedura, alla luce della limitata letteratura disponibile e della prima esperienza personale.

#285: Squamous variant of bladder cancer and colon adenocarcinoma with unusual presentation of hepatic metastases: a case report

Inviato da: dantedid@gmail.com

D. Di Domenico1, A.. Luongo2, B. Barone1, N. Gennarelli2, D. Prezioso1, I. Stanislao3
  • 1 Scuola di Medicina e Chirurgia - Università di Napoli Federico II, Scuola di Specializzazione in Urologia (Napoli)
  • 2 Scuola di Medicina e Chirurgia - Università di Napoli Federico II, Chirurgia Endoscopica (Napoli)
  • 3 Odontoiatria e Protesi Dentaria - Università di Napoli Federico II (Napoli)

Objective

Primary squamous cell carcinoma of urinary bladder is a rare disease variant, accounting for less than 5% of all primary bladder cancers [1]. The diagnosis of bscc is based on criteria established by the World Health Organization classification system [2] and it is a poorly differentiated tumor, it usually progresses rapidly and it characterizes by a worse prognosis than the most frequently represented bladder carcinoma, the urothelial carcinoma (UC) [3]. We report an unusual episode of a patient with squamous cell carcinoma of urinary bladder and contemporary adenocarcinoma of the descending colon asymptomatic, discovered in stages of staging and subsequently of hepatic metastases from colon adenocarcinoma. the patient underwent radical surgical therapy, ureterocutaneostomy and later chemiotherapy for metastases

Materials and Methods

The case report we are talking about concerns a 74-year-old patient, woman, who came to our attention for recurrent hematuria episodes, for several months (maybe eighteen), which have been treated with empirical antibiotic therapy (by general practitioner) without, however, investigate further with at least a radiological examination. After first stadiative investigations, the patient was diagnosed with a primary squamous bladder and a metacronous colon adenocarcinoma too, completely asymptomatic, so considered as an incidentaloma in the radiological diagnosis of staging.
The complete diagnosis was obtained by ultrasound, cystoscopy, trans urethral bladder resection, colonoscopy with biopsy and PET / CT (by usingfluoro-deoxyglucoseas radiopharmaceutical).
In 2017 the patient underwent transurethral resection of bladder cancer (TURBT) at our institution; the histological diagnosis elaborated was "Solid urothelial carcinoma (G3), with marked squamous differentiation infiltrating also the muscular tunic present".
Subsequently the patient was subjected to a stadiative PET/CT, which showed presence of a descending colon circular neoformation. The patient was then subjected to a colonoscopy [Image 1], which confirmed the PET/CT (F-18 + FDG) suspected diagnosis, finding a circular lumen stenosing and ulcerated lesion, 40 cm away from the anal margin, and the lesion did not allow flexible endoscope further transit. Moreover, thanks to sub optimal intestinal cleansing (Boston Score = 3, as the other two traits score were not assigned), it was possible to appreciate the presence of a pedunculated polyp (size 8mm), 10 cm away from the anal margin, despite the numerous and persistent diffuse intestinal musculature’s spasms. During endoscopy, several biopsy samples were taken by the descending colon stenosing lesion, and the histological examination (in GB staining) revealed as outcome adenocarcinoma tissue.
In January 2018 the patient underwent radical cystectomy with ureterocutaneostomy, partial colon resection with termino-terminal anastomosis, left lymphandenectomy and enlarged hysterectomy with partial vaginectomy.
The histological report of the surgical specimen confirmed transurethral resection (TURBT) previous report: "solid urothelial carcinoma (G3) with marked squamous differentiation with muscular tunic infiltration".
Colon resection showed the presence of adenocarcinoma, the surgical resection margin was negative.
No infiltration of tumor cells was found in the uterus, in the excised appendages, in the anterior wall of the vagina and no involvement of the nearby nodes was detected.
The patient performed both PET / CT (F-18 + FDG) and abdomen ultrasound six-month follow-ups.
In February 2019, PET / CT (F-18 + FDG) detected, in the liver, altered glucose metabolism in some areas as VII (SUV max 5.31), VIII (SUV max 11.5 vs 3.91 previous PET control on 07/05/2018), III segment (SUV max 11.6) and in VI segment (SUV max 6.92) [Image 2 – 3].
The remaining examined body areas were negative, within the methodic’s limits.
In March 2019, the patient underwent liver lesions’ biopsy, shown by the PET/CT (F-18 FDG) last February, which confirmed the presence of liver metastases, of intestinal origin, with adenocarcinoma metastasis’ characters.
Since May 2019 She has undergone chemotherapy cycles, with Folfox protocol (5-fluoro-uracil, folinic acid, oxaliplatin), currently the patient is still receiving therapy (with poor performance status and poor compliance) and she is monitored with general follow-ups.

Results

The patient after the surgical phase had a recovery without complications. The management of ureterocutaneostomy was home-based and all tests were negative until the appearance of asymptomatic liver metastases.

Conclusion

The patient had a long disease-free duration after radical surgery. The presentation of hepatic metastases observed in our case was an event that emerged in the less-awaited follow-up compared to the possibility of local secondary or recurrence that we would have expected from the squamous cell carcinoma of urinary bladder.

Reference

1. Sunil V.J., J Clin Diagn Res. Primary Squamous Cell Carcinoma of Urinary Bladder – A Rare Histological Variant. Epub, 2015.

2. J. N. Eble, WHO Classification of the Tumours. Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs, IARC Press lon, France, 2004.

3. Tavora F, Epstein JI. Bladder cancer, pathological classification and staging. BJU International.2008.

#282: Single-institution experience with “penile patches” in patients with Peyronie’s disease and Erectile Dysfunction

Inviato da: francescok86@gmail.com

Argomenti: 

M. Carrino1, F. Chiancone2, N.A. Langella2, P. Cardone2, M. Fasbender Jacobitti1, P. Fedelini2, L. Pucci2
  • 1 Andrology Department, A.O.R.N. “A. Cardarelli” (Naples)
  • 2 Urology Department, A.O.R.N. “A. Cardarelli” (Naples)

Objective

Multiple guidelines endorse the use of surgery in the treatment of penile deformity as a result of Peyronie's disease. Penile prosthesis implantation is a treatment choice in patients with erectile dysfunction (ED) and concomitant penile curvature due to Peyronie’s disease1. Residual curvature correction during inflatable penile prosthesis (IPP) implantation in patients with Peyronie’s disease (PD) is common. The aim of this single-institute analysis was to compare surgical outcomes between hemostatic patches and pericardium patches in patients with Peyronie’s diseas and ED managed with inflantable penile prosthesis (IPP) and plaque incision with grafting in case of persistent curve more than 30° after manual modelling.

Materials and Methods

From January 2015 to December 2018, 62 patients with Peyronie’s diseas and ED received inflantable penile prosthesis implantation and tunical incision and patch graft for persistent curve more than 30° after manual modelling. Tunical defects were more than 2 cm and graft used were Permacol™ (Covidien) or hemopatches [TachoSil® (Takeda) or more recently Hemopatch (Baxter AG)]. All data were collected in a prospectively maintained database and retrospectively analysed.

Results

Hemopatches were used in 38 patients (Group A) while Permacol™ was used in 24 patients (Group B). Mean operative time was significantly shorter in the group A (94.16±18.07) than the group B (122.14±28.8) [p10° was present in 3 out of 38 patients of Group A and in 4 out of 24 patients of Group B (p=0.2878). There were no complications due to material used or herniation of IPP trough the tunical defect.

Discussions

A lot of patches are commonly used for surgical correction of Peyronie’s disease (autologous dermis, tunica vaginalis, dura mater, fascia, saphenous vein, tunica albuginea, buccal mucosa, porcine intestinal submucosa, pericardium, TachoSil®, Hemopatch and synthetic material). The ideal patch should be traction‐resistant, easy to suture and manipulate and flexible, although not to the extent that it allows aneurysmatic dilatation or interferes with the veno‐occlusive function of the albuginea. The cost should also be reasonable2. Nowadays the ideal patch has yet to be determined. Permacol™ (Covidien) was commonly used for ventral hernia repair and abdominal wall reconstruction while TachoSil® and Hemopatch are commonly used for surgical haemostasis.
In our experience the time of procedures with the use of hemopatches was significantly lower probably because it does not require to be suturing to the albuginea. With the use of Permacol we assisted to a more proportion of residual curvature even if it does not reach the statistical significance. Moreover in our experience hemopatch is better than tachosil in adherence to tunica albuginea and appear more stable than Tachosil that is easily fragmentable e it is not stable during the suturing of superficial penile layers. A limitation of this study was the low number of patients and the monocentric nature of the analysis.

Conclusion

In our experience hemopatches [in particular the Hemopatch (Baxter AG)] are better than the Permacol™ in management of patients with ED and Peyronies’ disease. Despite this, nowadays , the final decision will depend on the surgeon's experience, the patient's preferences, economic considerations and the characteristics of the plaque.

Reference

1-Carson CC. Penile prosthesis implantation in the treatment of Peyronie's disease and erectile dysfunction. Int J Impot Res. 2000 Oct;12 Suppl 4:S122-6.

2- Garcia-Gomez B, Ralph D, Levine L, et al. Grafts for Peyronie's disease: a comprehensive review. Andrology. 2018 Jan;6(1):117-126.

#281: VAC-THERAPY IN UROLOGICAL SURGERY: PRELIMINARY EXPERIENCE

Inviato da: danydoc@libero.it

Argomenti: 

D. Masala1, M.G. Tronino1, L. Romis1, M. Punziano1, M.R. Nugnes1, G.. Di Lauro1
  • 1 Ospedale Santa Maria delle Grazie (Pozzuoli)

Objective

A review of the literature does not currently have reports on the use of Vac-Therapy in Urology. This therapy has instead been used successfully for years in general surgery, orthopedics, dermatology and burn centers. The aim of this work is to present our experience with Vac Therapy, unique in its kind in the post-surgical management of a complex case of massive abscess of scrotal integuments and cavernous bodies. The Vac-Therapy was born on the basis of the concept borrowed from the doctor Louis Argenta, a scholar of diabetic pathology and diabetic sores and from the bioengineer Michael Morykwas of negative pressure exercisable by an aspiration device. The negative pressure is a pressure lower than the normal atmospheric one, that is 760 mmHg. To obtain the negative pressure it is necessary to remove the gaseous molecules from the affected area (for example a wound) using a suction system. This technique, which involved the use of polyurethane foam and a mechanical vacuum, was called "vacuum-assisted closure (VAC) therapy system" and developed in 1995 with the first marketing after FAD approval. Until 2005, VAC therapy was the only one available on the market to provide suitable negative pressure therapy in the world. The fundamental substrate of Vac Therapy is polyurethane foam, a polymer with large holes (400-600 micrometers) as it ensures, while maintaining porosity, a uniform pressure distribution over the entire site of action. In addition, the volume of the foam undergoing a depressurized reduction determines 3 substantial phenomena: a) stretching of the cells, b) contraction of the wound from the margins to the center with facilitation of the closure of itself, c) total elimination of the fluids present on the site that may favor infections and healing delay. The inert dressing, positioned on the wound and connected to the aspiration source, exerts on it a localized and controlled negative pressure, such as to induce cellular proliferation. Dressings generally need to be replaced every 48 to 56 hours. In the presence of site infection the most frequent medication is recommended. Too long dressing time causes discomfort to the patient by incorporating the granulation tissue into the polyurethane foam.

Materials and Methods

On 2 July 2019 a 72-year-old diabetic and cardiopathic patient in poor general conditions came to our observation in emergency, for severe post-circumcision complications, in a feverish state, with severe tenderness of the entire genital region, bladder anuria from about 12 hours, with complete swelling of scrotal integuments and supra-pubic region, without signs of cutaneous fistulization, incarceration of the penis of which only the extremity of the glans was recognized. The laboratory framework laid down for mild neutrophilic leukocytosis, with no evidence of PCR and PCT modifications. He was immediately catheterized with RUA resolution and subjected to echocolordoppler examination followed by extemporaneous integration with echocontrastographic survey after bolus administration of 2.4 ml of ecodedicated contrast that confirmed the diagnostic suspicion of a large abscess localized to the scrotal sac and the corpus cavernosum to peno-scrotal angle, where caverno-scrotal fistula was located with saving didymas. On admission the patient was subjected to combination antibiotic therapy with Cefazolin and Metronidazole. A few hours after the observation, the patient underwent an urgent scrototomy surgery with a complete toilet on the intrascrotal and suprapubic abscess caves, identification of incarcerated cavernous bodies and bilateral corporotomy, fistulectomy with subsequent toilet and a wide excision of cutaneous margins; finally two suprapubic and scrotal aspiration drains were positioned. In the postoperative period there was a stabilization of the symptoms but a progressive loss of substance from the surgical site and progressive necrosis of the scrotal suture margins, despite the meticulous dressings with hydrogen peroxide and chlorhexidine. After 5 days it was decided to subject the patient to a new operation this time to remove the necrotic tissue, scarify the scrotal surgical bed and place the Vac-Therapy.

Results

The wound was healed using "Vac white foam Small" as a polyurethane foam-based dressing for the treatment of exposed noble structures and with the installation of "Vac Veraflo Medium" instrumentation to obtain negative pressure. Medications were followed twice weekly for 10 days, during which the pressurization device was temporarily deactivated, using only physiological saline and sterile gauze. On 19 July the patient presented a wound with a vital bed, absolutely free of signs of infection and / or contamination with correct granulation. Therefore the Vac Therapy was interrupted and it was decided to proceed with a third surgical intervention aimed at grafting the INTEGRA dermal matrix substitute and at discharge the following day. The patient checked at 90 days was in perfect clinical condition, with complete regeneration of the neoderm and realignment of the scrotal margins on the prosthetic graft which is no longer visible.

Conclusion

VAC is a non-invasive integrated therapeutic system that uses negative pressure, localized and controlled, continuous or intermittent to promote the wound healing process and is particularly effective in the treatment of complex wounds such as: burns, ulcers, diabetic lesions and abscess caves, guaranteeing them a correct asepsis, favoring an early juxtaposition of the margins and an early formation of the granulation tissue. Vac Therapy is contraindicated in the suspicion of cancer cells in the lesion and in the following cases: untreated osteomyelitis, non-enteric and unexplored fistulas, necrotic tissue with eschar. If until now the use of Vac Therapy was almost exclusive at orthopedic, abdominal surgical and dermatological level, our favorable experience on a complex case of scrotum-cavernous abscess allows us to propose the use of Vac Therapy also in urological and andrological surgery.

Reference

1) Negative pressure wound therapy with saline instillation: 131 patients case series. D. Brinkert, M.Ali, M. Naud, N. Maire, C. Trial, L. Teot. International wound journal ISSN 1742-4801 (2012)
2) Negative pressure wound therapy with instillation, a cost-effective traetment for abdominal mesh exposure. E. Deleyto, A. Garcia-Ruano, J.R. Gonzalez-Lopez. Aest Plast Surg (2017) Hernia DOI 10.1007/s10029-017-1691-y.
3) Platelet-rich plasma, bilareyed acellular matrix grafting and negative pressure wound therapy in diabetic foot infection. W. Deng, J. Boey, B. Chen, S. Byun, E. Lew, Z. Liang, D.G. Armstrong. Jpurnal of Wound Care vol. 25 no 7 July 2016.
4) A new method of salvaging breast reconstruction after breast implant using negative pressurewound therapy and instillation. Ju Yong Cheong, David Goltsman, Sanjay Warrier. Aest Plast Surg (2016) 40:745-748.
5) Negative Pressure Wound Therapy with Instillation and dwell time used to treat infected orthopedic implants: a 4 patients case series. R. Dettmers, W. Brekelmans, M. Leijnen, B. Borger van der Burg, E. Ritchie. US Tomy Wound Management september 2016
6) Sterile-Water negative pressure instillation therapy for complex wounds and NPWT failures. S. Fluieraru, F. Bekara, M. Naud, C. Herlin, C. Faure, C. Trial, L. Teot. 2013 MA Healthcare.
7) L’apport d’une nouvelle mousse dans la therapie par pression negative avec instillation dans la detersiondes plaies. S. Fluieraru, F. Boissiere, C. Faure, L. Teot. Revue francophone de cicatrisation n.2 avril-juin 2017.
8) The impact of negative pressure wound therapy with instillation compared with standard negative-pressure wound therapy: a retrospective, historical, cohort, controlled study. Paul J. Kim, Christopher E. Attinger, John S. Steinberg, Karen K. Evans, Kelly A. Powers, Rex W. Hung, Jesse R. Smith, Zinnia M. Rocha, Larry Lavery. Plastic and reconstructive surgery. March 2014.
9) Vacuum -assisted closure ulta with Veraflo Instillation for the healing of diabetic foot wounds. A. Nather, Wong Le Yi Joy, Chua Chui Wei Mae, Claire Chan Shu-Yi. Scientia Ricerca Vol 1 Issue 1 2016.
10) Novel Foam dressing using negative pressure wound therapy with instillation to remove thick exudate. L. Teot, F. Boissiere, S. Fluieraru. International Wound Journal ISSN 1742-4801 march 2017.
11) The Use of Negative pressure wound therapy with an automated , volumetric fluid administration: an advancement in wound care. Tom Wolvos. Wounds 2013;25(3):75-83.

#280: ABSCESS OF PENILE’S CAVERNOSIS BODIES: ROLE OF THE "CEUS" IN DIAGNOSIS AND IN POST-OPERATIVE CONTROL OUR EXPERIENCE IN TWO CASES

Inviato da: danydoc@libero.it

Argomenti: 

D. Masala1, R. Lobianco2, S. Mordente1, M.R. Nugnes1, S. Capuano2, A.. Coletta2, G.. Di Lauro1
  • 1 Ospedale Santa Maria delle Grazie (Pozzuoli)
  • 2 Ospedale Anna Rizzoli (Ischia)

Objective

The abscess of cavernous bodies is a rare urological problem. The literature review highlights only a few sporadic reports. The primary symptomatology is swelling, pain and fever. Most penile abscesses are anatomically localized in the cavernous body and are often secondary to intracavernous injections of drugs for erection, perineal and / or perianal abscesses, and trauma to the penis. Immunodeficiency and immunosuppression constitute predisposing factors. The gold standard treatment is early surgery and followed by medical therapy. Often, however, severe postoperative complications occur, such as: penile curvature and erectile deficit. The ecocolordoppler is today the first-level investigation in the study of penile pathology. The ultrasound study of the penis is performed using high frequency linear transducers with longitudinal and transverse scans on the ventral aspect of the shaft. Cavernous bodies in transverse scans appear as two relatively hypoechoic symmetrical structures with fine homogeneously distributed echoes; inside the corpora cavernosa it is possible to identify the cavernous arteries in the form of small roundish images with hyperechoic walls. The albuginea is recognizable as a hyperechogenic interface that envelops the corpora cavernosa and continues in the central part with the intercavernous septum, which presents itself with a hypo-anechoic band with posterior attenuation of the beam. The spongy body appears as a median and ventral oval structure with echogenicity similar to that of the cavernous body. In longitudinal scans the vessels appear as tubular structures running parallel to the probe. Basal ultrasound does not always allow a precise identification of a possible abscess collection. In more advanced cases the abscesses can appear as hypoechoic collections, with irregular profiles with mobile echoes, located in the internal erectile bodies or between the connective sheaths. Such situations are often associated with swelling of the mucosa and subcutaneous tissue and with a marked hyperemia of the corpora cavernosa. The ecocontrastographic study underlines in physiological conditions a mild homogeneous and progressive impregnation of the cavernosal arteries, of the hilarine arteries and of the sinusoids of the cavernous tissue. The objective of this work of ours is to show the semiology and to propose the role of CEUS in the diagnosis and post-therapeutic follow-up in cases of abscesses of cavernous bodies.

Materials and Methods

Between June and August 2019 two cases of cavernous corpse abscess reached our observation of the PS. The first appeared as a very rare case of spontaneous abscess of the left cavernous body in a 49-year-old patient, in apparent good general condition, arrived in PS in a febrile state and with severe pain, due to marked swelling and pain in the penis and scrotum associated with the appearance of alkaline pyuria and gland-preputial and caverno-preputial multiple fistulas in the previous 24 h from clinical observation. The laboratory framework was positive for massive neutrophil leukocytosis and increase in PCR. The second case, a 72-year-old patient, diabetic and cardiopathic in poor general conditions, arrived in PS following severe post-circumcision complications, in a feverish state, bladder-like anuria for about 12 hours, with complete swelling of scrotal integuments and suprapubic region, without signs of cutaneous fistulization, incarceration of the penis of which only the extremity of the glans was recognized. The laboratory framework laid down for mild neutrophilic leukocytosis, with no evidence of PCR and PCT modifications. In both cases, ECD examinations were performed using a LA533 multi-frequency linear probe on Esaote My Lab Classic C device followed by extemporaneous integration with ecocontrastographic investigations following bolus administration of 2.4 ml of ecodedicated contrast medium (Sonovue-Bracco-Switzerland) followed by flush of SF 10 ml with real time acquisitions up to 6 minutes.

Results

In accordance with the data present in the literature, in the two cases we observed the basal ultrasound examination did not allow a precise identification of the abscess collection that appeared only in a slightly hypoechoic manner, therefore suspected but hardly stadibile for entity and characterization; however, it showed the fistulous hypoechoic directed to the glans towards the balano-prepuzial sulcus in the first case and the fistulously highly hypoechoic cavernous scrotal via contained in the dartos in the second case. At the evaluation after contrast injection CEUS in correspondence with the basal hypoechogenicity, in the two cases the suspected abscesses collections were on one hand characterized with certainty presenting themselves as areas of absent central perfusion delimited by irregular rims with discrete, early and non-fleeting peripheral enhancement, from another has allowed us to document the wider distribution and extent of the abscess compared to the baseline suspicion. The fistulous tract has been well documented in both cases after CEUS as a perfusion free tubuliform area. Patients were initially treated with combination antibiotics Cefazolin 2 g every 12 hours and Metronidazole 500 mg every 8 hours and subsequently after 24 hours they underwent exploratory surgeries with left corporotomy followed by toilet in the first case and scrototomy with toilet complete of the intrascrotal and suprapubic abscess caves, identification of incarcerated cavernous bodies and bilateral corporotomy with subsequent toilet. Postoperative controls at 30 days showed no post-surgical sequelae, showing a physiological mild homogeneous and progressive impregnation of the cavernous arteries, the helicine arteries and the sinusoids of the cavernous tissue.

Conclusion

The CEUS is a non-invasive method, "bed-side" executable, which in the cases presented, allowed to obtain a more precise assessment on the localization, characterization, staging of abscess of the corpora cavernosa, allowing the patient to be directed to the most appropriate therapy. The CEUS control in post-operative follow-up allowed to exclude possible sequelae or complications.

Reference

[1] Shamloul R, Kamel I: Early treatment of cavernositis resulted in erectile function preservation. J Sex Med 2006;3:320–322.
[2] Vives A, Collado A, Ribe N, Segarra J, Ruiz Castane E, Pomerol JM: Cavernositis following intracavernous injection of vasoactive drugs. Urol Int 2001;67:111–112
[3] Maitê Aline Vieira Fernandes,1 Luis Ronan Marquez Ferreira de Souza,2 and Luciano Pousa Cartafina Ultrasound evaluation of the penis. Radiol Bras. 2018 Jul-Aug; 51(4): 257–261
[4] M. Bertolotto, C. Gasparini, L. Calderan, A. Lissiani, M.A. Cova 1 L’eco-color Doppler penieno: stato dell’arte Giornale Italiano di Ecografia 2005; 8(2): 113-127
[5] Dugdale CM, Tompkins AJ, Reece RM, Gardner AF. Cavernosal abscess due to Streptococcus anginosus: a case report and comprehensive review of the literature. Curr Urol. 2013 Aug;7(1):51–56
[6]Topsoee JF. Investigation of Penile Conditions by Ultrasound and Contrast-Enhanced Ultrasound – Presentation of Three Clinical Case. Ultrasound International Open 2015

#121: THE USE OF AUTOEXPANDABLE URETERAL PROSTHESYS ALLIUM FOR THE POST URETERORENOSCOPIC URETERAL STRICTURES TREATMENT

Inviato da: ferdinandodemarco@gmail.com

F. De Marco1, G. Ricciuti2
  • 1 Istituto Neurotraumatologico Italiano (I.N.I.) (Grottaferrata)
  • 2 Università La Sapienza, Dipartimento di Urologia (Roma)

Objective

Ureteral strictures are severe and difficult to treat disorders and significantly affects the quality of life of patients. Usually the definitive resolution required laser incision or surgical reconstructive procedures or ureteral stent replacement. In our experience we evaluate the use of new expandable ureteral stent (ALLIUM®) in the post endourological ureteral strictures as alternative to standard ureteral stent or reconstructive surgery.

Materials and Methods

From September 2013 to May 2019, 118 patients were enrolled in the study and underwent to endoscopic positioning of the urinary tract autoexpandable prosthesys Allium® for different ureteral disorders. We selected 54 out of 118 patients with ureteral strictures ost-ureterolithotripsy. In this group the location and the lenght of the stenosys were evaluated , such as , the presence and the grade of hydroneprosys. In these patients an ureteral balloon dilatation was always performed and the positioning of the Allium was obtaining by both endoscopic and Xray control. The lenght and the design of the Allium depended on the location and the lenght of the strictures. All the patients were followed up by ultrasound adn KUB after 30 , 90 and 180 days. At 6 months the Allium system was removed and patients re-evaluated.

Results

In 46 out of 54 patients we removed the Allium at 6 months and 8 patients are still in evaluation . In 36 out of 46 patients (78.2%) we obtained the absence of hydronephosis at 6 months. 10 patients required reconstructive surgery for the persistence of the strictures. We reported 3 cases of stent migration and no infective complications were reported.

Conclusion

The autoexpandablre ureteral prosthesys Allium® can be considered an option in the treatment of postoperative ureteral strictures with a succes rate of 78.2%. It requires, as usually, a learning curve, it has minimal post-operative complications and lower negative impact on the quality of life of patients. In our experience all the failures and complications were reported in the first period of learning curve.

#122: THE „GREY ZONE“ OF 10-20 mm KIDNEY STONES: WHAT ABOUT THE EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY RESULTS?

Inviato da: ferdinandodemarco@gmail.com

Argomenti: 

F. De Marco1, G. Ricciuti2
  • 1 Istituto Neurotraumatologico Italiano (I.N.I.) (Grottaferrata)
  • 2 Università La Sapienza, Dipartimento di Urologia (Roma)

Objective

Based on EAU guidelines the indication for the active removal of 10-20 mm is based on both endourological approach and ESWL.
Very often the choice of the treatment depends on the urologist or on the patients preferences. In some case the indications depends in the availability of instruments but, still the stone free rates and the complication rates of ESWL and endourological approaches, are confusing.
Worldwide the number of endourological procedures are increasing, in the treatment of renal stones, reporting high stone free rates and the question if the ESWL is competitive is still on debate

Materials and Methods

Material and Methods
We report our experience in a single Stone Center on 2856 out of 6477 patients with 10 – 20 mm urinary tract stones, using a lithotripter equipped with the EMSE type 220F-XXP.

From October 2001 till May 2019, 6477 patients were treated using the Dornier Lithotripter DLS II. We evaluated retrospectively the stone free rates and the complication rates on the group of patients (2856) with a 10-20 mm kidney stone. The inclusion criteria were patients with kidney stones for which ESWL were appropriate. All stone localization and chemical composition were included (whatever Hounsfield Unit).

Results

The overall "stone free rate" was equal to 85.0% ( 2430 out of 2856 patients)
after a single treatment. Based on the stone localizations, the 3 month stone free rates, were: in the pelvic stones group 1680 out of 1890 (88.8%) , for stones of the upper calyx 93 out of 112 patients (83.0%) , for medium calyx stones 58 out of 105 (55.2%), and for lower calyx stones 599 put of 749 (79.9%).
38 (1.4%) out of 2856 patients needed a post ESWL endourological approach to remove fragments blocked in the ureter and 3 patients underwent to double J insertion to treat a clinically evident subacapsular hematoma.

Discussions

The results showed a large stone free rates and lower complications rates in the 10-20 mm kidney stones. The evaluation of the results based on the localization indicates good results for lower calyx stones. Therefore, better results could be obtained by the evaluation of HU of the stones and following the best practice rules.

Conclusion

In such way, probably , the next guidelines must be redefine the treatment of choice of the “grey zone” of 10-20 mm kidney stones, maintain the leader role of ESWL in the treatment of urinary tract stones.

#123: HIFEM™ TECHNOLOGY CAN IMPROVE QUALITY OF LIFE OF INCONTINENT PATIENTS

Inviato da: edoardo.tartaglia@aslroma2.it

Argomenti: 

E. Tartaglia1, S. Signore1, C. Tartaglia2
  • 1 Ospedale Sant'Eugenio, U.O.C. Urologia (Roma)
  • 2 Universita' degli Studi Tor Vergata (Roma)

Objective

The aim was to investigate the effect of High-Intensity Focused Electromagnetic technology (HIFEM) on QoL of incontinent patients.(1)High-intensity Focused Electromagnetic technology (HIFEM) triggers intense pelvic floor muscles contractions by targeting neuromuscular tissue and inducing electric currents. Electric currents depolarize neurons resulting in concentric contractions and lift up of all pelvic floor muscles. Key effectiveness is based on focused electromagnetic energy, in-depth penetration, and stimulation of the entire pelvic floor area. The HIFEM technology brings deep PFM stimulation and restoration of the neuromuscular control. The HIFEM passes non-invasively through pelvic floor area. Therefore, it represents a non-invasive solution for incontinent patients, who remain fully clothed during the therapy (2-10, 12, 14-19).

Materials and Methods

15 women (mean age 63.05 years) with stress, urge and mixed type of UI took part in the pilot study. They attended 6 therapies scheduled 2x a week. QoL was assessed through King’s Health Questionnaire (KHQ). The number of used hygienic pads and patients’ subjective feedback were recorded. Data was collected pre-, post-treatment, during 2- and 4-month follow-ups. KHQ scores were statistically evaluated through t-test (p&lt;0.05). Number of used hygienic pads and patients’ subjective feedback were evaluated through frequency of occurence.3.3. Exclusion criteria
Women with pacemakers, metal implants, blood coagulation disorders, tumors, fever, menstruation and pregnant women were not included in this study. In this pilot study, FDA and EMA approved device for female urinary incontinence treatment BTL EMSELLA (BTL EMSELLA, BTL Industries Inc.) was used.Frequency range 20-30 Hz with trapezoid intensity modulation was used to achieve gradual motor unit recruitment. Relative intensity (in %) was gradually increased from patients’ motor up to above the motor threshold.All women absolved 6 therapies scheduled 2x a week. Therapy was performed by medical personnel, who positioned patients fully dressed into a comfortable sitting position, feet on the floor, hip, knee and ankle joints perpendicularly flexed. 30-minute duration for each treatment session.
Attachement 1

Results

After 6 treatments, 95 % of treated patients improved their QoL according to the scores of the KHQ. These results were maintained during the 2- and 4-month follow-ups. 67 % of the treated patients reduced or totally eliminated the use of hygienic pads in day-to-day life. 100 % of patients reported better awareness of the pelvic floor muscles.Additionally, patients answered the question ‘What is the major difference you noticed after the BTL EMSELLA therapies?’40 % of patients reported that they are able to perform proper contraction of the PFM; 28 % of patients were able to contract PFM selectively; 20 % of patients reported better muscle firmness and 12 % of patients reported that the period between micturition is longer. Additionally, all patients (n=15; 100 %) reported better awareness of pelvic floor muscles.

Discussions

To regain continence, regular pelvic floor muscles exercising is required. Normally, 300-500 contractions of the pelvic floor muscles should be performed to begin to develop a new motor pattern, whereas 3,000-5,000 contractions are required to erase and correct poor motor pattern. During 1 session using HIFEM technology, thousands PFM contractions are performed. This method is extremely important to PFM re-education as the patients are not able to perform this high-repetition rate pattern due to PFM weakness and an inability to consistently contract this muscle group. After 6 therapeutic sessions with HIFEM therapy, patients developed the new motor pattern needed to better control pelvic floor muscles and also regained muscle strength and continence control (3-9, 12-16).

Conclusion

UI represents a significant psycho-socio-economical healthcare problem that has a major negative impact on today’s modern lifestyles. The majority of patients are not satisfied with the current treatment methods offered, which include surgical intervention, drug therapy, pelvic floor muscles exercising (Kegel) or minimally invasive intravaginal procedures. This latest research, as well as, previous studies suggest that HIFEM technology leads to significant improvement in QoL of incontinent patients, maintains a patient’s privacy all while avoiding more invasive approaches.

Reference

1)Abrams P, Blaivas JG, Stanton SL, Andersen JT. The Standardisation of Terminology of Lower Urinary Tract Function. The International Continence Society Committee on Standartisation of Terminology. Scand d Suppl 1998; 114:5-19
2)Abulhasan, J., Rumble, Y., Morgan, E., Slatter, W. and Grey, M. (2016). Peripheral Electrical and Magnetic Stimulation to Augment Resistance Training. Journal of Functional Morphology and Kinesiology, 1(3), pp.328-342
3)Almeida FG, Bruschini H, Srougi M.: Urodynamic and clinical evaluation of 91 female patients with urinary incontinence treated with perineal magnetic stimulation: 1-year follow-up. J Urol. 2004 Apr; 171(4), pages 1571-4
4)Bickford, R., Guidi, M., Fortesque, P. and Swenson, M. (1987). Magnetic stimulation of human peripheral nerve and brain. Neurosurgery, 20(1), pp.110-116.Bustamante, V., de Santa María, E., Gorostiza, A., Jiménez, 5)U. and 5Gáldiz, J. (2010). Muscle training with repetitive magnetic stimulation of the quadriceps in severe COPD patients. Respiratory Medicine, 104(2), pp.237-245.
6)Coletti, D., Teodori, L., Albertini, M., Rocchi, M., Pristerà, A., Fini, M., Molinaro, M. and Adamo, S. (2007). Static magnetic fields enhance skeletal muscle differentiation in vitro by improving myoblast alignment. Cytometry Part A, 71A(10), pp.846-856.
7)Feldman M., Magnetic Stimulation for the Treatment of Urinary Incontinence in Women, California Technology Assessment Forum, San Francisco, CA, October 20, 2004
8)Han T.R., Shin H.I., Kim I.S. Magnetic stimulation of the quadriceps femoris muscle: comparison of pain with electrical stimulation. Am J Phys Med Rehabil 2006; 85(7):593-599.
9)Ishikawa N., Suda S., Sasaki T. et al., Development of a non-invasive treatment system for urinary incontinence using a functional continuous magnetic stimulator (FCMS) , Medical &amp; Biological Engineering &amp; Computing, 1998, 36, 704-710
10)Man, W. (2004). Magnetic stimulation for the measurement of respiratory and skeletal muscle function. European Respiratory Journal, 24(5), pp.846-860.
11)National Association for Incontinence (NAFC), www.nafc.org Ostrovidov, S., Hosseini, V., Ahadian, S., Fujie, T., Parthiban, S., Ramalingam, M., Bae, H., Kaji, H. and Khademhosseini, A. (2014).
12)Skeletal Muscle Tissue Engineering: Methods to Form Skeletal Myotubes and Their Applications. Tissue Engineering Part B: Reviews, 20(5), pp.403-436.
13)Sand PK, Richardson DA, Staskin DR. Pelvic floor electrical stimulation in the treatment of genuine stress incontinence: a multicenter, placebo-controlled trial. Am. J. Obstet. Gynecol. 1995; 173, pages 72–9
14)M., Arnold, A.StÖlting,, Haralampieva, D., Handschin, C., Sulser, T. and Eberli, D. (2016). Magnetic stimulation supports muscle and nerve regeneration after trauma in mice. Muscle &amp; Nerve, 53(4), pp.598-607. 15)Truijen G, Wyndaele 13)JJ, Weyler J.: Conservative treatment of stress urinary incontinence in women: Who will benefit? Int Urogynecol J Pelvic Floor Dysfunct. 2001; 12(6), pages 386-90
16)Wallis, M., Davies, E., Thalib, L. and Griffiths, S. (2011). Pelvic Static Magnetic Stimulation to Control Urinary Incontinence in Older Women: A Randomized Controlled Trial. Clinical Medicine &amp; Research, 10(1), pp.7- 14.
17)Yamanishi T, Yasuda K, Suda S et al. Effect of functional continuous magnetic stimulation for urinary incontinence. J. Urol. 2000; 163, pages 456–9
18)Yamanishi T, Yasuda K, Sakakibara R et al. Pelvic floor electrical stimulation in the treatment of stress incontinence: an investigational study and a placebo controlled double- blind trial. J. Urol. 1997; 158, pages 2127–31
19)Yang, S., Jee, S., Hwang, S. and Sohn, M. (2017). Strengthening of Quadriceps by Neuromuscular Magnetic Stimulation in Healthy Subjects. PM&amp;R.

#135: Fractional CO2 laser for treatment of stress urinary incontinence

Inviato da: edoardo.tartaglia@aslroma2.it

Argomenti: 

E. Tartaglia1, S. Signore1, C. Tartaglia2
  • 1 Ospedale Sant'Eugenio, U.O.C. Urologia (Roma)
  • 2 Università degli Studi Tor Vergata (Roma)

Objective

To evaluate the impact of trans-vaginal fractional CO2 laser treatment on symptoms of stress urinary incontinence (SUI) in women
Urinary incontinence (UI), defined as the complaint of any involuntary leakage of urine, affects nearly 40% of women; stress urinary incontinence (SUI) accounts for approximately half of all UI [1]. UI significantly impacts on quality of life, affecting the woman’s physical, mental, social and sexual well-being and leading to avoidance of intimacy, depression and social isolation [[2], [3], [4]]
Surgical options for SUI include trans-vaginal insertion of a mid-urethral sling (MUS) and the more invasive, traditional gold-standard Burch colposuspension procedure, requiring an abdominal approach (laparotomic or laparoscopic)
Fractional micro-ablative laser therapy has been shown to be a potential non-surgical treatment alternative for SUI [10,11]. The subclinical thermal tissue effect from the laser beam induces human dermal fibroblasts to initiate an inflammatory healing cascade, stimulating de novo collagen and elastin synthesis resulting in a thicker vaginal epithelium with larger diameter, glycogen-rich epithelial cells [[12], [13], [14]].

The aim of this study is to evaluate the change in SUI symptoms after trans-vaginal fractional micro-ablative CO2 laser in women at baseline, compared to follow-up at 3 months and 12–24 months post-treatment.

Materials and Methods

25 Women clinically diagnosed with SUI preferring non-surgical treatment were recruited to the study. Fractional CO2 laser system (MonaLisa T, DEKA) treatments were administered trans-vaginally every 4–6 weeks for a total of three treatments. Response to treatment was assessed at baseline (T1), at 3 months after treatment completion (T2) and at 12–24-month follow-up (T3) using KHQ scores . Number of used hygienic pads and patients’ subjective feedback were evaluated through frequency of occurence. The primary outcome was changes in reported symptoms of SUI. Secondary outcomes assessed included bladder function, urgency, urge urinary incontinence (UUI), pad usage, impact of urinary incontinence on quality of life (QOL) and degree of bothersome bladd
During 2016–2019, 25 women aged 35 years or more being treated by a single urogynaecology consultant
Inclusion criteria were no/unsatisfactory response to conservative treatments and a preference for non-surgical management of bothersome SUI symptoms. The women also demonstrated a positive cough test and urethral hypermobility on ultrasound. All women that participated were offered urodynamic studies and encouraged to continue with topical oestrogen therapy and pelvic floor muscle exercises. Women with ≥stage II pelvic organ prolapse quantification system (POPQ) score, acute or recurrent urinary tract infections, pregnancy, current malignancy, known cervical dysplasia or undiagnosed abnormal uterine bleeding were excluded. All participants were asked to complete the bladder function section of the at baseline (T1), 3 months after third treatment (T2), and at 12–24 months’ follow-up (T3). The KHQ a validated self-administered pelvic floor questionnaire utilised for quantification of clinical and research outcomes [15]. The primary outcome of this study is to describe the change in self-reported SUI symptoms based on question The secondary outcomes were bladder function, urgency, urge incontinence, pad usage, quality of life, degree of bothersome bladder score as assessed by KHQ. Improvement of SUI was calculated based on severity scoring 0-3. Bladder function score was calculated by adding all 15 questions in the bladder subsection of APFQ, with maximum score of 45. Scores 0–11.25 was normal bladder function, 11.26–22.5 was mild bladder dysfunction, 22.6–33.75 was moderate bladder dysfunction, and 33.76–45 was severe bladder dysfunction. Questionnaires were distributed to participants and collated by practice staff; the identity of individual respondents remained blinded to the invest
igators.
25 women were recruited to the study with an average age of 57.4 ± 11.4 years (30–85 years); 14 were postmenopausal, 12 had urodynamic studies, which confirmed SUI. There were 12 women who were followed-up at 3 months and 13 at 12–24 months .

Results

In relation to the primary outcome , Fig. 1 illustrates the reduction in SUI symptoms reported by women at follow-up (T2 and T3) compared to baseline (T1). At T1, all 25 participants reported frequent or daily SUI symptoms. At T2, 80% reported an improvement in SUI symptoms, which included 46% participants reporting no SUI symptoms, 16.4% participants reported frequent symptoms, 3.6% reported daily symptoms. These changes were also reflected in the median score reduction for KHQ (p &lt; 0.01)
Similar results were demonstrated for secondary outcomes of bladder function , urge incontinence ) and bothersome bladder . Normal bladder function increased from 31% at 3 months to 72.2% at 12 months. This trend decreased to 69.4% at 24 months. There was an overall improvement in participants’ urge incontinence scores from T1 to T2, with an increase in the number of patients reporting “never” leaking urine when they rush to the toilet from this trend decreased slightly to at T3 (44.4%, p &lt; 0.01). There was an improvement in the participants’ degree of bothersome bladder from T2 toT3 months more women reported “not at all (bothersome)” from T2 to T3 (3.4% to 50%, p &lt; 0.01); this trend reduced at 24 months (36%, p = 0.01).

Discussions

This study describes the change in prevalence of SUI symptoms before and after fractionated CO2 laser to treat both pre- and post-menopausal women with SUI. The study showed that following 3 treatments at 4–6-week intervals, SUI symptoms improved in 80% of participants at 3 months (p &lt; 0.01) and that these benefits persisted in 75% of participants at 12 months (p &lt; 0.01).

Conclusion

In summary, micro-ablative fractional CO2 laser treatment appears to be a promising, non-surgical, non-hormonal, minimally invasive, durable, low risk treatment option for women with SUI. The safety this treatment modality and the reduced prevalence as per self-reported SUI symptom reduction from baseline suggests a possible alternative for women with SUI who are unwilling to accept the inherent risks of MUS and Burch colposuspension, or whose medical comorbidities exclude surgical treatment. Further research should compare the use of fractionated CO2 laser with placebo and/or established treatments, as well as determine whether booster treatment is required to sustain improvements in SUI symptoms longer term.

Reference

E.S. Lukacz, Y. Santiago-Lastra, M.E. Albo, L. Brubaker
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D.P. Keane, T.J. Sims, P. Abrams, A.J. Bailey
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T. Rechberger, K. Postawski, J.A. Jakowicki, Z. Gunja-Smith, J.F. Woessner Jr.
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N. Zerbinati, M. Serati, M. Origoni, M. Candiani, T. Iannitti, S. Salvatore, et al.
Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment
Lasers Med Sci, 30 (1) (2015), pp. 429-436
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S. Salvatore, U. Leone Roberti Maggiore, S. Athanasiou, M. Origoni, M. Candiani, A. Calligaro, et al.
Histological study on the effects of microablative fractional CO2 laser on atrophic vaginal tissue: an ex vivo study
Menopause, 22 (8) (2015), pp. 845-849
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K. Baessler, S.M. O’Neill, C.F. Maher, D. Battistutta
A validated self-administered female pelvic floor questionnaire
Int Urogynecol J, 21 (February (2)) (2010), pp. 163-172
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S. Salvatore, R.E. Nappi, N. Zerbinati, A. Calligaro, S. Ferrero, M. Origoni, et al.
A 12-week treatment with fractional CO2 laser for vulvovaginal atrophy: a pilot study
Climacteric, 17 (4) (2014), pp. 363-369
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A. Lipp, C. Shaw, K. Glavind
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Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observational Study
Menopause, 25 (January (1)) (2018), pp. 11-20
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#142: Preliminary results of treatment with Autologous Platelet-Rich Plasma and Polydeoxyribonucleotide for male genital lichen sclerosus

Inviato da: francescok86@gmail.com

Argomenti: 

M. Carrino1, F. Chiancone2, L. Pucci2, G. Romeo2, P. Fedelini2, M. Fasbender Jacobitti1
  • 1 Andrology Department, AORN “A. Cardarelli” (Naples)
  • 2 Urology Department, AORN “A. Cardarelli” (Naples)

Objective

Genital lichen sclerosus (LS) is a chronic lymphocyte-mediated inflammatory dermatosis that has a predilection for the genital skin in both sexes. In males LS affect mainly the foreskin, the glans and the meatus. It can cause phimosis and symptoms such as burning and pain due to scarring, atrophy, erosions and edema. It is a relatively common disease but true incidence is unknown and likely underestimated. Current guidelines suggest treating patients with a continuous administration of topical corticosteroids. The aim of this study was to investigate the efficacy of a conservative treatment for LS with a combined use of autologous platelet-rich plasma (PRP) and polydeoxyribonucleotide (PDRN). Both PRP and PDRN are successfully use in many branches of medicine (trichology, dermatology, aesthetic medicine, etc.) thanks to their high tolerability and handling.

Materials and Methods

16 patients aged 49.44±12.64 affected by LS who fulfilled the following criteria were enrolled in the study:
-hystopathological diagnosis of LS resulting from 4 mm punch biopsy;
-negative past medical history for coagulopathies and autoimmune diseases;
-no treatments with anticoagulants, corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying anti-rheumatic drugs (DMARDs).
The protocol included a total of 7 intra-dermal or submucosal injections to any affected areas, made with “micro-papule” technique:
-first cycle: 3 infiltrations of PRP (4 ml every 15 days);
-second cycle: 4 infiltrations of PDRN (1 vial of 5,625 mg / 3 ml every 7 days).
For the injections have been used needles for mesotherapy – intradermotherapy 27G x 4 mm and insulin syringes with Luer Lock. It was never necessary to use local anesthetics.
After providing written informed consent, at blood bank Department of our hospital, the venous whole blood (about 20 ml every time) taken from the patient was centrifuged at 6000 rpm for 6 minutes. Infiltrations of PRP occurred within 30 minutes from blood processing. After each session, patients were verbally interviewed about their symptoms (eg, pain and discomfort) and lesions were evaluated by digital penoscopy. The patients remained under observation for a short time in our Andrology Unit to assess the presence of any complications or side effects.

Results

At three months after the seventh infiltration (ie the fourth PDRN injection), all patients exhibited clinical improvement in the size of their lesions. 11 of the 16 patients (68.75%) had become symptom-free and no longer needed to use steroids. 4 patients (25%) had a reduction of symptoms and continued to use topical steroid intermittently. Only one patient (6.25%) reported moderate pain and did not benefit from therapeutic protocol. There were no evidence of local adverse events (p.e. bleeding, infection or hematoma) during the clinical study.

Discussions

The PRP infiltration is a simple, safe and immunologically biocompatible procedure. PRP works via the degranulation of the a-granules in platelets, which contain synthesized and pre-packaged growth factors. PRP induces tissue building capacity thanks to platelet derived growth factor (PDGF) – isoforms AB and BB, vascular endothelial growth factor (VEGF), transforming growth factor β (TGF-β), insulin like growth factor-1 (IGF-1). Moreover, PRP activates neoangiogenesis and improves blood flow and tissue oxygenation.
PDRN, instead, is a drug belonging to the official Italian pharmacopoeia. It is indicate in the treatment of cutaneous and connective lesions associated with dystrophic and dystrophic-ulcerative pathologies. It is used in off-label ways for skin bioregeneration. PDRN, consisting of several deoxyribonucleotides joined together by phosphodiester bonds, reaches the phlogistic site with high tropism, interacting with elements such as platelets and fibronectin and defining the formation of molecular complexes capable of facilitating cell regeneration. However, the inducing action on the cell cycle seems to be associated with the ability of the active principle to activate alternative signal pathways, capable of supporting gene expression, optimizing DNA synthesis and the subsequent process of cell proliferation and tissue regeneration.

Conclusion

Currently, steroids are the most used treatment but can cause side effects such as fibrosis and in some cases it is contraindicated, such as in diabetes. Use of PRP-PDRN integrated therapeutic protocol significantly improves the overall conditions in patients affected by LS with a significant reduction in lesions, inflammation and associated symptoms. Many research studies have been published on the use of PRP and PDRN for the treatment of LS. Currently, there are no clinical studies on the combined PRP-PDRN protocol to exploit the synergism of both infiltrative procedures.
Further clinical trials are necessary to evaluate long-term results, as well as what could be the best protocol for the combined treatment of LS with PRP and PDRN.

Reference

o Arena S, Romeo C. Polydeoxyribonucleotide Treatment in Genital Lichen Sclerosus in Males. Urol Int. 2017;98(1):111. doi: 10.1159/000449017. Epub 2016 Sep 13.
o Casabona F, Gambelli I, Casabona F, Santi P, Santori G, Baldelli I. Autologous platelet-rich plasma (PRP) in chronic penile lichen sclerosus: the impact on tissue repair and patient quality of life. Int Urol Nephrol. 2017 Apr;49(4):573-580. doi: 10.1007/s11255-017-1523-0. Epub 2017 Feb 4.
o Kim S, Kim J, Choi J, Jeong W, Kwon S. Polydeoxyribonucleotide Improves Peripheral Tissue Oxygenation and Accelerates Angiogenesis in Diabetic Foot Ulcers. Arch Plast Surg. 2017 Nov;44(6):482-489. doi: 10.5999/aps.2017.00801. Epub 2017 Oct 26.
o Laino L, Suetti S, Sperduti I. Polydeoxyribonucleotide Dermal Infiltration in Male Genital Lichen Sclerosus: Adjuvant Effects during Topical Therapy. Dermatol Res Pract. 2013;2013:654079. doi: 10.1155/2013/654079. Epub 2013 Dec 30.
o Polito F, Bitto A, Galeano M, Irrera N, Marini H, Calò M, Squadrito F, Altavilla D. Polydeoxyribonucleotide restores blood flow in an experimental model of ischemic skin flaps. J Vasc Surg. 2012 Feb;55(2):479-88. doi: 10.1016/j.jvs.2011.07.083. Epub 2011 Nov 3.
o Samadi P, Sheykhhasan M, Khoshinani HM. The Use of Platelet-Rich Plasma in Aesthetic and Regenerative Medicine: A Comprehensive Review. Aesthetic Plast Surg. 2019 Jun;43(3):803-814. doi: 10.1007/s00266-018-1293-9. Epub 2018 Dec 14. Review.
o Tedesco M, Pranteda G, Chichierchia G, Paolino G, Latini A, Orsini D, Cristaudo A, Foddai ML, Migliano E, Morrone A. The use of PRP (platelet-rich plasma) in patients affected by genital lichen sclerosus: clinical analysis and results. J Eur Acad Dermatol Venereol. 2019 Feb;33(2):e58-e59. doi: 10.1111/jdv.15190. Epub 2018 Sep 19.
o Veronesi F, Dallari D, Sabbioni G, Carubbi C, Martini L, Fini M. Polydeoxyribonucleotides (PDRNs) From Skin to Musculoskeletal Tissue Regeneration via Adenosine A2A Receptor Involvement. J Cell Physiol. 2017 Sep;232(9):2299-2307. doi: 10.1002/jcp.25663. Epub 2017 Mar 3.
o Zucchi A, Cai T, Cavallini G, D'Achille G, Pastore AL, Franco G, Lepri L, Costantini E. Genital Lichen Sclerosus in Male Patients: A New Treatment with Polydeoxyribonucleotide. Urol Int. 2016;97(1):98-103. doi: 10.1159/000443184. Epub 2016 Feb 2.

#144: Clamp-Less partial robotic nephrectomy (RPN): surgical feasibility, percentage of positive margins and intra- and post-operative complications

Inviato da: matteo.zanoni@materdomini.it

Argomenti: 

G. Taverna1, M. Zanoni1, P. Vota1, M. Justich1, G. Toia1, G. Malagola1, F. Grizzi2, A. Mandressi1, G.. Guazzoni3
  • 1 Department of Urology, Humanitas Mater Domini (Castellanza)
  • 2 Department of Immunology and Inflammation, Humanitas Clinical and Research Center (Rozzano)
  • 3 Department of Urology, Humanitas Clinical and Research Center (Rozzano)

Objective

Robotic partial nephrectomy (RPN) has emerged as an attractive minimally invasive nephron-sparing surgical option. However, on-going concerns about RPN include: prolonged ischaemia time with potential implications on renal functional outcomes(1-2). We detail the technique and present perioperative outcomes of our technique of zero-ischaemia RPN for renal tumours (Clamp-less Robotic surgery)(3).

Materials and Methods

From January 2011 to September 2019 181 patients underwent PN Clamp-Less Robotic Assisted Care. RPN was offered to all patients with even partially exotic lesions, regardless of renal-vascular anatomy, contralateral kidney characteristics or renal function. 5/181 had dual unilateral tumours. 7/181 had monorene.
The mean diameter of the neoplasms was 3.9 cm (2.5 – 5.5 cm), the lesions were localized: 101 right kidney, 80 left kidney, 47 upper polar, 53 middle, 80 lower.
The operating technique involved the use of 3 robotic doors (camera + scissors and Prograsp) + 1 accessory door. After isolation of the kidney and the lesion, hot enucle/tumorectomy was performed with subsequent diathermocoagulation of the enucleoresezine bed with positioning of fibrin glue and haemostatic material

Results

The RPN Zero-ischemia has been successful in all cases without the need for hilar clamping. The size of the median tumor (range) was 3.9 (2.5-5,5) cm. The time of warm ischemia was zero in all cases. The mean operating time was 60 (45-100) min, the estimated blood loss was 120 (50-300) ml. The average hospital stay was 4 (3-6) days. There were no intraoperative complications; 4/181 (0.02%) patients presented a post-operative haemorrhage that required a decisive laparotomy. None of the 4 patients had bleeding from the resection margins. 2 patients was bleeding from kidney fat and 2 from a robotic port. All tumour samples had negative surgical margins. The absolute median decrease in serum creatinine and the estimated glomerular filtration rate at discharge were 0 (0.2-0.7) mg / dL (P = 0.4) and 5 (-16-29) mL / min for 1.73 m (2) (P = 0.8), respectively.

Discussions

Zero-ischemic RPN for kidney cancer is safe and feasible. The elimination of hot ischemia can optimally preserve renal function.

Conclusion

Randomized prospective studies are required to confirm any renal functional advantages of RPN without clamping.

Reference

1. Zero-ischaemia robotic partial nephrectomy (RPN) for hilar tumours.
Abreu AL, Gill IS, Desai MM.
BJU Int. 2011 Sep;108(6 Pt 2):948-54
2. Off-clamp robot-assisted partial nephrectomy does not benefit short-term renal function: a matched cohort analysis.
Anderson BG, Potretzke AM, Du K, Vetter J, Figenshau RS.
J Robot Surg. 2018 Sep;12(3):401-407. doi: 10.1007/s11701-017-0745-6. Epub 2017 Aug 31
3. On-clamp versus off-clamp robotic partial nephrectomy: A systematic review and meta-analysis.
Antonelli A, Veccia A, Francavilla S, Bertolo R, Bove P, Hampton LJ, Mari A, Palumbo C, Simeone C, Minervini A, Autorino R.
Urologia. 2019 May;86(2):52-62.

#143: Effects of Protoves- M1® on the prevention and the treatment of irritative symptoms after GreenLight laser photoselective vaporization (PVP) of benign prostatic hyperplasia (BPH)

Inviato da: francescok86@gmail.com

F. Chiancone1, L. Pucci1, M. Fasbender Jacobitti2, F. Persico1, P.. Fedelini1, M. Carrino2
  • 1 Urology Department, AORN “A. Cardarelli” (Naples)
  • 2 Andrology Department, AORN “A. Cardarelli” (Naples)

Objective

The aim of this study was to analyse the role of two alkaloid, Protopine and Nuciferine (Protoves-M1®) in the prevention and the treatment of irritative symptoms (urgency and dysuria) after GreenLight laser photoselective vaporization (PVP) of benign prostatic hyperplasia (BPH)1.

Materials and Methods

Between July 2017 to September 2019, 120 patients with benign prostatic hyperplasia whose underwent GreenLight laser photoselective vaporization were prospectively randomized into two groups (Group A=Protoves M1® syrup, 10 ml, once a day, for 6 weeks; Group B= placebo (flavoured coloured water), 10 ml, once a day, for 6 weeks). They started therapy two weeks before the surgery. The primary endpoint was the evaluation of the efficacy of the therapy with Protoves M1® in controlling of the irritative symptoms.
The patients were evaluated at baseline (the day after removal of vesical catheter) and after 4 weeks (six weeks of therapy). All patients underwent IPSS (International Prostatic Symptoms Score) questionnaire, OverActive Bladder questionnaire-short form (OABq-SF) 6 and 13 and patient perception of intensity of urgency scale (PPIUS). Improvement was evaluated with the Patient Global Impression of Improvement questionnaire (PGI-I), that is a global index that may be used to rate the response of a condition to a therapy. PGI-I was evaluated at 4 weeks follow-up.

Results

The two groups showed no differences in terms of patients’ demographics as well as baseline characteristics in all variables analysed (p&gt;0.05). No significant differences were seen in the baseline results of questionnaires in the two groups (p&gt;0.05).
The patients of Group A showed a better IPSS score (p&lt;0.001), a better control of urgency symptoms (PPIUS) (p=0.020) and a better OAB1-SF 6 (p=0.001) and 13 (p=0.001) than Group B at 4 weeks follow-up (Table 1).
PGI-I demonstrated a better satisfaction of the treatment in the group A than in the Group B (p&lt;0.001).

Discussions

The Greenlight laser is a continuous wave laser which initially used a potassium titanyl phosphate (KTP) crystal to produce a light beam at a wavelength of 532 nm. This wavelength is selectively absorbed by oxyhemoglobin in prostatic tissue at a power level of 80 W, allowing for tissue photovaporization with a short depth of penetration. Despite this, irritative symptoms including prolonged urgency and dysuria after GreenLight laser photoselective vaporization (PVP) of benign prostatic hyperplasia (BPH) are common complication. In our experience, these symptoms self improved after some months. The use of Protoves-M1 before and after surgery improved the control of these irritative symptoms as demonstrated by the questionnaires administrated to our patients.
Protopine has a confirmed anticholinergic-antimuscarinic2 and GABAergic3 action and it can impact some neurological systems responsible of bladder functions. Nuciferine is a partial antagonist of D2-like receptor and has a well established regulatory action on the dopaminergic system (responsible of urination onset4). Moreover Nuciferine has a role in reducing states of tension and anxiety on a psychological level5. In addiction, Nuciferine reduce inflammation by inhibiting TLR4/PI3K/NF-κB signaling.

Conclusion

Protoves M1® can be an interesting alternative to antinflammatory agents to treat irritative symptoms of GreenLight laser photoselective vaporization of benign prostatic hyperplasia.

Reference

1-Sun I, Yoo S, Park J, et all. Quality of life after photo-selective vaporization and holmium-laser enucleation of the prostate: 5-year outcomes. Sci Rep. 2019 Jun 4;9(1):8261.
2-Ustunes L., Laekeman GM, Gözler B, Vlietinck AJ, Ozer A, Herman AG. In Vitro Study of the anticholinergic and antihistaminic activities of Protopine and some derivatives. Journal of Natural Products, 1988
3-Kardos J., Blaskó G, Simonyi M. Enhancement of gamma-aminobutyric acid receptor binding by protopine-type alkaloids. Arzneimittelforschung, 1986
4-Fowler C.J., Griffiths D, de Groat WC. The neural control of micturition. Nat Rev Neurosci. 2008 Jun; 9(6): 453–466.
5-Kang M., Shin D, Oh JW, Cho C, Lee HJ, Yoon DW et al. The Anti-Depressant Effect of Nelumbinis Semen on Rats under Chronic Mild Stress Induced Depression-Like Symptoms. Am J Chin Med., 2005

#147: ADAR1 is highly expressed in primary prostate cancer and correlated with CD8+ T-lymphocytes density

Inviato da: matteo.zanoni@materdomini.it

G. Taverna1, F. Grizzi2, M. Zanoni1, P.. Vota1, M. Justich1, G. Toia1, G. Malagola1, A. Mandressi1, G. Guazzoni3
  • 1 Department of Urology, Humanitas Mater Domini (Castellanza)
  • 2 Department of Immunology and Inflammation, Humanitas Clinical and Research Center (Rozzano)
  • 3 Department of Urology, Humanitas Clinical and Research Center (Rozzano)

Objective

It is now recognized that the evolution of cancer cells is dependent by genetic or epigenetic alterations. However, this concept has recently been challenged by another mode of nucleotide alteration, RNA editing, which is frequently upregulated in cancer(1) RNA editing is a biochemical process in which either Adenosine or Cytosine is deaminated by a group of RNA editing enzymes including ADAR (Adenosine deaminase; RNA specific) The result of RNA editing is usually adenosine to inosine (A-to-I) or cytidine to uridine (C-to-U) transition, which can affect protein coding, RNA stability, splicing and microRNA-target interactions(2). The aim of this study was to preliminarily investigate the expression of ADAR1 in a series of prostate cancer specimens and benign prostatic hyperplasia (BPH) following transurethral resection of the prostate (TURP).

Materials and Methods

Sixty prostate specimens were investigated. Fifty specimens were diagnosed as prostate carcinoma and 15 as benign prostate hyperplasia. The samples were fixed in 10% formaldehyde and paraffin-embedded. Two-micrometer thick sections were cut and processed for immunohistochemistry with primary antibodies raised against ADAR1 (SantaCruz Biotechnology, Dallas, TX, USA) or CD8+ T-lymphocytes (Dako, Milan, Italy). 3,3’-Diaminobenzidine tetrahydrochloride was used as a chromogen to yield brown reaction products. To quantify the surface covered by infiltrating CTLs each histological section was digitized using an automated image analysis system with incorporated ad hoc constructed image analysis software. The system automatically selected the surface covered by the CTL on the basis of red, green and blue (RGB) color segmentation.

Results

ADAR1 up-regulation was heterogeneously detected in a high percentage of prostate cancer tissues, but to a much lesser extent in adjacent non-malignant tissues or tissue affected by BPH (p &lt;0.001). Prostate cancers with high ADAR1 expression exhibited high tumor-infiltrating CD8 + T lymphocyte. ADAR expression is associated with several diseases including cancer, neurological disorders, metabolic diseases, viral infections, and autoimmune disorders

Discussions

This study first shows that ADAR1 is highly expressed in a high percentage of prostate cancer tissues, but to a much lesser extent in adjacent non-malignant tissues or tissue affected by benign prostatic hyperplasia. Additionally, prostate cancers with high ADAR1 expression exhibited high tumor-infiltrating CD8 + T lymphocyte

Conclusion

Our findings indicated that ADAR1 might play an important role in the occurrence, progression, and prognosis of prostate cancer, and open new ways for the development of new and more effective immunological therapeutic strategies.

Reference

1) A-to-I RNA editing in leukemia stem cells – set ADAR1 on the radar. Jiang Q, Diep R, Jamieson C.
Oncotarget. 2019 Oct 22;10(58):6047-6048. doi: 10.18632/oncotarget.27261. eCollection 2019 Oct 22

2) IL6R-STAT3-ADAR1 (P150) interplay promotes oncogenicity in 1q21(amp) multiple myeloma.
Teoh PJ, Chung TH, Chng PYZ, Toh SHM, Chng WJ.
Haematologica. 2019 Aug 14. pii: haematol.2019.221176. doi: 10.3324/haematol.2019.221176.

#152: Video content analysis of 20 robot-assisted laparoscopic prostatectomies for evaluating potential mechanisms of iatrogenic nerve lesions and preventive practical suggestions

Inviato da: dott.alessandro.izzo@gmail.com

A.. Izzo1, M.. Cascella1, G. Grimaldi1, G. Quarto1, R. Muscariello1, L. Castaldo1, D. Franzese1, M. Perra1, S.. Perdonà1
  • 1 Istituto Nazionale dei Tumori di Napoli - IRCCS - Fondazione "G. Pascale" (Napoli)

Objective

Robot-assisted laparoscopic prostatectomy (RALP)[1]is the most frequent strategy used for the surgical remedy of patients with localized prostate cancer. Although there is awareness about potential patient positioning nerve injuries, iatrogenic nerve lesions are less described in the literature [2]. Here, we report 3 cases of patients who presented with neuropathic painful complications due to RALP-associated nerve lesions.

Materials and Methods

A 62-year-old patient (case 1), a 72-year-old male (case 2), and a 57-year-old patient (case 3) presented at the clinic with symptoms of neuropathic pain after RALP surgery.
Patients were diagnosed with a potential injury of different branches of the pudendal nerve (cases 1 and 2), and left obturator nerve (case 3).
Patients underwent multimodal pharmacologic treatment through pregabalin, weak opioids, strong opioid, paracetamol, and adjuvants. In cases 2 and 3, a multidisciplinary approach was needed. As the patients responded to conservative treatment, invasive approaches were not necessary.

Results

After treatment, the patients of case 1 showed pain relief after 4 days, paresthesia resolved in 15 days, whereas the anal crushing sensation lasted for approximately 1 month. In case 2, after 4 weeks of treatment, the patient experienced a considerable decrement in pain intensity with complete response after 4 months. In case 3, pain relief was achieved after 2 days, motor symptoms recovery after 2 weeks, and neuropathic features resolved completely after 5 weeks although the obturator sign resolved within 2 months.

Discussions

During RALP surgery, a wide range of surgical injury to the pelvic nerves may occur. The pathophysiology of these damages recognizes different mechanisms such as compression (e.g., due to hematoma or pelvic lymphoceles), transection, incision, traction, thermal injuries, entrapment with clips.
The evaluation of possible risk factors is of fundamental importance both for the prevention of complications and for their rapid identification and treatment [3-6]. In case 1, the damage to the inferior rectal nerve occurred for thermal injury or traction on straight during the preparation procedure of the backplane, or during Rocco stitch. The complication was probably also related to the extent of prostatic pathology, as reported by the definitive histologic examination. The extent of the pathology, therefore, was certainly a major risk factor. Concerning the mechanism of neuropathy responsible for the clinical picture described in the second case, it can be explained as a possible injury occurred during the running stitch and the additional suture of Santorini plexus. The bilateral nerve damage may explain the severity of the neuropathic painful condition, whereas the presence of a particularly represented plexus and a connective tissue at the pubic symphysis represented a considerable risk factor. Case 3 regards a lesion of the left obturator nerve. This nerve originates from the ventral rami of the 2nd, 3rd, and 4th lumbar nerve roots. It follows the iliopectineal line into the lesser pelvis, runs along the lateral pelvic wall and then enters into the obturator foramen via the obturator canal. Within the canal, the nerve divides into an anterior branch, posterior branch, and a branch to the external obturator muscle then. Then, it exits through the obturator tunnel and enters the thigh. The sensory distribution of the nerve encompasses the anteromedial hip joint, the medial knee joint, and the skin on the inner thigh just above the medial knee from the anterior branch. The obturator nerve injury is described as a rare complication of robotic-assisted PLND. Because the obturator nerve can be adherent to lymph nodes or enclosed by them, a careful nerve mobilization should be performed, and fixed lymph nodes should not be mobilized roughly. Specifically, the proximal part of the obturator nerve runs closely the external iliac vein and the internal iliac artery. This is the location of the internal iliac lymph nodes. In our case, we suppose that the nerve damage was caused during the extensive PLND through a thermal injury of the nerve at the entrance of the obturator fossa . Alternatively, a compressive effect on the nerve was produced by a PLND-induced lymphocele. The combination of both mechanisms seems to be another plausible explanation. According to this latter hypothesis, the early multimodal pain strategy and antiedematous therapy may explain the rapid resolution of the clinical picture [7-8].
Several suggestions focused on improving surgical technique and aimed at avoiding neurologic complications can be proposed. Firstly, the thermal energy should be minimized by using bipolar output energy &lt;35 and &lt;50 W in monopolar. Furthermore, hemostasis through microsutures (e.g., 4-0 brainded absorbable suture CV-25 TAPER 1/2 circle 17 mm Polysorb; Covidien) can represent a less invasive approach. Other suggestions concern the use of titanium clip during dissection, Rocco stitch (e.g., 3-0 V-Loc barbed absorbable suture GU-46 TAPER 5/8 circle 27 mm; Covidien) performed not through full-thickness modality. Finally, because the different branches of the pudendal nerve run laterally and dorsal to the rectum it should be recommended to minimize traction maneuvers during the procedure of prostate detachment.

Conclusion

The RALP-associated neurologic injuries may occur even when performed by highly experienced surgeons. A better understanding of the potential iatrogenic nerve lesions can surely allow an improvement in the surgical technique. A multidisciplinary approach and early multimodal pain strategy are mandatory for managing these complications.

Reference

1. Du Y, Long Q, Guan B, et al. Robot-assisted radical prostatectomy is more beneficial for prostate cancer patients: a system review and meta-analysis. Med Sci Monit 2018;24:272–87
2. Ahmed F, Rhee J, Sutherland D, et al. Surgical complications after robot-assisted laparoscopic radical prostatectomy: the initial 1000 cases stratified by the Clavien classification system. J Endourol 2012;26:135–9.
3. Novara G, Ficarra V, D’Elia C, et al. Prospective evaluation with standardised criteria for postoperative complications after robotic-assisted laparoscopic radical prostatectomy. Eur Urol 2010;57:363–70
4. Ou YC, Yang CR, Wang J, et al. The learning curve for reducing complications of robotic-assisted laparoscopic radical prostatectomy by a single surgeon. BJU Int 2011;108:420–5.
5. Ou YC, Yang CK, Chang KS, et al. Prevention and management of complications during robotic-assisted laparoscopic radical prostatectomy following comprehensive planning: a large series involving a single surgeon. Anticancer Res 2016;36:1991–8.
6. Murphy DG, Bjartell A, Ficarra V, et al. Downsides of robot-assisted laparoscopic radical prostatectomy: limitations and complications. Eur Urol 2010;57:735–46.
7. Maerz DA, Beck LN, Sim AJ, et al. Complications of robotic-assisted laparoscopic surgery distant from the surgical site. Br J Anaesth 2017;118:492–503.

#153: COLLINS LOOP EN BLOC RESECTION( CLEBR) FOR ACCURATE STAGING OF PRIMARY NON MUSCLE INVASIVE BLADDER CANCER: OUR EXPERIENCE

Inviato da: dott.alessandro.izzo@gmail.com

A.. Izzo1, G. Grimaldi1, G. Quarto1, R. Muscariello1, L. Castaldo1, S. Perdona1
  • 1 Istituto Nazionale dei Tumori di Napoli - IRCCS - Fondazione "G. Pascale" (Napoli)

Objective

A primary aim of transurethral resection of bladder (TURB) tumors is to determine the depth of invasion or clinical stage. Transurethral resection is a stochastic procedure subject to variations in tumor type, surgical technique and pathological evaluation.
Exact pathological staging of bladder cancer is crucial for determination of further treatment. A limiting factor is the surgical ‘incise and scatter’ technique that might contribute to tumour recurrence.
We present our results with using a Collins loop (with a cutting current) en bloc resection (CLebR-ET) of bladder tumours for treatment and accurate staging of solitary transitional cell carcinoma of the bladder.

Materials and Methods

January 2015 – December 2019, 134 patients (96 male – 38 female) with non muscle-invasive bladder cancer (NMIBC) underwent transurethral en bloc resection using a Collins Loop. Tumor size ranged to 0.5- 45 mm and multifocality was present in 6% of cases. En bloc resection was applied on all of the tumours. On 118 of the 134 patients, a re-TURB was performed after 6 weeks. The bladder wall is incised around the lesion using a Collins loop, starting from apparently “normal” mucosa surrounding the base and then extending through the subepithelial connective tissue, muscularis mucosae and muscularis propria strata. The resected 1-piece specimen was grasped with a loop electrode and retrieved. After bladder tumor resection the resected base was observed carefully to assess perforation and bleeding. When the tumor size was greater than 3 cm, excision of the lesion could be easily achieved by mean of a resectoscope with a 5 mm working channel. After resection, the lesion is grasped with the forceps and retrieved with the resectoscope. All cases of high-risk NMIBC underwent second-look after 30-45 days.

Results

Pathology reported urothelial carcinoma with low grade stage Ta, T1 high –grade and T2 high-grade respectively in 76 (56,7%), 46 ( 34,3%), 12 ( 8,9%). All of the resected specimens provided detrusor muscle, No uncontrollable bleeding, perforation or other serious complications were observed. To date, with a mean follow up of 16.5 months, the recurrence rate in patients with NMIBC is 13.5%

Discussions

TURBT is a procedure with a varied outcome in terms of adequacy of resection, recurrence and progression. There is no clinical yardstick to judge the completeness of resection. There are
a few surrogate markers to assess adequate resection such as presence of detrusor muscle in the specimen and the rate of subsequent recurrence. Successful management of
bladder tumors (particularly non-muscle-invasive tumors), relies on adequate initial resection and accurate histological diagnosis.
An ideal TURBT would mean complete resection of the visible tumor, resection of the surrounding healthy looking mucosa for up to 1 cm and then the removal of detrusor muscle. Herr and
Donat described three ways to measure the quality of a good TURBT, i.e., complete resection, presence of deep muscle in the specimen and the rate of recurrence at the site of previous
TURBT. [1] They also suggested classifying tumor resection as R0; microscopic negative margin, R1 with microscopic positive margin and R2 that is macroscopic positive margin. This kind
of assessment is not practical in CT, but could be possible in en-bloc resection, where we can have a piece of tumor tissue, which has all three layers, i.e., urothelium, lamina propria and
detrusor muscle in contiguity. The outer-most surface of the detrusor muscle in the resected specimen could then be inked to assess margin status and thereby discerning a true perspective of level of resection, i.e., R0-R1.
Inadequacy of CT is not only judged by absence of detrusor muscle in an initial specimen, but also by the rate of recurrence. Recurrence is seen in 50-70% of non-muscle invasive bladder
cancer, mostly during the 1 st year. These may be due to incomplete resection, cell implantation or the tumor biology itself. [2] Incomplete resection seems to be the most important reason for the recurrence. In a review of seven randomized controlled trials, after controlling established factors for recurrence such as tumor size, multiplicity, stage and grade, it was concluded that a wide range of recurrence rate, i.e., 0-46%, was due to the difference in quality of resection. [3] Inadequate resection leading to higher rate of recurrence at the samesite is supported by another study where 81% of recurred tumor occurred at the site of previous resection. [4]
Various techniques using different kinds of loops and laser have been described to improve the quality of TURBT. En-bloc resection technique is one of the ways to provide better pathological evaluation for Ta and T1 tumors. In a study on ET, a flat loop electrode was used to resect tumors of less than 2.5 cm. [1] Although the authors did not describe presence or absence of detrusor muscle in the resected specimen, they concluded that invasion of lamina was better delineated with en-bloc resection. A limitation of this technique was the inability to use a flat loop for tumors located at the anterior and upper posterior wall. Another limitation was that tumor of more than 2.5 cm was considered a contraindication.
Regarding the learning curve, CLebR-ET is rather more controlled technique of resection than CT as it gives better hemostasis and thereby a good vision, which is crucial to avoid complications.
Depth of the resection could also be modified with ET and it does not take more than three cases to get a knack of this technique if it is started with a relatively small tumor.

Conclusion

CLebR has been proven safe and effective for both, treatment and pathological staging of NMIBC; therefore could be an appropriate tool for accurate staging with possibly lower scattering potential for the assessment and treatment of patients with NMIBC.
The objective advantage of accurate pathological examination (identification of microfocal invasion of lamina propria or of muscular wall, surgical margins assessment) is associated with a substantial safe technique. Long term data and larger dataset of cases are necessary to demonstrate an advantage in terms of recurrence or progression.

Reference

1. Herr HW, Donat SM. A re-staging transurethral resection predicts early progression of superficial bladder cancer. BJU Int 2006;97:1194-8.
2. Maruniak NA, Takezawa K, Murphy WM. Accurate pathological staging of urothelial neoplasms requires better cystoscopic sampling. J Urol 2002;167:2404-7.
3. Brausi M, Collette L, Kurth K, van der Meijden AP, Oosterlinck W, Witjes JA, et al. Variability in the recurrence rate at first follow-up cystoscopy after TUR in stage Ta T1 transitional
cell carcinoma of the bladder: A combined analysis of seven EORTC studies. Eur Urol 2002;41:523-31.
4. Mariappan P, Smith G, Lamb AD, Grigor KM, Tolley DA. Pattern of recurrence changes in noninvasive bladder tumors observed during 2 decades. J Urol 2007;177:867-75.

#156: A single institute retrospective analysis between laparoscopic partial nephrectomy and open partial nephrectomy for the treatment of highly complex renal tumors with PADUA score ≥10

Inviato da: francescok86@gmail.com

Argomenti: 

F. Chiancone1, M. Fabiano1, C. Meccariello1, M. Fedelini1, F. Persico1, P. Fedelini1
  • 1 Urology Department, AORN “A. Cardarelli” (Naples)

Objective

Partial nephrectomy(PN) is considered the standard of care in patients with T1 tumours for whom a PN is feasible by any approach, including open (1). PN achieves equivalent oncological outcomes with those of radical nephrectomy(RN) also in patient with RCC ≥4cm (2). The indications for (nephron sparing surgery) NSS are expanding with the use of minimal invasive techniques. Studies comparing laparoscopic and open PN found no difference in PFS and OS in centers with laparoscopic expertise (3). Anatomical classification systems, such as the PADUA score, help the surgeon to evaluate the complexity of the tumor. We considered complex renal tumors as Preoperative Aspects and Dimensions Used for an anatomical (PADUA) ≥10 (4). We report our experience in conservative treatment of highly complex renal tumors with PADUA score ≥10.

Materials and Methods

We retrospectively evaluated all the patients treated in our department from January 2015 to September 2019. All procedures were performed by a single surgical team. 21 patient underwent an open partial nephrectomy (OPN) (Group A) and 72 underwent a laparoscopic partial nephrectomy (LPN) (Group B). All OPN were performed with a retroperitoneal approach and all LPN were performed with a transperitoneal approach. Postoperative complications have been classified according to the Clavien-Dindo system. Only the complications with a score ≥3 were considered in the analyses. 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). Statistical analyses were conducted using SAS version 9.3 software(SAS Institute, Inc., NC)

Conclusion

LPN represents a feasible and safe procedure for renal tumours of a high surgical complexity if performed in highly experienced laparoscopic centres. The procedure offers good intraoperative outcomes and a low rate of post-operative complications.

Reference

1- B. Ljungberg (Chair), L. Albiges, K. Bensalah, A. Bex (Vice-chair), R.H. Giles (Patient Advocate), M. Hora, M.A. Kuczyk, T. Lam, L. Marconi, A.S. Merseburger, T. Powles, M. Staehler, A. Volpe; EAU Guidelines 2019
2-Lee H, Oh JJ, Byun SS, et al. Can partial nephrectomy provide equal oncological efficiency and safety compared with radical nephrectomy in patients with renal cell carcinoma (≥4 cm)? A propensity score-matched study. Urol Oncol 2017;35:379–85.
3- Gill IS, Kavoussi LR, Lane BR, Blute ML, Babineau D, Colombo JR Jr, Frank I, Permpongkosol S, Weight CJ, Kaouk JH, Kattan MW, Novick AC. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors.J Urol. 2007 Jul;178(1):41-6. Epub 2007 May 11.
4- Ficarra V, Novara G, Secco S, et al. Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery. Eur Urol 2009;56:786–9.
5- Mir MC et al.; Decline in renal function after partial nephrectomy: etiology and prevention.; J Urol. 2015 Jun;193(6):1889-98.
6-Chang KD et al.; Functional and oncological outcomes of open, laparoscopic and robot-assisted partial nephrectomy: a multicentre comparative matched-pair analyses with a median of 5 years' follow-up; BJU Int. 2018 Oct;122(4):618-626.
7-Mohamed Abdelhafez , Amend Bastian, Steffen Rausch, et al. Laparoscopic Versus Open Partial Nephrectomy: Comparison of Overall and Subgroup Outcomes. Anticancer Res, 37 (1), 261-265. Jan 2017
8- Michael W Patton, Daniel A Salevitz, Mark D Tyson 2nd et al. Robot-assisted Partial Nephrectomy for Complex Renal Masses. J Robot Surg, 10 (1), 27-31 Mar 2016
9-Patard JJ et al. Morbidity and clinical outcome of nephron-sparing surgery in relation to tumour size and indication. Eur Urol. 2007;52(1):148–154
10- Marszalek M et al.;Laparoscopic and open partial nephrectomy: a matched-pair comparison of 200 patients; Eur Urol. 2009;55(5):1171–1178
11- Francesco Porpiglia, Riccardo Bertolo, Enrico Checcucci et al. Development and Validation of 3D Printed Virtual Models for Robot-Assisted Radical Prostatectomy and Partial Nephrectomy: Urologists' and Patients' Perception. World J Urol, 36 (2), 201-207. Feb 2018

#163: Physical Activity decreases the risk of cancer progression in patients on active surveillance: a multicenter retrospective study

Inviato da: puldet@gmail.com

A. Brassetti1, F. Proietti2, G. Napodano3, R. Sanseverino3, F. Badenchini4, U. Anceschi1, M. Ferriero1, R. Mastroianni1, G. Tuderti1, M. Gallucci2, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Università "Sapienza" (Roma)
  • 3 Ospedale Umberto I (Nocera)
  • 4 Istituto Nazionale Tumori (Milano)

Objective

Active surveillance (AS) is a viable and recommended option for men diagnosed with low-risk (LR) prostate cancer (PCa). However, a non-negligible share of them will receive radical treatments within 10 years due tof disease progression. Exercise has been shown to delay PCa upgrading/upstaging in animal models but its role in humans remains unclear. In the present study, we assessed the effect of physical activity on disease progression in a cohort of patients on AS.

Materials and Methods

Two participating institutions shared data from their prospectively maintained AS databases in the context of the PRIAS (Prostate Cancer Research International Active Surveillance) protocol.
Baseline demographic, anthropometric, clinical and pathologic data were collected. All patients had no more than 2 Gleason score 6 positive cores at biopsy, baseline PSA &lt;10 ng/mL and PSA density &lt;0.2. A validated PASE (Physical Activity Scale for the Elderly) score was provided to patients for a self-assessment ofg physical activity. Sedentary lifestyle was accordingly stratified into three classes: mild (PASE ≥ 120), moderate (45120), severe (PASE ≤45).
Disease progression (DP) was defined as PCa upgrading and/or upstaging. Chi square and Mann-Withney tests compared categorical and continuous variables, respectively. Uni-/multivariable Cox regression analyses assessed predictors of DP. Kaplan-Meier method was performed to estimate the predictive role of the three Sedentary lifestyle classes on the same outcome.

Results

Overall, 85 patients were included in the analysis with a median age of 66 (IQR 59-70) years and a BMI of 25.3 (23.5-27). Overall, 14 (16%) were active smokers, 7 (8%) were obese and one presented with metabolic syndrome. Median PASE score was 86 (61.5-115.8). DP occurred in 29% (n=25) of patients. Patients who experienced DP were comparable to those who did not for all baseline variables but PASE score (69.3 vs 87.8; p=0.05). Univariable Cox regression analysis identified physical activity as the only significant predictor of DP (HR 0.98, 95%CI 0.97-0.99, p=0.014). At Kaplan Meier analysis PASE stratification effectively depicted the risk of upgrading/upstaging during AS (log rank p=0.028).

Conclusion

Physical activity, assessed by means of the validated PASE questionnaire, represents a significant driver of PCa upgrading/upstaging during AS. Results from the upcoming randomized controlled trials are awaited to confirm our data.

#180: Combined assessment of main outcomes of partial or total adrenalectomy for functioning adrenal masses: a novel trifecta

Inviato da: puldet@gmail.com

U. Anceschi1, A. Brassetti1, G. Tuderti1, M. Costantini1, R. Mastroianni1, A. Bove1, M. Ferriero1, O. Zappalà2, A. Carrara2, M. Motter2, C. Fiori3, B. De Concilio4, F. Porpiglia3, G. Tirone2, A. Celia4, M. Gallucci5, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Ospedale regionale Santa Chiara (Trento)
  • 3 Ospedale San Luigi (Orbassano)
  • 4 Ospedale San Bassiano (Bassano del Grappa)
  • 5 Università "Sapienza" (Roma)

Objective

There is lack of validated tools to evaluate surgical and functional outcomes of partial (PA) and total adrenalectomy (TA) for unilateral benign disease. The aim of this study was to assess the impact of a novel trifecta for the evaluation of outcomes of patients with a solitary, functioning adrenal mass, treated with either minimally-invasive PA (MIPA) or TA (MITA) at four different institutions.

Materials and Methods

From March 2011 to October 2019, we analyzed a multicentric dataset of 109 consecutive patients who underwent MIPA (n=32) or MITA (N=77) for unilateral Conn’s syndrome (n=92) or pheochromocitoma (n=17). Trifecta was defined as “no clinical symptoms at 1 year follow-up”; “no major complications (Clavien 3-5)”; “no use of any speficic drug treatment at 1-year follow-up”. Baseline demographic, perioperative and functional data were collected and reported. Trifecta outcomes were assessed for MIPA and MITA. A descriptive analysis was used.

Results

Baseline, demographic and perioperative data are reported in Table 1. At a mean follow-up of 42,4 months (IQR 30-53) overall trifecta outcomes were achieved by 59 patients (54.1%). The trifecta rates for MIPA and TAPA were 65.6% and 49.4, respectively (p=0.12) (Fig.1).. No perioperative complications were observed in the PA group while the perioperative complications rate in the TA series was 13%.

Conclusion

We described a novel and reproducible clinical tool as an indicator of both surgical quality and clinical outcomes of minimally-invasive adrenalectomy for benign disease. In experienced centres, trifecta outcomes may be achieved approximately by half of the patients independently of the surgical approach chosen. In our series the quest for trifecta seems to be better accomplished by an adrenal-sparing approach, which is likely to become an established treatment in the urological armamentarium.

#184: Female pelvic prolapse: Considerations on Mesh Surgery and our experience with InGYNious(Ami tm) Mesh in 74 women with complicated pelvic Prolapses

Inviato da: edoardo.tartaglia@aslroma2.it

Argomenti: 

E. Tartaglia1, S. Signore1, G. Baffigo1
  • 1 Ospedale Sant'Eugenio, U.O.C. Urologia (Roma)

Objective

Pelvic organ prolapse (PoP) is a common condition in women. In fact in lifetime
the pelvic support system in and around a woman’s vagina weakens or collapses.
Among all current treatment options, surgery can be augmented with implantation
of mesh or graft materials. (1, 2, 3 )Different kinds of meshes have been developed.
During the last 4 years we treated 74 women with complicated pelvic prolapses by using a
new generation prolene mesh with single incision procedure and fixing points with I stich device
Then we analysed the results.

Materials and Methods

Seventy-four women underwent surgery for the correction of PoP using a prolene
mesh. All patients presented a III-IV stage prolapse (PoP Q criteria) and were
studied by urodynamics and cystography. In 55 women we positioned an anterior
mesh, in 19 women an anterior vault mesh. In 44 patients with SUI a sling under the urethra
was also positioned. The follow-up took place after 24 months and
urogyneaecological evaluation was performed after 1, 3, 6, 12, 20 months of surgery

Results

No vascular or visceral complications occurred. In 5 (6,7%) cases a mild perineal
hematoma occurred and in 5 (6,7%) cases presacral pain needed antinflammatory
drugs.. Three erosions of the mesh were recorded in 4 (5,4%), but nothing was removed.
Three II degree cystocele (4%) occurred. 3 (4%) presented in second post operative day
renal colic with hydronephrosis of 2 degree with TAC
An ureteral double J stent for 4 weeks has solved the problem
All patients are continent.

Discussions

We don't have serious complicance and the patients have good results and satisfaction
The new generation ultralight mesh presente less erosion and complications

Conclusion

A better knowledge is required regarding indications, efficay and safety of mesh
and graft usage with a validated and generally accepted measure of subjective
prolapse symptoms. However the surgical repair of the PoP by using new generation mesh
appears to be an extremely effective and safe procedure with encouraging outcomes, even in
complicated cases.

Reference

1. PetroS P.e., UlMSten U. :
An Integral Theory of Female urinary incontinence.
acta obstetricia et gynecologica Scandinavica 1990,69:1-79.
2. PetroS P.e. :
Vault prolapse II: restoration of dynamic vaginal supports by infracoccygeal
sacrocolpopexy, an axial day-case vaginal procedure.
int Urogynecol J Pelvic Floor Dysfunct 2001;12:296-303.
3. De lancey:
The anatomy of the pelvic floor.
obstet ginecol, 1994; 6: 313-316.
Urogynaecologia international

#276: Use of a complexed nutraceutical product based on flower pollen extract, vitamin B1, vitamin B2, vitamin B6, vitamin B12, vitamin PP and folic acid to lower prostate-specific antigen (PSA) levels in patients with asymptomatic benign prostate hyperplasia (BPH)

Inviato da: francescok86@gmail.com

M. Carrino1, M. Fasbender Jacobitti1, F. Chiancone2, D. Di Lorenzo2, L. Pucci2, P. Fedelini2
  • 1 Andrology Department, A.O.R.N. “A. Cardarelli" (Naples)
  • 2 Urology Department, A.O.R.N. “A. Cardarelli” (Naples)

Objective

“Modern” nutraceutical products are frequently used in uro-andrology [1,2]. Medicinal plants are excellent devices for the treatment of symptoms due to benign prostate hyperplasia (BPH) and other urological disorders (e.g., chronic pelvic pain syndrome and chronic prostatitis) [3] thanks to their antioxidant, anti-proliferative and anti-inflammatory effects [4,5]. The aim of our study is to determine efficacy of complexed nutraceutical product based on flower pollen extract, vitamin B1, vitamin B2, vitamin B6, vitamin B12, vitamin PP and folic acid to lower of prostate-specific antigen (PSA) with values between 4 and 10 ng/ml (so-called "gray zone") in patients with asymptomatic BPH.

Materials and Methods

26 men aged 60.53 (SD=4.24), mean PSA 7.35 ng/ml (SD=2.91), affected by asymptomatic BPH were treated with a nutraceutical product containing flower pollen extract and a multivitamin complex for three months. The therapeutic protocol provided for the administration of 2 tablets a day (together) to take 30 minutes before the main meal. Inclusion criteria were defined as follows:
 total PSA in a range of 4.0-10.0 ng/ml;
 prostate volume &lt;50 ml (by suprapubic ultrasound);
 digital rectal examination (DRE) negative for suspicious nodularity of gland;
 past medical history negative for previous pelvic surgery;
 no therapies in course with other phytotherapeutic agents, alpha-blockers, inhibitors of 5-alpha reductase (5-ARI), antibiotics by systemic route or anti-inflammatory drugs;
 absence of stone in bladder (by ultrasound assessment);
 negativity to Chlamydia Trachomatis test, Ureaplasma Urealyticum and Neisseria Gonorrhoeae;
 International Prostate Symptom Score (I-PSS) equal to zero.

Results

The dosage of PSA was performed at laboratories of our hospital at the time of the enrollment visit, at the first visit (D0), at the first check-up visit after 90 days (D90) and at the second check-up visit after 120 days (D120).
At D90 the PSA in 18 patients had a reduction of 33.5% and in 3 patients had a reduction of 15.3%. In one patient, the PSA did not have a significant reduction (0.9%), while in 4 patients there was a 39.3% increase. For this reason, these patients left the protocol and were subjected to multiparametric magnetic resonance imaging (mpMRI) using the Prostate Imaging-Reporting and Data System (PI-RADS) v2.1. In 3 patients PI-RADS score was 3, while in one patients the score was 4.
At D120 the PSA has remained stable in all patients without significant changes, while in 3 patients there was a slight increase (1.4%). No gastric or general side effects have been noticed during whole clinical study.

Discussions

Flower pollen extracts have provided evidence for efficacy and tolerability for the treatment of BPH and chronic prostatitis. Flower pollen extract is an effective anti-inflammatory nutraceutical product, thanks to inhibition of prostaglandin and leukotrienes synthesis as well as the inhibition of many cytokines as NF-kB (nuclear factor kappa-light-chain-enhancer of activated B cells) [6]. Lowering of PSA levels it can be useful to discriminate patients with asymptomatic BPH from those who need further tests like mpMRI or prostate biopsy. A limitation of the study was the low number of the patients. More randomized studies should be carried out to clarify the precise role of these active ingredients and their interactions.

Conclusion

In literature, flower pollen extracts and other nutraceutical products have shown the improvement of urinary symptoms and overall quality of life of patients affected by BPH [7]. This can be demonstrated with a significant reduction in PSA as an index of prostate inflammation. Therefore, this therapy can be useful to discriminate against patients with PSA in &quot;gray zone&quot; who need further assessments.

Reference

1. Allkanjari O, Vitalone A. What do we know about phytotherapy of benign prostatic hyperplasia? Life Sci. 2015 Apr 1;126:42-56. doi: 10.1016/j.lfs.2015.01.023. Epub 2015 Feb 20.
2. Pagano E, Laudato M, Griffo M, Capasso R. Phytotherapy of benign prostatic hyperplasia. A minireview. Phytother Res. 2014 Jul;28(7):949-55.3
3. Maurizi A, De Luca F, Zanghi A, Manzi E, Leonardo C, Guidotti M, Antonaccio FP, Olivieri V, De Dominicis C. The role of nutraceutical medications in men with non bacterial chronic prostatitis and chronic pelvic pain syndrome: A prospective non blinded study utilizing flower pollen extracts versus bioflavonoids. Arch Ital Urol Androl. 2019 Jan 18;90(4):260-264.
4. Cicero AFG, Allkanjari O, Busetto GM, Cai T, Larganà G, Magri V, Perletti G, Robustelli Della Cuna FS, Russo GI, Stamatiou K, Trinchieri A, Vitalone A. Nutraceutical treatment and prevention of benign prostatic hyperplasia and prostate cancer. Arch Ital Urol Androl. 2019 Oct 2;91(3).
5. Pirola GM, Puliatti S, Bocchialini T, Martorana E, Micali S, Bianchi G. Efficacy of pollen extract in association with group B vitamins for pain relief in chronic prostatitis/chronic pelvic pain syndrome: A survey of urologists&#039; knowledge about its clinical application. Arch Ital Urol Androl. 2017 Mar 31;89(1):22-25.
6. Cai T, Verze P, La Rocca R, Anceschi U, De Nunzio C, Mirone V. The role of flower pollen extract in managing patients affected by chronic prostatitis/chronic pelvic pain syndrome: a comprehensive analysis of all published clinical trials. BMC Urol. 2017 Apr 21;17(1):32.
7. Macchione N, Bernardini P, Piacentini I, Mangiarotti B, Del Nero A. Flower Pollen Extract in Association with Vitamins (Deprox 500®) Versus Serenoa repens in Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Comparative Analysis of Two Different Treatments. Antiinflamm Antiallergy Agents Med Chem. 2019;18(2):151-161.

#186: Clinical and psychological outcomes of patients undergoing Retrograde Intrarenal Surgery and Miniaturised Percutaneous Nephrolithotomy for kidney stones. A preliminary study Outcomes of surgery for kidney stones

Inviato da: eugeniodigrazia@hotmail.com

Argomenti: 

D. Di Mauro1, V.L. La Rosa2, S. Cimino1, F. Nicolosi3, L. D'Arrigo4, E. Di Grazia3
  • 1 UNICT, Dipartimento di Urologia (Catania)
  • 2 ARNAS Garibaldi (Catania)
  • 3 Ospedale S. Marco, U.O.C Urologia (Catania)
  • 4 Azienda Cannizzaro, U.O.C. Urologia (Catania)

Objective

Objective: To assess disease-specific and health-related QoL, anxiety and depression as well as satisfaction regarding RIRS and mPCNL intervention for kidney stones up to 2.5 cm. Secondarily, pain as well as perioperative and postoperative patient outcomes were evaluated.

Conclusion

These results open new scenarios in the treatment of kidney stones up to 2,5 cm when RIRS and mPCNL have interchangeable indications. Since in our experience complications and success rate are similar, the surgical choice of switching from RIRS to mPCNL in real-time and viceversa may be proposed to the patient in the preoperative counseling.

Reference

1. Davis NF, Quinlan MR, Poyet C, et al. Miniaturised percutaneous nephrolithotomy versus flexible ureteropyeloscopy: a systematic review and meta-analysis comparing clinical efficacy and safety profile. World J Urol. 2018 Jul;36(7):1127-38. PubMed PMID: 29450733. Epub 2018/02/17.
2. Garcia SF, Cella D, Clauser SB, et al. Standardizing patient-reported outcomes assessment in cancer clinical trials: a patient-reported outcomes measurement information system initiative. J Clin Oncol. 2007 Nov 10;25(32):5106-12. PubMed PMID: 17991929. Epub 2007/11/10.
3. Penniston KL, Antonelli JA, Viprakasit DP, et al. Validation and Reliability of the Wisconsin Stone Quality of Life Questionnaire. J Urol. 2017 May;197(5):1280-8. PubMed PMID: 27889419. Epub 2016/11/28.
4. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983 Jun;67(6):361-70. PubMed PMID: 6880820. Epub 1983/06/01.
5. Heller GZ, Manuguerra M, Chow R. How to analyze the Visual Analogue Scale: Myths, truths and clinical relevance. Scand J Pain. 2016 Oct;13:67-75. PubMed PMID: 28850536. Epub 2017/08/30.
6. de la Rosette JJ, Opondo D, Daels FP, et al. Categorisation of complications and validation of the Clavien score for percutaneous nephrolithotomy. Eur Urol. 2012 Aug;62(2):246-55. PubMed PMID: 22487016. Epub 2012/04/11.

#187: Renal Cell Carcinoma associated with pancreatic metastasis: a case raport

Inviato da: cotugnomichele25@gmail.com

Argomenti: 

M. Cotugno1, M. Potenzoni1, F. Cantoni1, D. Martens1, A. Savino1, S. Rollo2, A. Prati1
  • 1 Ospedale di Fidenza, U.O.C. Urologia (Fidenza)
  • 2 Ospedale di Fidenza, U.O.C. Chirurgia Generale (Fidenza)

Objective

We describe a case of right nephroureterectomy and contextual pancreatic nodulectomy in a patient with Renal Cell Carcinoma (RCC) associated with pancreatic metastasis.

Materials and Methods

81-year-old female patient. Medical history of compensated DM, hypertension, colonic diverticulosis, right mastectomy and adjuvant chemotherapy ( previous breast cancer). He went to our hospital institution for right abdominal pain not associated with other significant symptoms. Blood tests showed modest leukocytosis and a marked increase in PCR. Amylase and Lipase were regular. An abdominal ultrasound was performed that showed a lesion on the lower pole of the right kidney (9 x 6 cm) associated with hypo-anecogenic lesion of the pancreatic body (2,7 cm). Given the clinical and ultrasound picture, it was decided to perform a CT Abdomen with mdc which showed a heteroplasia of the lower pole of the right kidney (6,5 x 9 cm) inhomogeneously hypervascularized and with a central necrotic hemorrhagic area. In the perilesional area there were arterio-venous vascular ectasias with shunt effect. In the proximal portion of the pancreatic body there was a hypervascular nodular lesion (2 x 3 cm) compatible with pancreatic localization of RCC. This lesion caused dilation of the Wirsung. Given the good performance status of the patient, after multidisciplinary consultation it was decided to perform right nephro-adreno-ureterectomy and contextual removal of the pancreatic nodule (laparotomic technique). The wirsung duct upstream of the lesion was inoculated with Nelaton's catheter. This allowed the drainage of pancreatic juices outside the patient in post-surgery. The tract of Wirsung afferent to the duodenum was dissected with Ligasure to prevent the reflux of duodeno-gastic or bile juices. Two 24 ch tubular drainages were left (one in the renal loggia the other in the pancreatic loggia)

Results

The post-operative course was regular. Renal drainage was removed on 3th day and pancreatic drainage on 6th. The Nelaton catheter was removed on the 12th day. The patient was discharged in the 14th day with blood tests in the standard except for a modest anemia (Hb 9.9 g / dl) and leukocytosis (11000). The outcome of the histological examination was: clear cell RCC, 4° grade (sec. WHO / ISUP), TNM stage pT3a, Nx, M1. Pancreatic lesion was confirmed by clear cell RCC metastasis. Following oncologist counseling, the patient started targhet terapy with sunitinib. At the first postoperative control CT (3 months after surgery) there are no signs of local and distant recurrence. Pancreas preservation did not induce diabetic decompensation. Renal function was at Creatinine values ​​of 1.6 mg/dl.

Discussions

Metastasis in the pancreatic gland is infrequent, representing between 2-5% of the tumors that affect this organ. However, secondary lesions of clear cell renal carcinoma (CCRC) can occur mainly in this location and it is frequently the only site of dissemination (1). Many authors support the effectiveness of treatment in patients with good performance status even considering the fact that pancreatic resection for RCC showed better survival compared to other non-renal cell cancer (2). The European Metastatic RCC Guidelines state that cytoreductive nephrectomy in patients with complete contextual resection of a single metastasis or few metastases could increase survival and delay therapy systemic. This is supported by a low degree of evidence (level 3) (3). Zerbi et al. have shown that pancreatic metastatectomy can be beneficial in terms of OS compared to non-treatment (4). However, it remains to be clarified which category of patient with Metastatic RCC can really benefit from a surgical treatment of metastasis and primary tumor. What is certain is that the use of the IMDC (Metastatic Renal Cancer Database Consortium) can actually direct us to the most appropriate therapeutic choice. In this regard, the EAU suggests to offering cytoreductive nephrectomy to patients with metastatic RCC to low and intermediate risk (4). The decision to subject the patient to surgery was dictated by the fact that she had a good performance status and that she was in the low-risk category according to IMDC.

Conclusion

Our opinion is that in selected patients with good performance status radical surgery (of the primary and possibly secondary lesion) should be taken into consideration as it can improve oncological and functional outcomes.

Reference

(1) The pancreas as a target of metastasis from renal cell carcinoma: Results of surgical treatment in a single institution.
Ann Hepatobiliary Pancreat Surg. 2019 Aug;23(3):240-244. doi: 10.14701/ahbps.2019.23.3.240. Epub 2019 Aug 30.
Glinka J, Sanchez Claria R, Ardiles V, de Santibañes E, Pekolj J, de Santibañes M, Mazza O.
(2) Metastatic tumors to the pancreas: a systematic review and meta-analysis.
Minerva Chir. 2016 Oct;71(5):337-44. Epub 2016 Jul 14.
Sperti C, Pozza G, Brazzale AR, Buratin A, Moletta L, Beltrame V, Valmasoni M.
(3) EAU Metastatic RCC Guidelines 2018
(4) Pancreatic metastasis from renal cell carcinoma: which patients benefit from surgical resection? Ann Surg Oncol, 2008. 15: 1161.
Zerbi A, et al.

#188: Videolaparoscopic nephrectomy for retroperitoeneal angiosarcoma: case report

Inviato da: cotugnomichele25@gmail.com

Argomenti: 

M. Cotugno1, F. Cantoni1, M. Potenzoni1, S.P.C. Destro1, D. Martens1, N. Uliano1, A. Prati1
  • 1 Ospedale di Fidenza, U.O.C. Urologia (Fidenza)

Objective

We describe the case of retroperitoenal angiosarcoma treated at our center with laparoscopic technique.

Materials and Methods

71-year-old male patient. Not significant medical conditions. LUTS in good compensation with alpha-lytic. For 3-4 months he complained of chronic lumbar pain and significant fatigue. Several episodes of mild fever had occurred during this pain symptomatology. For this reason he decided to go to the our istitute where he performed abdominal ultrasound that showed left retroperitoenal mass with inhomogeneous echogenicity that seemed to derive from the homolateral kidney. Given the ultrasound it was decided to perform abdomen CT with mdc which showed an inhomogeneous retroperitoneal neoformation (8 cm x 5 cm) with markedly necrotic zones and peripheral hypervascularization. A safe cleavage plan from the ipsilateral kidney was not detected. The difficult characterization of imaging has led us to perform an eco-guided biopsy whose histological examination has show papillary-like frustules with sclero-hyaline stromal axes lined with mesothelial-like elements without clear atypia. .Given the histological examination, the good performance status and the probable absence of secondary reactions, it was decided to perform a laparoscopic radical nephrectomy.

Results

The post-operative course was regular. The patient was discharged on the 6th day, it was asymptomatic with hemoglobin values ​​of 14 g / dl and Creatinine of 1.38 mg / dl. The outcome of the histological examination showed for neoformation of the posterior perirenal adipose tissue (8 x 4.5 x 3.5 cm), brownish, multi-buried. The renal tissue did not show significant macroscopic alterations. The miscroscopic description relates to angiosarcoma of the retroperitoenal soft tissues, G3 sec FFCCCS (stage pT2). The lesion was in contact with the renal capsule which was not infiltrated. Following oncological evalutation the patient performed a first chemotherapy cycle with doxorubicin and gemcitabine. At 4 months the patient performed a negative abdomen CT due to local recurrence and secondary disease. Blood tests performed on this occasion were regular, including renal function (creatinine 1.2 mg / dl) and hemoglobin (14,3 g / dl). He is currently waiting to perform a second cycle of chemotherapy.

Discussions

Renal and retroperitoneal angiosarcoma is extremely rare but very aggressive tumor with often unfavorable progonosis (1). These tumors are predominantly found in older men (60-70 years of age) (2, 3). Patients with renal angiosarcoma frequently present with have pain and a palpable mass (2, 4). Due to the rarity of this tumor, there are no standard treatment guidelines for primary renal angiosarcomas (1, 3). Having said that most of the cases cited in the literature have been treated by performing a radical nephectomy (2, 3) and this was also done this time in our center also in relation to the fact that it is frequently difficult to differentiate between a primary kidney tumor or an extrarenal lesion.

Conclusion

Retroperitoneal angiosarcoma is an extremely rare and aggressive neoformation. Most of the times it is difficult with image diagnostics to differentiate between primitively renal or external kidney tumors. Our opinion is that in patients with good performance status and with localized disease, radical nephrectomy must be considered as part of a multimodal treatment.

Reference

1. Qayyum S, Parikh JG, Zafar N. Primary renal angiosarcoma with extensive necrosis: a difficult diagnosis. Case Rep Pathol. 2014;2014:416170.
2. Omiyale AO. Clinicopathological features of primary angiosarcoma of the kidney: a review of 62 cases. Transl Androl Urol. 2015;4:464-73.
3. Omiyale AO, Carton J. Clinical and Pathologic Features of Primary Angiosarcoma of the Kidney. Curr Urol Rep. 2018;19:4.
4. Zhang HM, Yan Y, Luo M, Xu YF, Peng B, Zheng JH. Primary angiosarcoma of the kidney: case analysis and literature review. Int J Clin Exp Pathol. 2014;7:3555-62

#189: “What do our boys know about sex?” Preliminary data of a new questionnaire for the evaluation of the knowledge of sexuality among adolescents

Inviato da: francescok86@gmail.com

Argomenti: 

F. Persico1, F. Chiancone1, R. Giannella1, L. Pucci1, M. Fasbender Jacobitti2, P. Fedelini1, M. Carrino2
  • 1 Urology Department, AORN “A. Cardarelli” (Naples)
  • 2 Andrology Department, AORN “A. Cardarelli” (Naples)

Objective

Adolescents under age 18 are underrepresented in sexual health research, resulting in a lack of data about the consciousness of young people about these issues. The aim of this study was to assess the knowledge about sexuality of adolescents under the age of 18.

Materials and Methods

The participants were enrolled during a cultural exchange project in September 2019. Adolescents were aged between 13 and 18 years. They come from four different countries: Italy, Portugal, Romania end Greece. The questionnaire was administered anonymously. The parents of the participants had previously signed a specific informed consent. Instructions were as follows: “We are conducting research on adolescent knowledge about sexuality. We invite you to answer as sincerely as possible after having read the instructions carefully. The information collected will not be subject to any merit assessment and will be considered strictly confidential. We thank you for the collaboration.” The survey consisted of three parts. The first part concerned generic anthropometric data and a subjective evaluation of the personal knowledge of sexuality and sexual health. The second part contained questions concerning knowledge of the male and female genitourinary system, physiology of reproduction, meaning of terms concerning the sexual sphere, contraceptive methods and sexually transmitted infections. The third part questioned the participants about personal sexual habits.

Results

The sample was comprised of 80 participants (M age = 16.33 years, SD = .97), 55% of whom identified as female, 45% male. Additional sample characteristics are presented in Table 1. 12.5 % of the participants believed they had insufficient knowledge of sexuality; 38.75 % scarce; 35 % sufficient; only 13.75 % believed they had a large knowledge of the subject. The main form of information was represented by internet (51.2%), followed by friends (28.75%). Only the 5% of the adolescents who completed the study stated that they had obtained information from doctors or scientific books. The other sources of information are summarized in Table 2. The percentage of correct and incorrect answers for each questions of Part 2 is shown in Table 3. Analyzing the data of part 3, we noticed that only the 10% had a stable partner. The 27.5 % of the participants has had a complete sexual intercourse. The 41.3 % had a regular masturbatory activity. 95.5 % of sexually active subjects used contraceptive methods; of these, the most common was the condom (85.7%), followed by the pill (14.3%). The other information is summarized in Table 4. 55 % of the participants had never talked to somebody about sexuality. Among those who had spoken with someone (45%), the preferred interlocutors were friends (61 %), followed by family members (22.2 %) and teachers (8.3). Additional data are presented in Table 5.

Discussions

Adolescents are at elevated risk for adverse sexual and reproductive health outcomes relative to their habits, including HIV, sexually transmitted infections (STIs) and unplanned pregnancy (1). The importance of sexual education is often underlyed in schools. Data from the first part indicated that young people did not believe they had sufficient knowledge of sexuality. In fact, 12.5 % of the participants believed they had insufficient knowledge of sexuality; 38.75 % scarce. Moreover, the first source of information was represented by internet for the 51.25% of the adolescents. Unfortunately, the web could be a source of distorted and misleading contents, especially in inexperienced hands. Although the participants declared to have a sufficient (35%) or large (13.75%) knowledge of the subject, we noticed that the percentage of correct answers was of only of 66.7%. Most errors were concentrated in the questions concerning the physiology of reproduction and in those concerning specific terminology. The results of questions concerning the anatomy of the genitourinary system and contraceptive methods and sexually transmitted infections were better. Data of the third part showed how the percentage of sexually active subjects was of 27.5%. Of these, only the 10% had a stable relationship. Teenagers had difficulty talking about sexuality, in particular, with family and doctors. About 55% of participants declared that they never discussed this topic with someone. Often confidants were represented by friends. This could increase confusion and misinformation, leading to incorrect behaviors and lifestyles. Our study has some limitations, first of all the sample size. However, it represents a preliminary experience which, if implemented on a larger scale, could be useful to assess the knowledge of sexual health among European adolescents.

Conclusion

We strongly encourage European nations to spread the importance of studying sexual health among adolescents in schools, creating targeted educational programs (2). Improving adolescents’ knowledge of these issues could help reduce the number of sexual health problems, such as sexually transmitted infections or unplanned pregnancies.

Reference

1. Axinn WG et al.; Mixed method data collection strategies; New York: Cambridge University Press; 2006
2. Brian Dodge, Michael Reece, Debby Herbenick et al. School-based Condom Education and Its Relations With Diagnoses of and Testing for Sexually Transmitted Infections Among Men in the United States. Am J Public Health, 99 (12), 2180-2 Dec 2009

#192: Androgen receptor copy number and circulating tumor cells as liquid biopsy profiling in castration resistant prostate cancer patients treated with cabazitaxel

Inviato da: fiorifo@tin.it

G. Gurioli1, S. Gargiulo1, V. Conteduca2, R. Gunelli3, M. Pulvirenti3, E. Fragalà3, C. Salaris3, E. Scarpi4, A. Altavilla2, C. Lolli2, G. Schepisi2, N. Brighi2, U. De Giorgi2
  • 1 Bioscience Laboratory, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS (Meldola)
  • 2 Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS (Meldola)
  • 3 Department of Urology, Morgagni Pierantoni Hospital (Forlì)
  • 4 Biostatistics Unit and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS (Meldola)

Objective

Cabazitaxel demonstrated overall survival (OS) benefit for the treatment of metastatic castration resistant prostate cancer (mCRPC) patients progressing after docetaxel [1]. Predictive biomarkers able to identify responsive patients are urgently needed to improve outcome of mCRPC patients. Liquid biopsy, including circulating plasma DNA and circulating tumor cells (CTCs), has the potential to guide treatment decision. Plasma androgen receptor (AR) copy number (CN) status has been identified as one of potential biomarker of response in patients with mCRPC receiving docetaxel [2] or the AR-targeted therapies (abiraterone or enzalutamide) [3]. CTCs profiling could also help to establish novel biomarkers. In this study (NCT03381326), we aimed to evaluate the prognostic role of plasma AR CN and CTCs biomarkers expression in mCRPC patients treated with cabazitaxel.

Materials and Methods

We included patients receiving cabazitaxel from January 2015 to December 2018. Progressive disease was defined according to Prostate Cancer Working Group 2 (PCWG2) criteria. Plasma DNA was isolated using QIAamp Circulating Nucleic Acid Kit and digital PCR was performed to assess AR CN status. CTCs enrichment was evaluated with AdnaTest EMT-2/StemCell kit. Expression analyses using real time PCR were performed for 17 genes and CTCs positivity was defined as the expression of at least one of the following seven relevant markers: AR-V7, AKT, AR, EPCAM, PSMA, PI3KCA, PSCA. This study is partially funded by Sanofi Genzyme.

Results

We enrolled 80 patients, all receiving prior docetaxel and 85% prior abiraterone and/or enzalutamide. Median age was 72 years (range 49-82). Median OS and progression-free survival (PFS) were 16.4 months (95% CI 11.1-27.0) and 6.7 months (95% CI 5.2-8.3), respectively. Baseline plasma AR CN gain was detected in 36 (45%) patients. AR CN normal and AR CN gain patients had a OS of 27 and 11.1 months, respectively (p=0.013). AR CN normal and AR CN gain patients had a PFS of 8.5 and 5.9 months, respectively (p=0.032). Fifty-eight (72.5%) patients showed CTCs positivity at baseline, whose 15 (26%) expressed &gt;3 markers in CTCs. Significantly worse OS was observed in patients with &gt;3 markers expressed in CTCs compared to those with ≤3 markers and CTCs negative patients [4.7 months vs 15.2 vs 31.7 months respectively, hazard ratio 6.05 (95% CI 2.07-17.73), p=0.004]. No significant difference was observed for PFS and PSA response. Twenty-eight patients showed AR CN gain and CTCs positivity, whose 9 expressed ≥3 markers, whereas 30 patients showed AR CN normal and CTCs positivity, whose 6 expressed ≥3 markers. No significant correlation between AR CN and CTCs positivity was found (p=0.3130). Expression analyses on CTCs biomarkers are ongoing.

Discussions

In this study we have investigated the role of AR CN and CTCs positivity in stratifying mCRPC patients treated with cabazitaxel. We found significantly worse OS and PFS in patients with AR CN gain compared to AR CN normal. These results are in line with those found in a recent multicenter study [4]. Moreover, we observed a significantly shorter OS in patients expressing &gt;3 markers compared to the others, showing the importance to characterize CTCs expression markers. Although no significant correlation was found between AR CN and CTCs positivity, ongoing expression analyses could reveal potential responsive or more aggressive tumors, leading to a better personalized treatment selection.

Conclusion

Liquid biopsy profiling, beyond any single biomarker, may improve prognostication of mCRPC patients treated with cabazitaxel. Further prospective larger studies are needed to validate the results.

Reference

[1] De Bono J. S. et al., Prednisone plus cabazitaxel or mitoxantrone for metastatic castration-resistant prostate cancer progressing after docetaxel treatment: A randomised open-label trial, Lancet, 2010.
[2] Conteduca V. et al., Plasma Androgen Receptor and Docetaxel for Metastatic Castration-resistant Prostate Cancer., Eur Urol. 2019.
[3] Conteduca V et al., Androgen receptor gene status in plasma DNA associates with worse outcome on enzalutamide or abiraterone for castration-resistant prostate cancer: a multi-institution correlative biomarker study. Ann Oncol., 2017.
[4] Conteduca V et al., Plasma AR status and cabazitaxel in heavily treated metastatic castration-resistant prostate cancer, Eur. J. Cancer, 2019.

#129: Colpo-istero-sacropessi laparoscopica: gold standard terapeutico per la correzione dei prolassi urogenitali

Inviato da: rnucciotti@gmail.com

Argomenti: 

R. Nucciotti1, C. Gulia1, F.M. Costantini1, E. Santini1, A. Bragaglia1, F. Viggiani1
  • 1 Ospedale della misericordia (Grosseto)

Objective

Abdominal sacrocohysteropexy is the gold standard treatment for pelvic organ prolapse (POP) and can be performed laparoscopically. The demand for treatment of pelvic floor disorders has been projected to increase significantly in the coming years, as Western countries are experiencing a rapid increase in the geriatric demographic. The prevalence of pelvic organ prolapse (POP), defined as stage ≥2 prolapse using the Pelvic Organ Prolapse Quantification (POP-Q) examination, was reported to be 37% in the general population and increased to 64.8% in an older population of women with a mean age of 68 yr . . To evaluate the surgical outcome, complications and benefits of laparoscopic single promonto-fixation for patients with pelvic prolapse.

Materials and Methods

Abdominal sacrocohysteropexy is the gold standard treatment for pelvic organ prolapse (POP) and can be performed laparoscopically. The demand for treatment of pelvic floor disorders has been projected to increase significantly in the coming years, as Western countries are experiencing a rapid increase in the geriatric demographic. The prevalence of pelvic organ prolapse (POP), defined as stage ≥2 prolapse using the Pelvic Organ Prolapse Quantification (POP-Q) examination, was reported to be 37% in the general population and increased to 64.8% in an older population of women with a mean age of 68 yr . . To evaluate the surgical outcome, complications and benefits of laparoscopic single promonto-fixation for patients with pelvic prolapse.

Results

A total of 243 patients were operated upon between 2005 and 2015. Their mean age was 63 (range 35–78), average follow-up was 14.6 months, the mean operating time was 102 minutes. There were 2 conversions due to anesthetic or surgical difficulties. Follow up was done by a postal questionnaire and physical examination at 6 months and then yearly. 96% were satisfied with the results of their operation and no patients complained of sexual dysfunction. There was a 2% recurrence rate of prolapse, 0 vaginal erosions. Perioperative complications were one vaginal effraction . The mean hospital stay was 3 days (2–5) . We observed no retraction of the mesh and no dyspareunia.With this type of conformation of the posterior mesh we have significantly reduced the dischezia compared to double promonto-fixation.

Discussions

Laparoscopic promonto-fixation is feasible and highly effective technique that offers good long-term results with complication rates similar to open surgery, with the added benefits of minimally invasive surgery We consider unnecessary remove uterus and promontory attached of the posterior mesh, reducing the risk of erosion, constipation and dischezia. De novo urgency was observed in 10 patients (10.5%) who had had previous high-grade cystocele (five with concomitant prolapse of other compartments). The symptoms were treated with short-term anticholinergic medications and always resolved in the first few weeks after surgery. Laparoscopic approach was developed to reduce surgical invasiveness and was shown to achieve similar results compared with the open approach . However, the procedure is technically challenging, particularly because of the need to perform intracorporeal sutures in a limited space, and is characterised by relatively long operative times.

Conclusion

With this technique we performed a complete treatment for severe prolapse by a minimally invasive approach with a low rate of recurrence at this point. Our technique of RASC with implant of polypropylene meshes is associated with low morbidity and good long-term results in the treatment of all types of POP. High BMI and previous abdominal or vaginal surgery, including previous treatments for POP, do not represent a contraindication for this surgical approach. Our study is limited by its retrospective and noncomparative design. Furthermore, we relied only on the Baden-Walker classification for assessment of POP without using the International Continence Society organ prolapse classification . We are also aware that the use of interviews before data analysis rather than standardised questionnaires or mandatory follow-up examinations might have led to an underestimation of symptoms or asymptomatic POP recurrences. Further prospective and comparative studies are needed to confirm these findings.

#196: EFFICACY OF GREEN LIGHT LASER PVP IN PATIENTS WITH BLADDER NECK SCLEROSIS. OUR EXPERIENCE

Inviato da: stefano.masciovecchio@hotmail.com

S. Masciovecchio1, A.B. Di Pasquale1, A. Cassani2, G. Zasa2, G. Romano1, G. Ranieri1, L. Di Clemente1
  • 1 P.O. "San Salvatore", U.O.C. Urologia (L'Aquila)
  • 2 Università degli Studi de L'Aquila (L'Aquila)

Objective

GREEN LIGHT LASER IS A NOTICEABLE SURGICAL OPTION TO TREAT BPE MOREOVER IN PATIENTS WITH COMORBILITIES AS COAGULOPATHIES OR MEDICAL TREATMENTS WITH ANTIPLATELET OR ANTICOAGULANT. IN OUR STUDY WE AIM TO DEMONSTRATE THE EFFICACY OF PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE (PVP) AS A TREATMENT OF BLADDER NECK SCLEROSIS AFTER PROSTATE SURGERY

Materials and Methods

WE PROSPECTIVELY COLLECTED DATA ABOUT PATIENTS WITH VOIDING LOWER URINARY TRACTS SINTOMS LUTS AFTER ENDOSCOPIC PROSTATE SURGERY. BLADDER NECK SCLEROSIS WAS IDENTIFIED WITH A STANDARD CYSTOSCOPHY. WE COLLECTED DATA ABOUT UROFLOWMETRY. ALL PATIENT UNDERWENT SURGICAL PVP WITH GREEN LIGHT LASER, THE PROCEDURE WAS PERFORMED WITH A 600 MICRON FIBRE HAVING A 532 NM WAVELENGHT INSERTED IN AN IGLESIAS 26 CH CYSTOSCOPE WITH A 0 DEGREES LENS, AS IRRIGANT WAS USED NACL 0.9% SOLUTION. THE FIBRE ACTIONS IS ACHIEVED AT AN ANGLE OF 90 DEGREES FROM THE END OF THE FIBRE WITH A “PAINT BRUSH FASHION” MOVEMENT NEAR THE TISSUE RESOULTING IN A PHOTOVAPORIZATION OF THE POINTED SITES. IN CASE OF BLEEDINGS WE PERFORMED A COAGULATION WITH A POWER SETTING OF 30 WATTS. AT THE END OF THE PROCEDURE A DUFOUR 22 CH CATHETHER WAS INSERTED IN THE BLADDER. WE CONSIDERED AS A SUCCESFULL RESPONSE AN IMPROVEMENT OF UROFLOWMETRY PARAMETERS POST OPERATIVELY COMPAIRED WITH PREOPERATIVELY ONES.

Results

WE ENROLLED 17 PATIENTS WITH BLADDER NECK SCLERORIS. ALL PATIENTS UNDERWENT PVP PERFORMED WITH SPINAL ANESTESIA. MEDIAN SURGICAL TIME WAS &lt; 10 MINUTES AND MEDIAN HOSPITAL STAY WAS 1 DAY. THE MEDIAN FOLLOW UP WAS MONTS. ALL PATIENTS HAD AN IMPROVEMENT OF UROFLOWMETRY PARAMETERS IDENTIFIED AS A HIGHER QMAX FROM 5 ML/S TO 26 ML/S POST OPERATIVELY. NO ADVERSE EFFECTS WERE RECORDED DURINNG THE PROCEDURE. NO ADVERSE EFFECTS WERE RECORDED DURING THE HOSPITAL STAY, AND DURING FOLLOW UP. NO PATIENTS REQUIRED SECOND TREATMENTS OR CATETHERIZATION AFTER THE PROCEDURE

Discussions

GREEN LIGHT LASER IN A SURGICAL TREATMENT COMMONLY USED FOR BPH. KUMAR ET ALL.[1] IN THEIR STUDY SHOWED THAT PVP TREATMENT WAS COMPARABILY IN EFFICACY WITH MONOPOLAR TURP AND BIPOLAR TURP IN 201 PATIENT WITH A SUCCESS RATE OF 63% IN IPSS SCORE AND 55% IN QOL WITH A 36 MONTHS FOLLOW UP. A META-ANALISIS LAI ET ALL [2]SHOWED A QOL IMPROVEMNT OF 95% IN PATIENTS TREATED WITH PVP VS TURP WITH LOWER ADVERSE EFFECT (THEY REPORTED FEW CASES OF DYSURIA AND REINTERVENTION MANAGED WITH NO INVASIVE TECNIQUEAND, THE ONLY LIMITATION IDENTIFIED WAS THE IMPOSSIBILITY OF HISTOLOGICAL TISSUE EXAMINATION WITH). THERE IS A LACK OF EVIDENCE IN LITERATURE DEALING WITH LUTS CAUSED BY BLADDER NECK SCLERORIS IN MALE.. IN OUR STUDY WE CONSIDERED MALE PATIENTS WITH BLASSER NECK SCLEROSIS TREATED WITH PVP WITH A SUCCESS RATE OF AND NO ADVERSE EFFECTS. THE LIMITATION OF OUR STUDY ARE THE FEW NUMBER OF PATIENTS, THE IMPOSSIBILITY OF AN HISTOLOGICAL EXAMINATION OF THE TISSUE.

Conclusion

PVP MAY BE A SAFE AND EFFICENT TREATMENT OPTION FOR BLADDER NECK SCLEROIS .

Reference

1. Kumar A, Vasudeva P, Kumar N, et al (2013) A Prospective Randomized Comparative Study of Monopolar and Bipolar Transurethral Resection of the Prostate and Photoselective Vaporization of the Prostate in Patients Who Present with Benign Prostatic Obstruction: A Single Center Experience. J Endourol 27:1245–1253. https://doi.org/10.1089/end.2013.0216
2. Lai S, Peng P, Diao T, et al (2019) Comparison of photoselective green light laser vaporisation versus traditional transurethral resection for benign prostate hyperplasia: an updated systematic review and meta-analysis of randomised controlled trials and prospective studies. BMJ Open 9:. https://doi.org/10.1136/bmjopen-2018-028855
3. Sharifian H, Zargham M, Khorami MH, et al (2019) Internal Urethrotomy in Treatment of Female with Anatomical Bladder Outlet Obstruction. Adv Biomed Res 8:. https://doi.org/10.4103/abr.abr_200_18

#197: LEARNING CURVE OF PVP WITH GREEN LIGHT LASER: IS LONGER IN PATIENTS WITH BLADDER CATHETHER?

Inviato da: stefano.masciovecchio@hotmail.com

S. Masciovecchio1, A.B. Di Pasquale1, G. Zasa2, A. Cassani1, G. Romano1, G. Ranieri1, L. Di Clemente1
  • 1 P.O. "San Salvatore", U.O.C. Urologia (L'Aquila)
  • 2 Università degli Studi de L'Aquila (L'Aquila)

Objective

LEARNING CURVE IS A TREATING ARGUMENT IN UROLOGICAL SURGERY, IS DEFINED AS THE NUMBER OF PROCEDURE TO GET INTRAOPERATIVE PARAMETER PLATEAU REGARDLESS OF SURGEON EXPERTISE AND INSTITUTIONAL BACKGROUND. THE AIM OF OUR STUDY IS TO SHOW THE DIFFERENCE FOR THE SURGEON DURING LEARNING CURVE TO GET TO THE PLATEAU FOR THE PVP WITH GREEN LIGHT LASER IN TWO GOUPS OF PATIENS WITH BPE/LUTS: PATIENTS WITH BLADDER CATHETHER FOR URINARY RETENTION AND PATIENTS WITH NO NEED OF CATHETERIZATION.

Materials and Methods

WE PROSPECTIVELY COLLECTED DATA FROM OUR CENTER DATABASE. WE ENROLLED PATIENTS WITH BPE/ LUTS UNRESPONDERS TO CONSERVATIVE TERAPHY (ALFA BLOCKERS AND/0R 5ARI) WITH IPSS &gt; 20. WE DIVIDED THE PATIENTS IN TWO GROUPS: GROUP 1 PATIENTS WITH CATHETHER. GROUP 2 : PATIENTS WITHOUT CATETHER. WE COLLECTED DATA ABOUT DEMOGRAPHICS, TYPE OF TREATMENT BEFORE PROCEDURES, IPSS BEFORE AND AFTER PROCEDURE, PSA LEVEL, PROSTATE VOLUME. ALL PATIENTS UNDERWENT STANDARD GREEN LIGHT LASER PHOTOSELECTIVE VAPORISATION OF THE PROSTATE, THE PROCEDURE IS PERFORMED WITH A 600 MICRON FIBRE HAVING A 532 NM WAVELENGHT INSERTED IN AN IGLESIAS 26 CH CYSTOSCOPE WITH A 0 DEGREES LENS, AS IRRIGANT WAS USED NACL 0.9% SOLUTION. THE FIBRE ACTIONS IS ACHIEVED AT AN ANGLE OF 90 DEGREES FROM THE END OF THE FIBRE WITH A “PAINT BRUSH FASHION” MOVEMENT NEAR THE TISSUE RESOULTING IN A PHOTOVAPORIZATION OF THE POINTED SITES. IN CASE OF BLEEDINGS WE PERFORMED A COAGULATION WITH A POWER SETTING OF 30 WATTS. AT THE AND OF THE PROCEDURE A DUFOUR 22 CH CATHETHER WAS INSERTED IN THE BLADDER. WE ANALIZED THE LEARNING CURVE IN TERMS OF: OPERATIVE TIMES, THE ENERGY DELIVERED/THE PROSTATE VOLUME TRYING TO ACHIEVE THE, DEFINED BY LITERATURE, STANDARD OF EXPERTISE: TO REACH AN AVERAGE ENERGY OF 5 KJ/1 CC OF PROSTATE VOLUME

Results

WE ENROLLED 42 PATIENTS WITH BPE/LUTS WE DIVIDED PATIENT IN TWO GROUPS GROUP 1 PATIENTS WITH CATHETHER (N=17), GROUP 2 WITHOUT CATETHER (N=25). PATIENTS PREOPERATIVELY CARATHERISTICS WERE SIMILAR,MEDIAN PROSTATE VOLUME WAS GROUP 1 45 CC, GROUP 2 55 CC, MEDIAN IPSS WAS 23. WE REPORTED DIFFERENCES IN VAPORITATION TIMES BETWEEN THE TWO GOUPS GROUP 28 MINUTES,GROUP 2 19 MINUTES; ENERGY DELIVERED GROUP 1 245 KJ ,GROUP 2 187 KJ. THE ENERGY DELIVERED/THE PROSTATE VOLUME RATIO GROUP 1: 8 KJ/CC) , GROUP 2: 4,6 KJ/CC. THE TWO GROUPS SHOWED STATISTICALLY SIGNIFICANT DIFFERENCE THAT AFFECTS THE LEARNING CURVE, THE GROUP 1 PATIENTS REQUIRED MORE EXPERTIZE HIGHLIGHTED AS LONGER OPERATIVE TIMES. HIGHER THE ENERGY DELIVERED/THE PROSTATE VOLUME RATIO SHOWING THAT TO GET A PLATEAU SURGEON NEEDS MORE PROCEDURE WHEN THE PATIENT IS A BLADDER CATHETHER CARRIER

Discussions

LEARNING CURVE IN UROLOGY IS CHALLENGING THE PLATEAU IS DEFINED BY LITERATURE AS DELIVERING AN AVERAGE ENERGY OF 5 KJ PER ML OF PROSTATE VOLUME [1]AND REACHING A LT/OT RATIO OF 66–80 %[2]. BASTARD ET AL. IN THEIR STUDY SHOWED THAT SURGEONS NEEDED MORE THAN 100 PROCEDURES TO GET A PLATEAU WHEN USING GREEN LIGHT LASER PVP, WITH NO HIGHLIGHTS OF PATIENTS CHARATERISTICS AS A VARIABLE AFFECTING THE LEARNING CURVE[3]. MISRAI ET ALL. IN THEIR STUDY SHOWED THAT 120 PROCEDURE ARE NECESSARY TO ACHIEVE THE STANDARDS OF LITERATURE, RATIO OF JOULES/ML INCREASED EVERY 10 PROCEDURE BY A MEAN OF 14 J/ML. THE LITERATURE STANDARDS IN THEIR EXPERIENCE WAS REACHED AT THE 75TH PATIENT. IN THEIR EXPERIENCE THE LT/OT RATIO EVERY 10 PATIENTS INCREASED BY A MEAN OF 1.2 % UNLINKED WITH PROSTATE VOLUME, LT/OT RATIO OF 75 % WAS REACHED BY THE 125TH PROCEDURE, WITH A 6% OFPROCEDURE CONVERTION TU TURP.
IN OUR EXPERIENCE WE NOTICED THE DIFFERENCE IN REACHING LEARNING CURVE PALTEAU WAS AFFECTED BY PATIENTS’ CARATHERISTICS. WE SHOWED A DIFFERENCE STATISTICALLY SIGNIFICATIVE IN TERMS OF NUMBER OF PROCEDURES NEEDED TO GET TO EXPERTIZE STANDARDS WHEN PATIENS HAVE INDWELLING CATHETERS

Conclusion

OUR STUDY SHOWS THAT PATIENTS CARATHERISTICS, MOREOVER THE INDWELLING CATHETER IS A PARAMETER THAT AFFECTS IN A NEGATIVE WAY THE REACHING OF THE LITERATURE STANDARD OF EXPERTIZE SLOWING THE SURGEON LEARNING CURVE.

Reference

1. Bachmann A, Muir GH, Collins EJ, et al (2012) 180-W XPS GreenLight Laser Therapy for Benign Prostate Hyperplasia: Early Safety, Efficacy, and Perioperative Outcome After 201 Procedures. Eur Urol 61:600–607. https://doi.org/10.1016/j.eururo.2011.11.041
2. Capitán C, Blázquez C, Martin MD, et al (2011) GreenLight HPS 120-W Laser Vaporization versus Transurethral Resection of the Prostate for the Treatment of Lower Urinary Tract Symptoms due to Benign Prostatic Hyperplasia: A Randomized Clinical Trial with 2-year Follow-up. Eur Urol 60:734–739. https://doi.org/10.1016/j.eururo.2011.05.043
3. Bastard C, Zorn K, Peyronnet B, et al (2019) Assessment of Learning Curves for 180-W GreenLight XPS Photoselective Vaporisation of the Prostate: A Multicentre Study. Eur Urol Focus 5:266–272. https://doi.org/10.1016/j.euf.2017.09.011

#198: URETROTHOMY SEC. OTIS WITH LOCAL ANESTESIA. IS IT POSSIBLE?

Inviato da: stefano.masciovecchio@hotmail.com

S. Masciovecchio1, A.B. Di Pasquale1, A. Cassani2, G. Zasa2, G. Romano1, G. Ranieri1, L. Di Clemente1
  • 1 P.O. "San Salvatore", U.O.C. Urologia (L'Aquila)
  • 2 Università degli Studi de L'Aquila (L'Aquila)

Objective

URETHROTHOMY SEC. OTIS IS A COMMON UROLOGICAL PROCEDURE PERFORMED WITH SPINAL ANESTESIA, IN OUR CENTER WE PERFORMED FOR THE FIRTS TIME THE PROCEDURE WITH LOCAL ANESTESIA: DORSAL PENILE NERVE BLOCK AND RING BLOCK AT THE BASE OF THE PENIS WITH SAME EFFICACY, NO PERI OPERATIVE PAIN, NO DIFFERENCE IN POST OPERATIVE PAIN COMPARING TO STANDARD PROCEDURE AND NO ADVERSE EVENT RELATED TO THE PROCEDURE

Materials and Methods

WE PROSPECTIVELY COLLECTED DATA FROM OUR CENTER DATABASE REGARDING PATIENTS TREATED WITH OTIS URETROTHOMY WITH DORSAL PENILE NERVE BLOCK.
ALL PATIENT UNDERWENT LOCAL ANESTESIA. DORSAL PENILE NERVE BLOCK [1]AT THE LEVEL OF THE PUBIC SYMPHYSIS AND RING BLOCK AT THE BASE OF THE PENIS WITH 10 CC OF LIDOCAINE 1% INJECTED WITH A 16 GAUGE NEEDLE. AFTER LOCAL ANESTESIA WE PERFORMED CLASSICAL OTIS URETROTHOMY A BLIND TRANS URETHRAL INCISION WITH OTIS URETHROME. WE INSERTED OTIS URETHROTOME IN THE URETHRA, THE URETHRA IS THEN DILATATED, STRECHED AND CUTTED AT 12 O’CLOCK IN ORDER TO ACHIEVE A SUFFICENT CALIBRUS. AT THE END OF THE PROCEDURE A FOLEY CATETHER IS POSITIONED INTO THE BLADDER. WE COLLECTED PRE AND POST OPERATIVE DATA ABOUT PATIENTS DEMOGRAFICS, IPSS SCORE PRE AND POST OPERATIVELY, WE PERFORMED A STANDARD CYSTOSCOPY TO DEFINE THE GRADE AND LENGHT OF THE STENOSIS AND A STANDARD UROFLOWMETRY PRE AND POST OPERATIVE.

Results

WE ENROLLED 19 PATIENTS WITH URETRAL STRICTURE FROM JANUARY 2019 TO OCTOBER 2019. MAIN AGE WAS 74 YEARS, MAIN FLUOMETRY PRE OPERATIVELY WAS QMAX: 5 ML/A; VV: 234 ML; PVR 60 ML, IPSS PRE OPERATIVELY WAS -. ALL PATIENTS UNDERWENT STANDARD CISTISCOPY PRE OPERATIVELY, ALL PATIENTS HAD A MEATAL (SUB)STENOSIS. STANDARD OTIS URETHROTOMY WAS PERFORMED UNDER LOCAL ANESTESIA, VAS SCALE AFTER THE PROCEDURE WAS 2. AT THE END OF THE PROCEDURE WE POSITIONED A FOLEY CATETHER IN THE OPERATORY ROOM KEPT FOR 7- 10 DAYS ACCORDING TO THE LENGHT OF STENOSIS.
POST OPERATIVELY UROFLOWMETRY RESOULT WAS QMAX 15 ML/S; VV ; PVR: 30 ML.
WE ACHIED A % OF SUCCESS IDENTIFIED AS BETTER UROFLOWMETRY VALUES AND NO EVIDENCY OF INCREASED PAIN LEVEL ANALIZED WITH VAS.

Discussions

S URETHROTOMY IS A STANDARD PROCEDURE USED BY UROLOGIST TO TREAT URETHRAL STRICTURE[2]. IN LITERATURE THERE IS A LACK OF EVIDENCE DEALING WITH THE PROCEDURES PAIN LEVEL. IT’S USUALLY PERFORMED UNDER SPINAL ANESTESIA, WE PERFORMED FOR THE FIRST TIME THE PROCEDURE WITH LOCAL ANESTESIA. COMMON KNOWN ADVERSE EFFECTS OF THE PROCEDURE WERE RECURRENCES OF THE STRICTURE, BLEEDING AND UNCOMMON ONES ERECTILE DYSFUNCTION AND URINARY INCONTINENCE. IN OUR EXPERIENCE WE REPORT NO ADVERSE EFFECTS. MAIN LIMITATION OF OUR STUDY WERE THE FEW NUMBER OF PATIENTS AND THE ABSENCE OF A CONTROL GROUP.

Conclusion

LOCAL ANESTESIA FOR OTIS URETROTHOMY MAY BE A VALID ALTERNATIVE WITH SAME EFFICACY AND NO INCREMANTATION OF PAIN LEVEL FOR THE PATIENTS. OUR STUDY SHOW ANALOGUOUS RESULTS IN CLINICAL OUTCOMES WITH AN IMPROVEMNT OF UROFLOUMETRY VALUES AND NO INCREASE IN PAIN LEVEL AFTER SURGERY .

Reference

1. McPhee AS, McKay AC (2018) Dorsal Penile Nerve Block. StatPearls Publishing
2. Internal Urethrotomy – www.urology-textbook.com. http://www.urology-textbook.com/internal-urethrotomy.html. Accessed 24 Nov 2019

#205: Elevated Neutrophil-to-Lymphocyte Ratio (NLR) predicts poor response to hyperthermic intravesical chemotherapy (HIVECTM) with mitomycin-C (MMC) in high-risk non muscle invasive bladder cancer: a single-institution analysis

Inviato da: francescok86@gmail.com

F. Chiancone1, C. Meccariello1, L. Pucci1, G. Battaglia1, F. Maurizio1, C. Maurizio2, P. Fedelini1
  • 1 Urology Department, AORN “A. Cardarelli” (Naples)
  • 2 Andrology Department, AORN "A. Cardarelli" (Naples)

Objective

Bladder cancer is the 9th most commonly diagnosed cancer worldwide and the 13th most frequent cause of cancer death worldwide (1). The aim of this study was to evaluate the neutrophil-to-lymphocyte ratio (NLR) as a prognostic factor for response of high risk non muscle invasive bladder cancer (HR-NMIBC) treated with HIVEC™ (hyperthermic intravesical chemotherapy) therapy (2).

Materials and Methods

Between March 2017 to May 2018, 53 consecutive patients with HR-NMIBC treated with HIVEC™ therapy (six weekly instillations) were retrospectively analysed. For each patient, we reported the pre-HIVEC and post-HIVEC hematologic and chemical data, including the total number of white blood cells (WBC), neutrophils (N) and lymphocytes (L). Patients underwent blood sampling the day before the first HIVEC™ instillation and the day after the last HIVEC™ instillation, in the morning, after at least 6 hours of fasting. We enrolled only patients without haematuria in order to avoid any sort of bias, especially in terms of total blood count. The NLR ratio was calculated by dividing the value of N by the value of L. All data were collected in a prospectively maintained database and analyzed. 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 patients were divided in two groups (Group A: responder group and Group B: non responder group; bladder cancer recurrence or progression to T2). Recurrence occurred in 7 patients and progression occurred in 6 patients. The mean value of NLR in all 53 cases was 3.21 ± 0.79 (Pre-HIVEC) and 3.13 ± 0.77 (Post-HIVEC) (p=0.59). NLR was not significantly different between the two groups before the HIVEC™ treatment (3.18 ± 0.79 in Group A and 3.31 ± 0.78 in Group B; p=0.63) while NLR was significantly different after the HIVEC™ treatment (2.89±0.73 in Group A and 3.87±0.30 in Group B; p=0.011).

Discussions

There are few studies on the association between SIR (Systemic inflammatory response ) markers and NMIBC. Most studies have been performed on muscle invasive bladder cancer (MIBC) and radical cystectomy. These studies suggest that NLR before radical cystectomy may help predict tumor prognosis (3).
Yuk HD et al (2019), demonstrated that NLR before treatment was correlated with both oncological outcomes and survival outcome in NMIBC patients undergoing initial intravesical BCG treatment after TURB. Increased NLR reflects poor prognosis of these outcomes (4).
Thermotherapy has profound effects on the immune system resulting in increased activation of more natural killer cells (NKC) that target heat stressed cancer cells as they signal heat shock proteins on the cancer cell surface. The consequence is that the cancer cells actively participate in their own demise through the natural process of apoptosis (5). In our study, NLR measured at the end of the last HIVEC™ treatment was correlated with the response to the therapy. In particular, an higher proportion of lymphocytes was revealed in the group of patients who response to the therapy (and then achieve an immune response against the bladder tumor).
This study has several limitations. First, it was a retrospective study of a single institution. Thus, it cannot be free from selection bias. Second, a single test does not represent the entire systemic immune response state. Third, large-scale prospective studies are needed to apply NLR to clinical practice.

Conclusion

NLR value could be a useful tool to predict bladder cancer response to HIVEC™ therapy. These results could lead to the development of more studies to assess the real prognostic value of NLR in HR-NMIBC.

Reference

1-Babjuk M, Bohle A, Burger M, Capoun O, Cohen D, Comperat EM, et al. EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder: update 2016. Eur Urol. (2017) 71:447–61.
2- Sousa A, Piñeiro I., Rodríguez S. et al. Recirculant hyperthermic IntraVEsical chemotherapy (HIVEC) in intermediate-high-risk non-muscle-invasive bladder cancer. Int J Hyperthermia 2016. PMID 26915466
3- Kim HS, Ku JH. Systemic inflammatory response based on neutrophil-to-lymphocyte ratio as a prognostic marker in bladder cancer. Dis Markers (2016) 2016:8345286. doi: 10.1155/2016/8345286
4-Hyeong Dong Yuk , Chang Wook Jeong, Cheol Kwak et al. Elevated Neutrophil to Lymphocyte Ratio Predicts Poor Prognosis in Non-muscle Invasive Bladder Cancer Patients: Initial Intravesical Bacillus Calmette-Guerin Treatment After Transurethral Resection of Bladder Tumor Setting Front Oncol 8, 642 2019 Jan 17
5-Fuse, K W Yoon, T Kato Heat-induced Apoptosis in Human Glioblastoma Cell Line A172Neurosurgery, 42 (4), 843-9 Apr 1998

#206: Magnetic Resonance-targeted cognitive biopsy versus Fusion biopsy transrectal ultrasound guided

Inviato da: afandella@libero.it

A. Fandella1, S.. Guazzieri1
  • 1 Casa di Cura Rizzola (San Donà di Piave )

Objective

The exact role of multiparametric magnetic resonance (mpMR)-targeted biopsy (TB) of the prostate before diagnosis is under examination. The balance between costs and advantage is controverse. To analize if, after first traditional negative biopsy, multiparametric magnetic resonance (MR)-targeted biopsy (TB) could be better of fusion biopsy we compare biopsy performance of the two approaches. Multiparametric magnetic resonance (MR)-cognitive targeted biopsy (CTB) with that of fusion biopsy (FB) detection of prostate cancer (PCa).

Materials and Methods

360 patients (Jan 2016 June 2019), with a previous negative biopsy 12 Core with informed consent who were suspected of having PCa underwent mpMR , we chose only patients with Pirads 4 and 5 suspicious abnormality (target) at pre-biopsy.
180 Patients underwent 12-core CTB with transrectal ultrasonographic (US) guidance, with four cores aimed visually (cognitive TB [TB-COG]) and 180 patients underwent four cores aimed using transrectal US-MR fusion software (fusion-guided TB [TB-FUS]). FB and TB positivity for cancer and sampling quality (mean longest core cancer length, Gleason score) were compared. Clinically significant PCa was any 3 mm or greater core cancer length or any greater than 3 Gleason pattern for SB or any cancer length for TB. Statistical analysis included t test, paired χ(2) test, and κ statistic. Primary end point (core cancer length) was calculated (paired t test).

Results

Among 360 patients (median age, 65 years; mean prostate-specific antigen level, 7,5 ng/mL, positivity rate for PCa was 59% for SB and 69% for TB (P = .033); rate for clinically significant PCa was 52% for SB and 67% for TB (P = .0011). Mean longest core cancer lengths were 4.6 mm for SB and 7.3 mm for TB (P &lt; .0001). In 12 of 51 (24%) MR imaging targets with positive SB and TB results, TB led to Gleason score upgrading. In MR imaging targets, positivity for cancer was 47% with TB-COG and 53% (n = 42) with TB-FUS (P = .16). Neither technique was superior for Gleason score assessment.

Discussions

Only a few studies have compared the detection rates of PCa between different targeting techniques. We compared CTB and MRGB in two statistical similar patient groups and found nearly similar detection rates of PCa for CTB and MRGB related to PI-RADS score and lesion location. However, correction shows that in lesions &lt; 1.5 ml MRGB is more accurate. Other studies concern mainly a comparison of CTB with MRI/TRUS-fusion biopsy (MTFGB) and the results are controversial. (1-5)
This study represents the true clinical setting, but has some limitations due to its retrospective design.
Though significant tumors ought to be detected within this period, a longer follow-up period could stronger endorse these study conclusions. However, despite these limitations, due to the comparability of both groups we believe the results of this study are very useful in clinical practice.

Conclusion

Three methods of fusing MRI for targeted biopsy have been recently described: MRI–ultrasound fusion, MRI–MRI fusion (‘in-bore’ biopsy) and cognitive fusion. Supportive data are emerging for the fusion devices. Working with the Toshiba device, we found that targeted biopsies are two to three times more sensitive for detection of CaP than nontargeted systematic biopsies; nearly 40% of men with Gleason score of at least 7 CaP are diagnosed only by targeted biopsy; nearly 90% of men with highly suspicious MRI lesions are diagnosed with CaP; ability to return to a prior biopsy site is highly accurate (within 1.2 ± 1.1 mm); and targeted and systematic biopsies are twice as accurate as systematic biopsies alone in predicting whole-organ disease.

Reference

1)Puech P, Rouviere O, Renard-Penna R, Villers A, Devos P, Colombel M, Bitker MO, Leroy X, Mège-Lechevallier F, Comperat E, Ouzzane A, Lemaitre L. Prostate cancer diagnosis: multiparametric MR-targeted biopsy with cognitive and transrectal US-MR fusion guidance versus systematic biopsy-prospective multicenter study. Radiology. 2013;268:461–469
2)Brown AM, Elbuluk O, Mertan F, Sankineni S, Margolis DJ, Wood BJ, Pinto PA, Choyke PL, Turkbey B. Recent advances in image-guided targeted prostate biopsy. Abdom Imaging. 2015;40:1788–1799.
3)Lee DJ, Recabal P, Sjoberg DD, Thong A, Lee JK, Eastham JA, Scardino PT, Vargas HA, Coleman J, Ehdaie B. Comparative effectiveness of targeted prostate biopsy using magnetic resonance imaging ultrasound fusion software and visual targeting: a prospective study. J Urol. 2016;196:697–702.

4). Wegelin O, van Melick HH, Hooft L, Bosch JLHR, Reitsma HB, Barentsz JO, Somford DM. Comparing three different techniques for magnetic resonance imaging-targeted prostate biopsies: a systematic review of in-bore versus magnetic resonance imaging-transrectal ultrasound fusion versus cognitive registration. Is there a preferred technique? Eur Urol. 2017;71:517–531.
5) Wegelin, Olivier et al.The FUTURE Trial: A Multicenter Randomised Controlled Trial on Target Biopsy Techniques Based on Magnetic Resonance Imaging in the Diagnosis of Prostate Cancer in Patients with Prior Negative Biopsies. European Urology, 2019 Volume 75, Issue 4, 582 – 590

#204: Perioperative surgical outcomes and anesthesiological management during Robot Assisted Laparoscopic radical Prostatectomy: a single institution experience with the use of transversus abdominis plane block (TAP-block)

Inviato da: francescok86@gmail.com

G. Visciola1, M. Ferraiuolo2, L. de Rosa2, E.. Prisco2, M. Fabiano3, M. Fedelini3, C. Meccariello3, P. Fedelini3, F. Chiancone3
  • 1 General and specialized surgery for women and children, University of Campania Luigi Vanvitelli (Naples)
  • 2 Department of Anesthesiology , TIPO e OTI, AORN A.Cardarelli (Naples)
  • 3 Urology Department, AORN A.Cardarelli (Naples)

Objective

With the implementation of the robotic assisted laparoscopic surgery, anesthesiologists have to face new challenges in the patient care. Shortening the hospital stay, while offering a good standard of postoperative care is often achieved by combining the minimally invasive robotic technique with a tailored multimodal anesthesia protocol. TAP block (Transversus Abdominis Plane Block) has been widely used in laparoscopic surgery, and many Authors are reporting his use in multimodal protocols applied to robotic assisted surgical procedures (1). However the use of TAP block in robotic assisted radical prostatectomy is not extensively reported. The aim of this study was to evaluate the role of TAP block in improvement of anesthesiological management and of perioperative surgical outcomes of robot-assisted laparoscopic radical prostatectomy (RALP).

Materials and Methods

25 patients whose underwent RALP at our institution were randomized in two groups (Group A: TAP block; Group B (No TAP block). All patients received as premedication Fentanyl 100 mcg, midazolam 2 mg. Anesthesia was induced using propofol 2 mg/kg, rocuronium 0,6 mg/kg and remifentanil titred according to the depth of the analgesia. After orotracheal intubation, if the TAP block was performed, we injected Ropivacaine 0,375% and dexamethasone 4mg. RALP was performed by a single surgical team with a transperitoneal approach. All data were collected in a prospectively maintained database and retrospectively analysed. Descriptive statistics of categorical variables focused on frequencies and proportions. 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). Statistical analyses were conducted using SAS version 9.3 software(SAS Institute, Inc., NC).

Results

The two groups showed no difference in terms of patients’ baseline characteristics in the most important variables [age, BMI, comorbidity according to ASA score, surgical time] (Table 1) Table 2 shows the perioperative outcomes of the two groups. In particular patients of group A showed a longer time of anaesthesia without reach the statistical significance. Group A was found to be similar to group B in terms of NRS PACU and at 12, 24, 48, 72 hours but not at 96 hours. Ketorolac doses used in Group A were not significantly lower than Group B. Rescue Analgesic Medication use was significantly higher in the Group B. In particular in a patient of Group A we used Contramal 50 mg /1 ml at T0 while in the Group B we used Morfine 2mg at 12 post-operative hours in two patients, Morfine 2mg in three patients at T0 and Ketorolac 30 mg in one patient at T0. In patients of Group A we used 128±156.84 mg of Tramadol while in the Group B we used 20 mg of Morphine in all patients. The dose of Remifentanil used was 0.05 mcg/kg/min in the Group A and it was lower (0.05 mcg/kg/min) than in the Group B. Moreover, patency of the intestinal tract and time to ambulation was significantly lower in the Group A.

Discussions

The peri-operative management of patients undergoing robotic-guided procedures is an interesting yet not fully explored field. Managing the intra and post-operative pain in this population may result challenging if the matter is not approached by the whole team involved in the procedure and in the care of the patient. Including the TAP block in our protocol resulted in a statistically significant better post-operative pain control in the first 72 hours (2) and faster complete recovery of bowel functionality. This can be correlated indeed with the reduction of intra and post-operative use of opiates and the switch from morphine (a strong opioid) to tramadol (a weak opioid) in the patients that received the preoperative TAP block. Moreover almost all patients who underwent TAP block got ambulation during the same operating day, probably due to the better pain control. However this result is not only limited to the application of this locoregional anesthesia technique, in fact different health professionals, to a different degree, contributed to reach such result. First of all, our surgical team applied of low pneumoperitoneum pressures along with the application of the AirSeal technology, reducing the irritative stimulation on the peritoneum and the phrenic nerve. Secondly, using the Pink Pad device the nurses placed and secured the patient on the operating table, allowing to maintain safely the steep Trendelenburg position (30° degrees) required for performing the robotic radical prostatectomy. This allowed us to avoid potential nervous lesions and post operative shoulder pain caused by the placing or the laparoscopic procedure itself. Lastly the PACU (post-anesthesia care unit) and ward nurses were specifically instructed to avoid administering rescue analgesia using morphine, prioritizing the use of NSAIDs (Nonsteroidal anti-inflammatory drugs) such as Ketorolac and Paracetamol and the reduction of the rescue analgesia intervention met our statistically significant threshold as well.

Conclusion

According to our result we are positive to conclude that a multimodal protocol that includes: locoregional anesthesia, reduction of intra and postoperative use of strong opiates, correct placing and 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.

Reference

1-Jan Jakobsson, Liselott Wickerts, Sune Forsberg et al.Transversus abdominal plane (TAP) block for postoperative pain management: a review. F1000Res. 2015; 4: F1000 Faculty Rev-1359. Published online 2015 Nov 26.
2-Grish P. Joshi, Thomas Jaschinski, Francis Bonnet, et al. Optimal pain management for radical prostatectomy surgery: what is the evidence? BMC Anesthesiol. 2015; 15: 159.

#185: LAPAROSCOPIC SIMPLE PROSTATECTOMY (LSP): PRELIMINARY EXPERIENCE

Inviato da: giampiero.cecchetti@libero.it

G. Cecchetti1, E. Nunzi1, E. Frumenzio1, E. Scarponi1, T. Villirillo1, R. Gilardi1, F. Iannelli1, F. Farneti1, W.A. Rociola1, P. Fornetti1, A. Posti1
  • 1 AUSL Umbria 1, SCA Urologia (Città di Castello)

Objective

The surgical treatment of lower urinary tract symptoms (LUTS) by benign prostatic hyperplasia (BPH) includes traditional transurethral resection of the prostate (TURP), laser surgery and open prostatectomy [1]. Open prostatectomy, usually indicated for high volume adenoma, is sometimes burdened by significant morbidity. Recent advances in holmium laser enucleation of the prostate (HoLEP) and laser vaporization are mininvasive options widely used despite some limitations [2]. Laparoscopic simple prostatectomy (LSP) is an intriguing alternative to open surgery in the hands of experienced laparoscopic surgeon [3,4]. Here we present our single centre preliminary results using laparoscopic simple prostatectomy in the treatment of large benign prostatic hyperplasia (BPH), with the aim of discussing its feasibility and safety.

Materials and Methods

Between January 2018 and September 2019, 28 patients were submitted to laparoscopic simple prostatectomy. Patients were selected according to LUTS questionnaire (International Prostate Symptom Score, IPSS), digital rectal examination, transrectal ultrasound scan, uroflowmetry with post-voidal residue, PSA. Inclusion criteria were a prostate volume &gt; 80 ml and/or presence of other conditions requiring surgical correction. All procedure were performed under general anesthesia. Surgical procedure was performed as an extraperitoneal adenomectomy according to Millin technique. The procedure was performed by using 3 operative trocars after dissection of Retzius space using a 0° optical lense connected to a 3D system. Adjunctive laparoscopic hernioplasty (3 pts), bladder lithotomy (3 pts) and bladder diverticolectomy (2 pts) were performed simultaneously when required. Demographic date and peri-operative results were analyzed.

Results

Mean age was 72 years (range 69-72 yrs). All procedure was performed laparoscopically and no patient required conversion to open surgery or re-surgery. The mean prostate volume was 105 ml (range 83-150 ml). Mean operative time was 130 minutes (range 110 -200 mins), while estimated blood loss was 190 ml (range 150-320 ml). Only one patient required blood transfusion. Mean hospital stay was 5.2 days (range 2-8) and mean catheterization time was 6.4 days (range 6-9). At 1 month follow up all patients were dry and potent.

Discussions

Our preliminary results show that LSP is feasible and safe, providing a short hospital stay with early return to normal activity. LSP has a low morbidity although it seems feasible and reproducible in high experienced laparoscopic centre [5]. As for open surgery, other advantage of LSP is the possibility of performing secondary procedures (as hernioplasty, bladder diverticulectomy and so on). The main disadvantage is the need of general anesthesia.

Conclusion

Laparoscopic Simple Prostatectomy (LSP) has a place in symptomatic and large benign prostatic hyperplasia (BPH) in the hands of experienced laparoscopic surgeons when open simple prostatectomy is needed. Despite the encouraging results, only long-term prospective and comparative studies will better define the role of LSP in high volume BPH.

Reference

1. Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline Amendment 2019. Foster HE, Dahm P, Kohler TS, Lerner LB, Parsons JK, Wilt TJ, McVary KT. J Urol. 2019 Sep;202(3):592-598

2. The role of minimally invasive surgical tecniques in the management of large-gland benign prostatic hypertrophy. Ganesh Sivarajan, Michael S. Borofsky, Ojas Shah. Rev Urol 2015;(3): 140-9

3. Laparoscopic extraperitoneal adenomectomy (Millin): pilot study on feasibility. Van Velthoven R, Peltier A, Laguna MP, Piechaud T. Eur Urol 2004;45(1): 103-9; discussion 109

4. The surgical treatment of a large prostatic adenoma; the laparoscopic approach-A systematic review. Asimakopoulos AD,Mugnier C, Hoepffner JL, Spera E. J endourol 2012 Aug; 26(8): 960-7

5. Perioperative outcomes of robotic and laparoscopic simple prostatectomy: a European -American Multi-institutional Analysis. Autorino R, Zargar H, Mariano MB, Sanchez-Salas R, Sotelo RJ, Chlosta PL, Castillo O, Matei DV, Celia A, Koc G, Vora A, Aron M, Parsons JK, Pini G, Jensen JC, Sutherland D, Cathelineau X, Nuñez Bragayrac LA, Varkarakis IM, Amparore D, Ferro M, Gallo G, Volpe A, Vuruskan H, Bandi G, Hwang J, Nething J, Muruve N, Chopra S, Patel ND, Derweesh I, Champ Weeks D, Spier R, Kowalczyk K, Lynch J, Harbin A, Verghese M, Samavedi S, Molina WR, Dias E, Ahallal Y, Laydner H, Cherullo E, De Cobelli O, Thiel DD, Lagerkvist M, Haber GP, Kaouk J, Kim FJ, Lima E, Patel V, White W, Mottrie A, Porpiglia F. Eur Urol. 2015 Jul;68(1):86-94.

#216: Urological-Geriatric Integrated Diagnostic-Therapeutic Pathway (PDTA) at Galliera Hospital in Genoa

Inviato da: hpyl@hotmail.it

F.. Bonini1, A. Di Domenico1, L.. Cammalleri2, M. Beverini3, G. Capponi1, M. Ennas1, F. Campodonico1, C. Brusasco4, A. Pilotto2, C. Introini1
  • 1 E. O. Ospedali Galliera, S.C. Urologia (Genova)
  • 2 E. O. Ospedali Galliera, S.C. Geriatria (Genova)
  • 3 Scuola di Specializzazione in Urologia, Università degli Studi di Genova (Genova)
  • 4 E. O. Ospedali Galliera, S.C. Anestesia e Rianimazione (Genova)

Objective

Aim of our study is to identify patients at moderate/severe geriatric risk in order to create an appropriate clinical pathway, using the following tools:
1) Definition of a clinical and functional prognosis, before and after urological surgery using the Multidimensional Prognostic Index (MPI);
2) Modification of existing clinical risk conditions before and after surgery;
3) Early initiation of an appropriate social-assistential path for elderly patients undergoing urological surgery

Materials and Methods

At the Galliera Hospital in Genoa we have developed a Urological-Geriatric Integrated Diagnostic-Therapeutic Pathway (PDTA) for patiens aged ≥65 years affected by urogenital pathologies requiring major laparoscopic or open surgery: radical cystectomy, radical or partial nephrectomy, radical prostatectomy. These patients, in a presurgical outpatient context, receive a Selfy_MPI, which is a validated self-assessment questionnaire of multi-dimensional risk for negative outcomes validated for≥65 years patients.1
In case of Selfy_MPI class 2 (moderate risk) or 3 (high risk) the patient is addressed to the urogeriatric team, which consists of various professional figures who cooperate together (urologist, geriatrician, anesthesiologist, nurse, social worker). In particular, the geriatrician evaluate the patient for clinical history, functional assessment and calculation of MPI.
Compared to other frailty measurements, MPI shows an higher positive predictive value of adverse outcomes in hospitalized older patients.2
When the MPI score identifies a patient in a class risk 2 or 3 a specific assessment of the risk areas is required, in order to improve clinical and functional parameters, follow patient after surgery during hospitalization, plan specific postoperative geriatric and urologic follow-up after 3 or 6 months.

Results

The PDTA started on February 2019 and until October 2019 it has included 54 patients aged from 66 to 92 years old. All patients performed the Selfy_MPI. 46 patients showed a Selfy_MPI at a risk class 1; 8 patients resulted into the risk class 2, so they were evaluated by geriatricians that performed full MPI, confirming the risk class (MPI 2). 2 patients had an ASA score 4 and the anesthesiologist excluded surgery, 1 patient developed metastasis and began chemotherapy ; 2 patients refused surgery and 3 patients were considered able to be operated. 49 patients underwent open or laparoscopic surgery: 17 patients were submitted to radical prostatectomy (15 laparoscopic, 2 open surgery), 12 to radical cystectomy (2 laparoscopic, 10 open), 15 to radical nephrectmy or nephroureterectomy (7 laparoscopic, 8 open), 3 to laparoscopic partial nephrectomy, 1 to synchronous bilateral laparoscopic radical partial nephrectomy for synchronous renal cancer, 1 to open radical cystectomy with concomitant nephroureterectomy.

Discussions

Several sudies reported the effects of frailty on falls, hospitalization and mortality, but only few focused on surgical patients and frailty is not included in the traditional surgical risk scales.3
The most common definition of frailty is an age-associated, biological syndrome characterized by decreased biological reserve, due to dysregulation of several physiological systems, and poor outcomes.4
Frail patients have an higher risk of adverse outomes including prolonged hospitalization, mortality and disability. 4,5
The prevalence of frailty increases with age: in people older than 65 years ranging from 7 to 16.3%, reaching 30% of people aged 85 years. 6,7
Literature shows an improvement of clinical outcomes of elderly people urdergoing surgery when they undergo an evaluation of frailty with multidimensional assessment. 8
In our PDTA we used the MPI score for patients at risk of negative outcomes. MPI is a widely accepted prognostic tool, based on a standard Comprehensive Geriatric Assessment (CGA): multicenter studies demonstrated that MPI was a significantly more accurate predictor of all-cause mortality than other frailty index.9
The European Medicines Agency (EMA), in 2018 reported that the MPI is able to extract information from CGA to categorized frailty in three subgroups with excellent prognostic value.

Conclusion

The objective of our PDTA is to create for elderly patients an individual treatment plann based on frailty degree. The creation of PDTA provides a better customization of the clinical /diagnostic pathway and prognostic classification of the patients. The results we have obtained so far are still preliminary, however, the possibility of extend the PDTA to patients requiring endoscopic surgery will be evaluated.

Reference

1. Development and Validation of a Self-Administered Multidimensional Prognostic Index to Predict Negative Health Outcomes in Community-Dwelling Persons. Pilotto A1, Veronese N1, Quispe Guerrero KL1, Zora S1, Boone ALD2, Puntoni M3, Giorgeschi A1, Cella A1, Rey Hidalgo I2, Pers YM4, Ferri A1, Fernandez JRH5, Pisano Gonzalez M6; EFFICHRONIC Consortium. Rejuvenation Res. 2019 Aug;22(4):299-305. doi: 10.1089/rej.2018.2103. Epub 2018 Dec 28
2. On behalf of the MPI_AGE Investigators Using the Multidimensional Prognostic Index to predict Clinical Outcomes of Hospitalizated Older Persons: a Prospective Multicentre. Pilotto A, Veronese N, Darajati J, et al. International Study. J Gerontol A Biol Sci Med 2018 (Epub ahead of print).
3.Redefining geriatric preoperative assessment using frailty, disability and co-morbidity.Robinson TN1, Eiseman B, Wallace JI, Church SD, McFann KK, Pfister SM, Sharp TJ, Moss M. . Ann Surg. 2009 Sep;250(3):449-55.
4. Frailty in elderly people.Clegg A1, Young J, Iliffe S, Rikkert MO, Rockwood K. Lancet. 2013 Mar 2;381(9868):752-62. doi: 10.1016/S0140-6736(12)62167-9.
5. Importance of frailty in patients with cardiovascular disease. Singh M1, Stewart R2, White H2. Eur Heart J. 2014 Jul;35(26):1726-31
6. Frailty in older adults: evidence for a phenotype.
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA; Cardiovascular Health Study Collaborative Research Group.
J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-56.
7. Older women are frailer, but less often die then men: a prospective study of older hospitalized people. Veronese N, Siri G, Cella A, Daragjati J, Cruz-Jentoft AJ, Polidori MC, Mattace-Raso F, Paccalin M, Topinkova E, Greco A, Mangoni AA, Maggi S, Ferrucci L, Pilotto A; MPI AGE Investigators. Maturitas. 2019 Oct;128:81-86
8. Frailty as a predictor of surgical outcomes in older patients. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. J Am Coll Surg. 2010 Jun;210(6):901-8.
9. Comparing the prognostic accuracy for all-cause mortality of frailty instruments: a multicentre 1-year follow-up in hospitalized older patients. Pilotto A1, Rengo F, Marchionni N, Sancarlo D, Fontana A, Panza F, Ferrucci L; FIRI-SIGG Study Group. PLoS One. 2012;7(1):e29090
10. Change in the Multidimensional Prognostic Index Score During Hospitalization in Older Patients. Volpato S, Daragjati J, Simonato M, Fontana A, Ferrucci L, Pilotto A. Rejuvenation Res. 2016 Jun;19(3):244-51

#220: SAFETY PROFILE OF TREATMENT WITH GREENLIGHT VERSUS THULIUM LASER FOR BENIGN PROSTATIC HYPERPLASIA

Inviato da: tommaso.bocchialini@libero.it

D. Campobasso1, T. Bocchialini2, A. Barbieri2, S. Ferretti2, F. Dinale2, N. Azzolini2, E. Simonetti2, D. Cerasi1, F. Facchini1, M.S. Grande1, J.E.. Kwe1, M. Larosa1, M. Moretti1, G.L. Pozzoli1, U.V. Maestroni2, A. Frattini3
  • 1 Ospedale Civile di Guastalla, AUSL-IRCCS di Reggio Emilia, U.O.C. di Urologia (Guastalla)
  • 2 Azienda Ospedaliero‐Universitaria di Parma, S.C. di Urologia (Parma)
  • 3 Ospedale Civile di Guastalla, AUSL-IRCCS di Reggio Emilia, U.O.C. di Urologia (Parma)

Objective

Surgical treatment of benign prostatic hyperplasia (BPH) might take advantage of laser technologies. Different types of laser are utilized for this disease. Their major strengths are reduced morbidity compared to endoscopic resection with lower complication rate, bleeding, hospital and catheterization time. No studies analyzed the different risk of intra/peri-operative events between patients undergoing Thulium vs. GreenLight procedure.

Materials and Methods

We retrospectively reviewed 100 consecutive cases undergoing GreenLight standard or anatomical vaporization performed by an expert laser surgeon and Thulim vapoenucleation performed during the learning curve of an expert endoscopic surgeon. Pre-operative data (age, ASA score, prostate volume, use of antiplatelet and anticoagulant medications, urinary retention), intra and post-operative events at 90 days were analyzed (conversion to TURP, hospital and catheterization time, complications, access to hospital for consultation/readmission, incontinence, erectile dysfunction). The independent sample t-test &amp; chi-square tests were used for statistical analysis. A p&lt;0.05 was considered statistically significant.

Results

All data are reported in Table 1. No major differences were observed between the two groups in terms of pre-operative data, no statistical differences were found in terms of hospital stay, catheterization time, capsular perforation, erectile dysfunction, post-operative storage symptoms, urinary retention and de novo urgency. Blood transfusion (p&lt;0.0038), intra-operative use of resectoscope for hemostasis (p&lt;0.0086), and transient stress urinary incontinence (IUS) in the Thulium group were statistically significant. On the contrary the presence of indwelling catheter (p&lt;0.0029) and lack of conversion to TURP (p&lt;0.023) were in favor of Thulium patients. 25% of post-operative readmissions were necessary in the GreenLight group vs. 16% in the Thulium group. The overall complication rate in GreenLight and Thulium groups were 29% versus 37% respectively, with 9% Clavien 3b in the Thulium patients versus 1% in GreenLight.

Conclusion

Despite the bias present in this study (different expertise, difference between the vapoenucleation and the pure enucleation technique), GreenLight and Thulium laser treatments for BPH show similar safety profiles. The higher rate of transient IUS in Thulium patients might be explained by the use of enucleation technique in contrast to vaporization or vapoenucleation technique with GreenLight. Furthermore, the higher use of resectoscope for hemostasis during Thulium enucleation may also be linked to the need to perform a safety morcellation procedure. Larger study population reflecting multicenter experience would be necessary to better clarify the rate of major complications in Thulium group, the real incidence of post-operative erectile dysfunction and the grade and durability of post-operative storage symptoms in these patients’ populations.

#221: Synchronous Bilateral Renal Surgery for Renal Tumors: a single center experience

Inviato da: hpyl@hotmail.it

Argomenti: 

C. Introini1, A. Di Domenico1, M. Ennas1, M. Beverini1, F. Campodonico1, F. Bonini1, C. Brusasco1
  • 1 E. O. Ospedali Galliera (Genova)

Objective

Presentation of synchronous bilateral renal lesions is a rare condition [1-2]. We report our experience with the surgical management of these lesions in a single procedure.
Our purpose is to report the technical feasibility and safety of this approach; further we evaluate functional and oncological outcomes of our patients treated with a synchronous bilateral surgical procedure for renal neoplasia.

Materials and Methods

We retrospectively reviewed the records of all patients that underwent surgery for renal tumors at our institution between September 2015 and November 2019.
A total of 167 patients were opereted; 5 had bilateral synchronous lesions.
We analysed the following data concerning these five patients: pre and postoperative renal function, operative time, pre and post-operative hemoglobin, complications according to Clavien Dindo Classification, hospital length of stay (HLOS), pathological and oncological outcomes.
All patients had follow-up studies at regular timing to exclude local recurrence and systemic progression, using imaging studies, e.g. renal ultrasonography, Computerized Tomography (CT) or MRI of the kidney(s) and abdomen, and chest X-ray or CT.

Results

In our series bilateral synchronous sporadic RCC accounted for 2.9%.
Mean age at diagnosis was 67 years (range 52-78 y.o.) and the male to female ratio was 3:2. All patients underwent synchronous bilateral renal surgery. Two patients (40%) were metastatic at diagnosis, one presenting a single pancreatic metastases and another one had a single bone lesion.
Four patients were submitted to nephron sparing surgery (NSS) to one side and total nephrectomy to the other one (open vs videolaparoscopic ratio was 1:1) . One patient underwent bilateral videolaparoscopic NSS.
Mean operative time was 156 minutes (110-210 minutes). The increase of the average operative time is due to positioning twice the patient during the videolaparoscopic procedures.
One patient developed fever post-operatively requiring antibiotics (Clavien Dindo II) and another one was re-hospitalized after 2 days for anuria due to ureteral lithiasis requiring ureteral stenting under general anesthesia (Clavien Dindo IIIb).

The mean pre-operative serum creatinine level was 0,60 mg/dL and 1,00 mg/dL for bilateral NSS and NSS and controlateral RN, respectively.
The mean post-operative serum creatinine level was 0,60 mg/dL and 1,36 mg/dL for bilateal NSS and NSS and controlateral RN, respectively.
No patient developed chronic renal failure or required dialysis.

The mean pre-operative hemoglobin level was 141,0 g/L and 138,0 g/L for bilateal NSS and NSS and controlateral RN, respectively.
The mean post-operative hemoglobin level was 99,0 g/L and 119,7 g/L for bilateal NSS and NSS and controlateral RN, respectively.
No patient required blood transfusion.

No patient needed transfusions nor post-operative dialysis. Median HLOS was 7 days (range 4-20 days).

The histological subtypes of renal neoplasia were clear cell carcinoma in 40%, papillary type 2 in 20%, chromophobe in 20% and angiomyolipoma in 20%.
The mean tumour size was 3,2 centimeters (range 1,0 – 7,5 cm) for the 6 lesions submitted to NSS and 6.4 centimeters (range 2.5–10,0) cm for the lasting 4 lesions treated with total nephrectomy. The distribution of malignant tumour stages was pT1aNx 25%, pT1bNx 25%, pT2Nx 25% and pT4N1 25%.
One patient had positive surgical margins after partial nephrectomy.

Follow-up (FU) ranged from 4 to 19 months (mean FU of 13,6 months). To date all patients are alive and no one is on dialysis. The patient with pancreatic metastases underwent metastasectomy. The patient with bone metastases underwent medical therapy.

Discussions

Surgery is the treatment of choice for sporadic bilateral RCCs as it has been shown to progress similarly to unilateral RCC and may have a similar prognosis [3-4].
Nephron Sparing Surgery (NSS) is the treatment of choice for bilateral renas tumors; this can be accomplished by open, laparoscopic, or robot-assisted laparoscopic technique [2, 5-7]. According to the literature, the surgical approach can be single or staged: it depends on the number, location and size of renal tumors, patients features (in terms of performance status) as well as to the surgeon experience.
Our preference is to adopt synchronous bilateral nephronsparing surgery (NSS) in order to preserve the renal reserve for possible secondary interventions, unfortunately, in this series it was possible just in one case, so, when NSS is unfeasible, Total Nephrectomy should be considered. Surgeons must balance the need for complete eradication of malignant tissue with maintenance of renal function [8] .
We prefere to start with the most favourable lesion, so that when partial nephrectomy is achived to one side we can approach more friendly the more complex lesion with extreme nephron sparing surgery, but we can also change the second procedure to a Total Nephrectomy.

The surgery can be done in either a single setting or a staged setting. Small cohort studies have not shown a significant difference in tumor recurrence, postoperative complications, or length-of-stay when comparing single versus staged procedures. We prefered to achieve complete tumors removal in a single surgery, decreasing the risks associated with a second procedure [9] . Further we feel that it allows to better control the quality of the hemostasis on the side of the first procedure while and after performing the second one, avoiding some early bleeding requiring second surgery or embolization .

Conclusion

Synchronous bilateral renal tumor constitute a rare clinical entity and a stressful challenge for surgeons [2,5]. Conservative surgical therapy should be the treatment of choice as it allows both an adequate local control of the disease and better functional results.
In the appropriate setting, surgical management of synchronous bilateral renal lesions can be done safely in a single procedure by an expert surgeon.

Reference

1) Qi N, Li T, Ning X, Peng X, Cai L, Gong K: Clinicopathologic features and prognosis of sporadic bilateral renal cell carcinoma: a series of 148 cases. Clin Genitourin Cancer 2017;15:618–624.
2) S. Pahernik, D. Cudovic, F. Roos, S. W. Melchior, and J. W. Th¨uroff, “Bilateral synchronous sporadic renal cell carcinoma: Surgical management, oncological and functional outcomes,” BJU International, vol. 100, no. 1, pp. 26–29, 2007.
3) L. Mearini, E. Nunzi, A. Vianello, M.Di Biase, andM. Porena, “Margin and complication rates in clampless partial nephrectomy: a comparison of open, laparoscopic and robotic surgeries,” Journal of Robotic Surgery, vol. 10,no. 2, pp. 135–144, 2016.
4) Blute ML, Itano NB, Cheville JC, Weaver AL, Lohse CM, Zincke H. The effect of bilaterality, pathological features and surgical outcome in nonhereditary renal cell carcinoma. J Urol 2003; 169 : 1276–81
5) W. T. Lowrance,D. S. Yee, A. C.Maschino et al., “Developments in the surgical management of sporadic synchronous bilateral renal tumours,” BJU International, vol. 105, no. 8, pp. 1093–1097, 2010.
6) F. N. S. Boy, O. H. Yuksel, and A. Verit, “Bilateral sporadic synchronous renal clear-cell carcinoma treated by bilateral partial laparoscopic nephrectomy: Report of two cases,” Archivos Espa˜noles de Urolog´ıa, vol. 68, no. 9, pp. 718–721, 2015.
7) B. Woodson, R. Fernandez, C. Stewart, S. Mandava, L. Wang, and B. R. Lee, “Bilateral synchronous sporadic renal masses: intermediate functional and oncological outcomes at a single institution,” International Urology and Nephrology, vol. 45, no. 3, pp. 619–625, 2013.
8) Grimaldi G, Reuter V, Russo P: Bilateral non-familial renal cell carcinoma. Ann Surg On­col 1998;5:548–552.
9) Jacobs BL, Gibbons EP, Gayed BA, Whet­stone JL, Hrebinko RL: Management of bi­lateral synchronous renal cell carcinoma in a single versus staged procedure. Can J Urol 2009;16:4507–4511

#223: CyberKnife Radiotherapy versus Robot Assisted Radical Prostatectomy in low-intermediate risk Prostate Cancer patients. Results from the first Italian retrospective, single-centre comparative study

Inviato da: maida.bada@yahoo.com

M. Bada1, M. Justich1, B. De Concilio1, F. Crocetto2, G. Zeccolini1, G. Mazzon1, C. Baiocchi3, A. Celia1
  • 1 Ospedale San Bassiano (Bassano del Grappa)
  • 2 Università degli Studi di Napoli Federico II", Dipartimento di Neuroscienze e Scienze Riproduttive ed Odontostomatologiche (Napoli)
  • 3 Ospedale San Bortolo (Vicenza)

Objective

We aimed to compare robot assisted radical prostatectomy (RARP) and CyberKnife Radiotherapy (RCK) in Prostate Cancer (PCa) patients at low and intermediate risk terms of oncological and functional outcomes.

Materials and Methods

Material and Methods. We performed a single center retrospective comparative study. Patients that underwent RCK and RARP between January 2009 and June 2015 were enrolled. Demographic and clinical data were collected in both groups including Prostate Specific Antigen (PSA) measured before and after 1, 3, 6, 12, 24 months and then yearly, International Prostate Symptom Score ( IPSS), International Index of Erectile Function score 5 (IIEF-5), . Treatment complications were evaluated through the RTOG score And Clavien Dindo in RCK and RARP groups respectively.

Results

Results. A total of 156 patients were enrolled: 78 underwent RARP and 78 received RCK. Median PSA at the diagnosis was 5.035 ng/ml and 6 ng/ml in the RALP and RCK arms, respectively. The number of patients with low, intermediate, and high risk PCa in the RALP and RCK groups were: 46, 14, 18, and 31, 27, 20, respectively. . Median follow-up was 31 months for the surgery and 34 months for RCK. IPSS score decreased by 4% and 3.8 % in RARP and RCK arms respectively. PSA values recorded at 6, 12, and 24 months follow-up in the RCK group were: 0,83ng/mL, 0,49ng/mL and 0,43 ng/mL, respectively. Progression Free Survival (PFS) was 92,4% in RALP arm and 96,2% in RCK group. No acute urinary and rectal toxicity was evident in 57,7% and 62,8% of cases, while no late toxicity (both urinary and rectal) was observed in 88,5% and 96,2% of patients. For both the arms, no treatment-related deaths were registered.

Discussions

To our knowledge, we performed for the first time in Italy, a direct comparison between CyberKnife Radiotherapy and Robot Assisted Radical Prostatectomy in low-intermediate risk PCa patients
In the last 10 years, thanks to the development of HY technique, an increasing number of PCa resulted in EBRT and it represents a standard of care treatment also in other tumours like lung, brain and abdominal cancer. To understand how best to support men diagnosed with localised PCa to decide which treatment option best suits their need, when RALP and EBRT are equally appropriate to offer them, Smith et al. reported that the choice’s treatment is largely dependent on clinicians’ recommendations 13.

Urinary incontinence and erectile dysfunction are common post-operative complications after RALP. Hence, we reported in our RALP arm, an improvement of IIEF-5 and IPSS score before and after 24 months according the current literature. Networks performing and not performing EBRT did not differ in rates of surgery and active surveillance, yet networks performing EBRT had lower rates of BT. EBRT may represent an alternative to BT more so than for active surveillance 16 .According to phase 3 CHHiP trial, patients with localised PCa treated by CK HY dose (60 Gy) had similar outcomes compared to conventionally fractionated schedule ( 74 Gy) in terms of clinical and biochemical failure at a median follow up of 5 years, 17 .The profile of toxicity of CK is low, with a minimal impact on long term urinary and bowel complications. Katz et al. investigated long/term toxicity after EBRT for low risk PCa patients and found acute GI toxicity to occur in 0.06% of patients and grade 4 in 0.03%,. Nevertheless, There was a significant association with increasing dose and late grade 3 GU toxicity, but no significant association with dose and late grade 3 GI toxicity 18 . Our real life resulrs are in line with published data,. Currently,,, CK limitations include: no published phase III data, limited evidence in high-risk patients, contraindication for certain patients, including patients with bilateral hip replacements. King et al. reported the largest multi-center report on CK treatment in clinically localized PC: in a median follow up of 36 months, the 5-year biochemical relapse-free survival (bRFS) defined as nadir 2 ng/mL was 95%, 84%, and 81% for low-, intermediate-, and high-risk prostate cancer, respectively19. The largest single-center institution series was published by Katz et al.: there were a total of 324 low-, 153 intermediate-, and 38 high-risk patients included with the 8-year bRFS being 94%, 84%, and 65%, respectively. An updated 10-year analysis of 230 low-risk patients showed 93% bRFS 20 .Despite very fast PSA decline in first 4 months after CK, Lee et al. reported that this decline is slower than after conventional irradiation 21.Compared to BT, however, SBRT produces similar or higher PSA levels22.In the RALP arm, patients after prostate surgery, who had a detectable nadir and reached nadir within 1 to 3 months after surgery had the greatest Biochemical recurrence (BCR) risk. Importantly, about half of men with a detectable PSA within 1 to 3 months after surgery had a lower value when checked 3 to 6 months after surgery23.As shown in Figure 2, the PSA nadir post CK reported the initial rapid decline of PSA followed by a prolonged slow decay. They suggested that rapid decline of PSA in initial phase is caused by de- struction of malignant cells and further prolonged de- crease reflects the decline of PSA produced by benign tissues. Nevertheless in RALP group, The PSA has a slow increase after 31 months of follow up. Freeman et al. reported 5-year outcome of SBRT with 35–36.25 Gy / 5 fractions in 41 low-risk prostate cancers patients. The biochemical PFS rate was 93%, which they suggest comparable to brachytherapy or surgery with less toxicity profiles 24.
In our experience, at the end of follow up, CK arm presented PFS similary to RALP arm, according to the literature. Nevertheless, no randomized study has demonstrated that the radiotherapeutic dose fractionation or target volume affects PC specific or overall survival 25. We must acknowledge some important limitations to our study. It is a retrospective and monocentric analysis of a prospective collected database and it includes all the possible limitations of these studies such as the under-reporting of adverse events, incompleteness of data collection and selection biases. However, all these possible drawbacks did not affect the ability to correctly evaluate the survival outcomes. Notwithstanding all these limitations, our study represents an early monocentric Italian experience, the first study that comparing two different approach (ralp vs CK) in low-intermediate risk patients of PC.

Conclusion

RCK is a safe therapeutic strategy for low- and intermediate risk PCa patients.

Reference

1. Illic D, Diulbegovic M, Jung JH et al. Prostate cancer screening with prostate-specific antigen (PSA) test: a systematic review and meta-analysis. BMJ 2018;362: k3519.
2. Vickers AJ. Prostate cancer screening: time to question how to optimize the ratio of benefits and harms. Ann Intern Med 2017;167:509-10.
3. D’Amico AV, Whittington R, Malkowicz SB, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA. 1998;280:969–74.
4. Carlsson S, Jäderling F, Wallerstedt A, et al. Oncological and functional outcomes 1 year after radical prostatectomy for very-low-risk prostate cancer: results from the prospective LAPPRO trial. BJU Int. 2016;118(2):205-12.
5. Nyberg M, Hugosson J, Wiklund P, et al. LAPPRO group. Functional and Oncologic Outcomes Between Open and Robotic Radical Prostatectomy at 24-month Follow-up in the Swedish LAPPRO Trial. Eur Urol Oncol. 2018;1(5):353-60.
6. Incrocci L, Wortel RC, Alemayehu WG, et al. Hypofractionated versus conventionally fractionated radiotherapy for patients with localised prostate cancer (HYPRO): final efficacy results from a randomized, multicenter, open-label, phase 3 trial. Lancet Oncol. 2016 ;17(8):1061-1069.
7. Lee DK, Figg WD. A new predictive tool for postoperative radiotherapy in prostate cancer. Cancer Biol Ther. 2017;18(5):277-278.
8. Fowler JF. The radiobiology of prostate cancer including new aspects of fractionated radiotherapy. Acta Oncol. 2005;44(3):265-76.
9. Matta R, Chapple CR, Fisch M, et al. Pelvic Complications After Prostate Cancer Radiation Therapy and Their Management: An International Collaborative Narrative Review. Eur Urol. 2019;75(3):464-476.
10. EAU guidelines prostate cancer 2019
11. Weinreb, J.C., et al. PI-RADS Prostate Imaging – Reporting and Data System: 2015, Version 2. Eur Urol, 2016. 69: 16.
12. Briganti, A., et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores. Eur Urol, 2012. 61: 480.
13. Smith A', Rincones O, Sidhom M, et al. Robot or radiation? A qualitative study of the decision support needs of men with localised prostate cancer choosing between robotic prostatectomy and radiotherapy treatment. Patient Educ Couns. 2019;102(7):1364-1372.
14. Zattoni F, Artibani W, Patel V, et al.Technical innovations to optimize continence recovery after robotic assisted radical prostatectomy.Minerva Urol Nefrol. 2019;71(4):324-338.
15. De Carvalho PA, Barbosa JABA, Guglielmetti GB, et al. Retrograde Release of the Neurovascular Bundle with Preservation of Dorsal Venous Complex During Robot-assisted Radical Prostatectomy: Optimizing Functional Outcomes. Eur Urol. 2018.
16. Jacobs BL, Yabes JG, Lopa SH, et al.The Influence of Stereotactic Body Radiation Therapy Adoption on Prostate Cancer Treatment Patterns. J Urol. 2019;30:101097.
17. Dearnaley D, Syndikus I, Mossop H, et al. CHHiP Investigators. Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: 5-year outcomes of the randomised, non-inferiority, phase 3 CHHiP trial. Lancet Oncol. 2016;17(8):1047-1060.
18. Katz AJ, Kang et al. Quality of life and toxicity after SBRT for organ-confined prostate cancer, a 7-year Study. Front Oncol.2014;4:301.
19. King CR, Freeman D, Kaplan I, et al. Stereotactic body radio- therapy for localized prostate cancer: pooled analysis from a multi-institutional consortium of prospective phase II trials. Radiother Oncol. 2013;109(2):217-221.
20. Katz A,Formenti SC,Kang J.Predicting biochemical disease-free survival after prostate stereotactic body radiotherapy: risk- stratification and patterns of failure. Front Oncol. 2016;6:168.

#224: Inguinal lymphadenectomy (IL) in penile cancer patients: comparison with laparoscopic (LIL) and open (OIL) techniques. Multicenter analysis with a median follow up of 5 years

Inviato da: maida.bada@yahoo.com

Argomenti: 

M. Bada1, P. Nyirady2, V. Pagliarulo3, F.. Crocetto4, B. Barone4, B. De Concilio1, G. Mazzon1, T. Silvestri1, A. Celia1
  • 1 Ospedale San Bassiano (Bassano del Grappa)
  • 2 Ospedale Budapest (Budapest)
  • 3 Università degli Studi di Bari (Bari)
  • 4 Università degli Studi di Napoli Federico II (Napoli)

Objective

Penile cancer (PC) is a rare malignant disease in Western countries: squamous cell carcinoma (SCC) of the penis accounts for &gt;95% of cases of PC. Lymph node metastases occur in 20-40% of patients with SCC and are one of the strongest predictors of mortality: for these reasons, curative IL is recommended in any T1 grade 3-4 SCC and in all &gt;T2 SCC. However, this procedure has been reported to lead to postoperative complications. The aim of our study is to compare differences of operative outcomes, post operative complications and survival outcomes between OIL and LIL cases in a multicenter series with a median follow up of 5 years.

Materials and Methods

A total of 55 patients with proven SCC underwent IL (according to EAU guidelines) in 3 centers, 26 LIL and 29 OIL 2were retrospectively analyzed. From September 2011 to January 2019 all patients were treated with bilateral IL open and laparoscopic approaches: we used preservation of the saphenous vein technique. In each center, an experiences laparoscopic surgeon performed all IL. We collected pre operative and operative data, complication rate, number of lymph nodes removed, survival outcomes. All data were compared during follow up period. Kaplan Meier curves were used to evaluate the survival outcomes.

Results

All LIL were completed successfully without conversion to OIL approach.
The median age was 60 (37-85) in OIL group and 59.3 (38-77) in LIL group.
For LIL and OIL groups, the mean operative time was 202 +/- 22 (180-250) and 148.4 +/- 32.1 (110-250) minutes, respectively. The numbers of superficial lymph nodes removed were similar the the both groups (12+/- 5 in the LIL and 12+/- 3.4 in the OIL), nevertheless, the deep lymph nodes were 3+/- 4.9 and 4+/- 2.6 in OIL versus LIL groups.
Hospital stays were lower in LIL group with mean 3.76 (3-10) as compared to OIL 8.4 (6-20).
As concerning the 30 days post-operative complications (POC), 4 (15%) patients in LIL group reported minimal wound complications. In OIL group, 8 (27.5%) patients had POC, 4 reported leg lymphedemas resolved in 2 months: 2 patients had deep venous thrombosis in &gt;90 days complications.
In a median follow up period of 60 months, the overall survival was 65.5 and 84.6 in OIL and LIL groups respectively.

Discussions

The treatment for penile cancer in patients without evidence of lymphatic involvement is dictated by a risk–benefit analysis. At the moment, there is not enough evidence that allows for the standardization of the inguinal lymphadenctomy inn particular as concerning surgical technique.
Standard inguinal lymphadenectomy provides important information about the prognosis of the patient and it helps to remove early micrometastasis, nevertheless, the procedure has a high morbidity rate. Besides, other noninvasive methods such as the detection of metastasis with CT, MRI, high-resolution ultrasonography, and positron emission tomography/CT result in higher false-negative rates. the minimally invasive approach with laparoscopic technique as view in our study offers minor complications in comparison with open approach and the higher number of lymph nodes removed with best oncological outcomes.

Conclusion

The LIL is a safe procedure with better post-operative outcomes, minor complications rate and better survival in PC patients.

Reference

1. Van Poppel, H., et al. Penile cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol, 2013. 24 Suppl 6: vi115.
2. Chaux, A., et al. Epidemiologic profile, sexual history, pathologic features, and human papillomavirus status of 103 patients with penile carcinoma. World J Urol, 2013. 31: 861.
3. Verhoeven RH, Janssen-Heijnen ML, Saum KU et al. Population-based survival of penile cancer patients in Europe and the United States of America: no improvement since 1990. Eur J Cancer 2013;49:1414-21.
4. Stabile A, Muttin F, Zamboni S, et al. Therapeutic approaches for lymph node involvement in prostate, bladder and kidney cancer. Expert Rev Anticancer Ther. 2019;19(9):739-755-
5. Chipollini J, Azizi M, Lo Vullo S, et al. Identifying an optimal lymph node yield for penile squamous cell carcinoma: prognostic impact of surgical dissection. BJU Int. 2019;29.
6. EAU guidelines Penile cancer 2019

#225: The role of renal biopsy to improve diagnosis and management of small renal masses: are there predictive factors for detective higher diagnostic rate? The first Italian study of 100 cases

Inviato da: maida.bada@yahoo.com

Argomenti: 

M. Bada1, S. Rapisarda2, C. Cicero1, M. Di Mauro2, M.. Sebben1, B. De Concilio1, G. Mazzon1, A. Celia1
  • 1 Ospedale San Bassiano (Bassano del grappa)
  • 2 Università degli Studi di Catania (Catania)

Objective

Incidence of small renal masses (SRMs) has increased over the last decade: in order to reduce overtreatment of benign lesions, renal tumor biopsy (RTB) has been advocated. The primary aim of this study were to establish the rate of diagnostic biopsies and the concordance rate between RTB and surgical pathology with regard to tumor histology. The secondary aim was to identify what predictive factors are associated with an initial diagnostic biopsy.

Materials and Methods

We retrospectively analyzed RTB performed in our centre in patients with SRMs between 2015 and 2017. We assessed patient demographics and clinical status, lesion characteristics and procedural factors. The categorical variables were tested with the chi-square test. We used univariate and multivariate analysis to identify what factors are indicative of non diagnostic biopsies. We used the SPSS statistics 23.

Results

We performed a total of 100 RTBs to management 94 patients. The initial biopsy was diagnostic in 88 patients (67malignant and 21 benign lesion). The six remaining patients had repeat biopsies, of which four were diagnostic. Complications rate was 5% prevalently local hematoma treated with surveillance. Agreement between biopsy and surgical histology was found in 94% of cases. On contingency analysis and on univariate and multivariate analysis, these factors ( age, tumour size, exophytic location, and type of imaging used) were not predictive with diagnostic biopsy.

Discussions

In the last years, Nephron-sparing surgery (NSS) is the gold standard for treating small renal masses. In about 30% of cases, the final histopathological report describes a benign lesion. Over the last few years, a consensus has developed that renal tumor biopsy (RTB) has the potential to reduce overtreatment and increase recourse to ablative therapy and active surveillance when appropriate. RTB can also help detect a metastatic disease before systemic treatment, with considerable benefit for patient management.8 Despite the increasing level of evidence, RTB remains a debated procedure mostly due to concerns regarding the risk of complications. Of these, hematoma and pain are not uncommon in literature (4.9 and 1.2% of cases, respectively), whereas gross haematuria, bleeding, and pneumothorax are rare (1%, 0.4%, and 0.6% of cases, respectively).9
Richard et al. reported data from a prospective dataset of 509 RTBs. Adverse events were observed in 42 patients (8.5%), with the most common being peri renal hematoma (Clavien grade 1).10 Our experience is in line with existing literature and confirms the safety of the procedure. All RTBs were performed with local anesthesia, an 18-gauge needle with a coaxial technique: most of our complications were hematomas that had a tendency to resolve spontaneously with observation and a conservative approach. No cases of seeding was observed. A number of papers in the literature report histologically evident biopsy tract seeding. In 2013, Mullins et al. reported the case of a male patient, aged 68, with a 4.7-cm incidental left renal cyst, a diagnosis of RCC, and evidence of seeding in the perinephric fat11 In another study conducted on a seven-patient series, one patient had RCC seeding. Some authors suggest using a coaxial sheath to minimise the occurrence of seeding12.
The primary objective of RTB is to inform both clinicians and patients about the benign or malignant nature of small renal masses before planning treatment. In a recent meta-analysis, the malignant detection rate of RTB was reported at around 90-100%, with high sensitivity of CB and FNA (range: 92-99%).7,13
The literature reports an incidence 13 cm, and endophytic SRMs. In our study, the rate of no diagnostic RTBs did not seem to be influenced by the physician’s or evaluating pathologist’s level of experience. In all published reports, repeat biopsies have a high diagnostic rate and low level of risk.16 Despite the current literature, in our univariate and multivariate analyses, we didn’t find factors more likely to be associated with a diagnostic biopsy. According to Richard et al., the exophytic localization and tumor size are two predictive factor to obtained a diagnostic biopsy10.
The concordance rate with regard to histologic subtypes between RTB and surgical pathology was a stark 94%. Again, this is in line with the 86- 98% range reported in the literature (with higher rates for RCC and a somewhat poor detection capability for chromophobe RCC).17
RTB seems to be less accurate in determining Fuhrman grade (e.g., low vs high grade), with a tendency to undergrad compared with surgical pathology. In general, increasing the number of cores during renal biopsy seems to improve the accuracy of malignancy, subtype, and grade detection.18 A diagnostic pre-treatment biopsy often provides useful information, and in our experience helped avoid invasive treatment in 24 patients with benign lesions.
The findings of our study should be tempered in light of its limitations. First, its retrospective design limits the quality of results. Additionally, not all patients diagnosed with SRMs were biopsied and a selection bias may be present. Finally, some SRMs were not surgically excised in our department; their number, albeit small, inevitably led to loss of data.

Conclusion

RTB for SRMs helps establish pre-treatment diagnosis, reduce overtreatment, with a low risk of complications and high diagnostic rate. In our experience, we did not find predictive factors more likely associated with a diagnostic biopsy.

Reference

1. Volpe A, Mattar K, Finelli A et al. Contemporary results of percutaneous biopsy of 100 small renal masses: a single center experience. J Urol.2008;180(6):2333-7.

2. Burruni R, Lhermitte B, Cerantola Y, et al. The role of renal biopsy in small renal masses. Can Urol Assoc J (2016); 10: E28-E33.

3. Sanchez A, Feldman AS, Hakimi AA. Current Management of small renal masses, including patient selection, renal tumor biopsy, active surveillance, and thermal ablation. J Clin Oncol. 2018.

4. Leveridge MJ, Finelli A, Kachura JR et al. Outcomes of small renal mass needle core biopsy, nondiagnostic percutaneous biopsy, and the role of repeat biopsy. Eur Urol. 2011;60(3):578-84.

5. Haifler M, Kutikov A. Current Role of Renal Biopsy in Urologic Practice. Urol Clin North Am. 2017;44(2):203-11.

6. Gupta M, Alam R, Patel HD, et al. Use of delayed intervention for small renal masses initially managed with active surveillance. Urol Oncol. 2019; 37 (1):18-25.

7. Marconi L, Lam TB, Bex A, et al. Systematic Review and Meta-analysis of Diagnostic Accuracy of Percutaneous Renal Tumour Biopsy. Eur Urol 2016; 69:660-73.

8. Volpe A, Finelli A, Gill IS, et al. Rationale for percutaneous biopsy and histologic characterization of renal tumours. Eur Urol 2012; 62: 491-504.

9. Patel HD, Johnson MH, Aerorazio PM, et al. Diagnostic accuracy and risks of biopsy in the diagnosis of a renal mass suspicious for localized renal cell carcinoma: systematic review of the literature. J Urol 2016;195(5):1340-7.

10. Richard PO, Jewett MA, Bhatt JR et al. Renal tumor biopsy for small renal masses: a single center 13-year experience. Eur Urol 2015; 68(6):1007-13.

11.Mullins JK, Rodriguez R. Renal cell carcinoma seeding of a percutaneous biopsy tract. Can Urol Assoc J 2013;7:E176-9.

12.Macklin PS, Sullivan ME, Tapping CR et al. Tumour Seeding in the Tract of Percutaneous Renal Tumour Biopsy: A Report on Seven Cases from a UK Tertiary Referral Centre. Eur Urol. 2018.

13.Marconi, Jeon HG, Seo SI, Jeong BC et al. Percutaneous kidney biopsy for a small renal mass: a critical appraisal of results. J Urol 2016;195(3):568-73.

14.Kominsky HD, Parker DC, Hohil D et al. Some renal masses did not “read the book”: a case of a high grade hybrid renal tumor masque rading as a renal cyst on noncontrast imaging. Urol Case Rep 2015;3(6):219-20.

15.Marconi L, Dabestani S, Lam TB et al. Systematic review and meta-analysis of diagnostic accuracy of percutaneous renal tumour biopsy. Eur Urol 2016;69(4):660-73.

16.Prince J, Bulttan E, Hinshaw L et al. Patient and tumor characteristics can repeat non diagnostic renal mass biopsy findings. J Urol 2015; 193(6):1899-904.

17.Von Rundstedt FC, Mata DA, Kryvenko ON et al. Diagnostic accuracy of renal mass biopsy: an ex vivo study of 100 nephrectomy specimens. INT J Surg Pathol 2016:24(3):213-8.

18.Al-Aynati M, Chen V, Salama S, et al. Interobserver and intraobserver variability using the Fuhrman grading system for renal cell carcinoma. Arch Pathol Lab Med 2003;127:593-6.

#230: Embolizzazione della prostata in pazienti con catetere a permanenza

Inviato da: claudiocec@hotmail.it

C.. Ceccherini1, A.. Auci1, L. Lorenzi1, J.. Pazzagli1, M. Gallucci2
  • 1 Noa (Massa Carrara)
  • 2 Policlinico Umberto I (Roma)

Objective

Lo scopo dello studio è quello di valutare prospetticamente dopo embolizzazione delle arterie prostatiche (PAE) la rimozione del catetere vescicale a permanenza (IBC) e la riduzione dei sintomi del tratto urinario inferiore (LUTS) da iperplasia prostatica benigna (IPB).

Materials and Methods

Sono stati candidati alla procedura di PAE i pazienti non idonei all'intervento chirurgico con almeno 1 mese di catetere a permanenza e pazienti con LUTS secondaria a BPH; i criteri di esclusione per la PAE includevano l'idoneità all'intervento chirurgico, il cancro alla vescica o il carcinoma prostatico noto. Il successo tecnico e clinico dell'embolizzazione è stato definito
Dall’embolizzazione della prostata bilaterale, rimozione dell'IBC e riduzione scomparsa dei sitmoni da LUTS. I pazienti sono stati seguiti per almeno 6 mesi e valutati per il punteggio internazionale dei sintomi della prostata, la qualità della vita, la dimensione della prostata e i parametri dell’uroflussimetria.

Results

Sono stati arruolati 129 pazienti in totale; L'embolizzazione bilaterale è stata eseguita in 99 (76,7%), l'embolizzazione unilaterale in 24 (18,6%); in 6 pazienti è stato possibile eseguire l’embolizzaione per avanzata ateromasia dei vasi pelvici associata ad occlusione dei rami di divisione anteriore (4,7%). Tra i pazienti che sono stati embolizzati, la dimensione media della prostata è diminuita da 75,6 ± 33,2 a 63,0 ± 23,2 g (classifica dei segni p = 0,0001, riduzione media del 19,6 ± 17,3%) e la rimozione dell'IBC è stata raggiunta in 99 pazienti (80,5%). Complicazioni di Clavien II sono state riportate in 27 pazienti (21,9%) e comprendevano infezione del tratto urinario (9 pazienti, 7,3%) e ritenzione urinaria acuta ricorrente (18 pazienti, 14,6%). Nove pazienti (22,0%) hanno manifestato sindrome post-embolizzazione.

Discussions

Lo sviluppo delle tecniche mini-invasive per il trattamento dell’ipertrofia prostatica benigna sintomatica sta diventando un grande argomento di ricerca internazionale.
Nella nostra esperienza l'embolizzazione della prostata si è dimostrata sicura ed efficace senza significative complicazioni post embolizzazione.

Conclusion

La PAE è sicura e fattibile per il sollievo di LUTS e IBC in pazienti con comorbidità senza opzioni di trattamento chirurgico.

Reference

1) DeMeritt JS, Elmasri FF, Esposito MP, Rosenberg GS. Relief of benign prostatic hyperplasia-related bladder outlet obstruction after transarterial polyvinyl alcohol prostate embolization. J Vasc Interv Radiol. 2000 Jun;11(6):767-70. PubMed PMID: 10877424.

2)Pisco JM, Pinheiro LC, Bilhim T, Duarte M, Mendes JR, Oliveira AG. Prostatic arterial embolization to treat benign prostatic hyperplasia. J Vasc Interv Radiol. 2011 Jan;22(1):11-9; quiz 20. doi: 10.1016/j.jvir.2010.09.030. PubMed PMID: 21195898.

3)Carnevale FC, Antunes AA. Prostatic artery embolization for enlarged prostates due to benign prostatic hyperplasia. How I do it. Cardiovasc Intervent Radiol. 2013 Dec;36(6):1452-63. doi: 10.1007/s00270-013-0680-5. Epub 2013 Aug 1. Review. PubMed PMID: 23903785.

4)Bilhim T, Pisco J, Campos Pinheiro L, Rio Tinto H, Fernandes L, Pereira JA, Duarte M, Oliveira AG. Does polyvinyl alcohol particle size change the outcome of prostatic arterial embolization for benign prostatic hyperplasia? Results from a single-center randomized prospective study. J Vasc Interv Radiol. 2013 Nov;24(11):1595-602.e1. doi: 10.1016/j.jvir.2013.06.003. Epub 2013 Aug 3. PubMed PMID: 23916874

5) Carnevale FC, Moreira AM, Antunes AA. The ‘‘PErFecTED technique’’: proximal embolisation first, then embolize distal for benign prostatic hyperplasia. Cardiovasc Intervent Radiol. 2014;37(6):1602–5.

6) Carnevale FC, da Motta Leal Filho JM, Antunes AA, et al. 
Quality of life and clinical symptom improvement support pro- static artery embolisation for patients with acute urinary retention caused by benign prostatic hyperplasia. J Vasc Intervent Radiol. 2013;24:535–42. 

7) Assis AM, Moreira AM, de Paula Rodrigues VC, et al. Prostatic artery embolisation for treatment of benign prostatic hyperplasia 
in patients with prostates [90 g: a prospective single-center study. J Vasc Interv Radiol. 2015;26(1):87–93.

8) Brook OR, Faintuch S, Brook A, et al. Embolisation therapy for benign prostatic hyperplasia: influence of embolisation particle size on gland perfusion. J Magn Reson Imag. 2013;38:380–7.
9) Wang M, Guo L, Duan F, et al. Prostatic arterial embolisation for the treatment of lower urinary tract symptoms as a result of large benign prostatic hyperplasia: a prospective single-center investigation. Int J Urol. 2015;22(8):766–72.

10) Pisco JM, Rio Tinto H, Campos Pinheiro L, et al. Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of short- and mid-term follow-up. Eur Radiol. 2013;23:2561–72. 

11) Antunes AA, Carnevale FC, da Motta-Leal-Filho JM, et al. Clinical, laboratorial and urodynamic findings of prostatic artery embolisation for the treatment of urinary retention related to benign prostatic hyperplasia. a prospective singe-center pilot study. Cardiovasc Intervent Radiol. 2013;36:978–86. 

12) Bagla S, Martin CP, van Breda A, et al. Early Results from a United States Trial of Prostatic Artery Embolisation in the Treatment of Benign Prostatic Hyperplasia. J Vasc Interv Radiol. 2014;25:47–52. 

13) Assis AM, Moreira AM, de Paula Rodrigues VC, et al. Prostatic artery embolisation for treatment of benign prostatic hyperplasia 
in patients with prostates [90 g: a prospective single-center study. J Vasc Interv Radiol. 2015;26(1):87–93.
15. Frenk NE, Baroni RH, Carnevale FC, et al. MRI findings after prostatic artery embolisation for treatment of benign hyperplasia. Am J Roentgenol. 2013;203:813–21.

14) Brook OR, Faintuch S, Brook A, et al. Embolisation therapy for benign prostatic hyperplasia: influence of embolisation particle size on gland perfusion. J Magn Reson Imag. 2013;38:380–7.
15) Wang M, Guo L, Duan F, et al. Prostatic arterial embolisation for the treatment of lower urinary tract symptoms as a result of large benign prostatic hyperplasia: a prospective single-center investigation. Int J Urol. 2015;22(8):766–72.

16) Amouyal G, Thiounn N, Pellerin O, Yen-Ting L, Del Giudice C, Dean C, Pereira H, Chatellier G, Sapoval M. Clinical results after prostatic artery embolisation using the PErFecTED technique: a single-center study. Cardiovasc Intervent Radiol. 2016;39(3): 367–75.
17) Laborda A, de Assis AM, Ioakeim I, Sa ́nchez-Ballestin M, Car- nevale FC, de Gregorio MA. Radiodermatitis after prostatic artery embolisation: case report and review of the literature. Cardiovasc Intervent Radiol. 2015;38:755–9.

#233: Subcapsular renal hematoma after Retrograde Intra Renal Surgery (RIRS) and Holmium laser Litotripsy: a case report

Inviato da: diego.rosso@aslcn1.it

Argomenti: 

D. Rosso1, M.T. Filocamo1, R. Rossi1, P. Mondino1, G. Cordara1, R. Borsa1, P. Polledro1, P. Coppola1
  • 1 ASL CN1 Savigliano, S.O.C. Urologia (Savigliano)

Objective

We present a case report of subcapsular renal hematoma after Retrograde Intrarenal Surgery (RIRS) and literature review.

Materials and Methods

A 71-years-old female patient was diagnosed by abdominal contrast-enhanced computerized tomography (CT) scan with moderate dilatation of the upper left ureter, left hydronephrosis, left ureteral stone of 5 mm and 2 more left kidney stones of 5 and 7 mm in prior PCNL, performed in 2013. The patient presented with an history of diabetes and prior thyroidectomy. The patient was admitted to our hospital with negative uroculture to perform left ureteroscopy after written informed consent was obtained. During the procedure because of the stone migration into the kidney was observed, a RIRS procedure was performed, with Holmium lithotripsy, fragments removal and a double J stent placement. In the second post-operative day the patients complained of pain in the left lumber region and fever with development of uro-sepsis. The emergent abdominal CT Scan revealed a great sub-capsular renal hematoma of 8x11cm and a 14 mm perirenal fluid collection.

Results

The routine blood tests revealed normal hemoglobin level stable compared of preoperative levels. Vital signs, urine volume and routine blood tests were monitored. The case was managed in conservative manner with intravenous fluid intake, antibiotics, and FANS. The patients was discharged in tenth post-operative day with double J stent in place and antibiotics therapy. Outpatient ultrasonography after three months revealed subcapsular renal hematoma resolution. The double J stent was removed after three months.

Discussions

RIRS as a transurethral, minimally invasive and efficient procedure has become a regular operation for treatment of renal calculi. The postoperative complication rate of RIRS is low, with the most frequent complication being a fever, flank pain, hematuria, stein strasse, uro-sepsi. Complication rate varies from 0 to 25% ( 1 , 2 , 3, 4 , 5 ). Renal hematoma after RIRS lithotripsy using holmium laser is a rare complication. The physiologic intrarenal pressure is about 10 mmHg, although the minimum threshold pressure for pielo-venous and pielo-lynphatic reflux is about 30-45 mmHg ( 6 , 7 ). It was demonstrated that high intrarenal pressure is a clear risk factor for sepsis complication ( 8 ). Bleeding complications can occur owing to the lesion of laser on renal parenchima or due to calix avulsion. Moreover, parenchimal or fornix rupture due to high intrarenal pressure could occur during the procedure ( 9 , 10 , 11 ).

Conclusion

RIRS is a safe and affective procedure for renal stones with generally acceptable complication rate. Post-RIRS subcapsular hematoma is a rare but potentially serious complication. A high index of suspicion is needed when patients present with significant loin pain and fever after RIRS. The management of post-RIRS subcapsular hematomas could be conservative but needs to be customized for each patient.

Reference

1. Cho SY. Current status of flexible ureteroscopy in urology. Korean J Urol. 2015;56:680–688.
2. Geavlete P, Multescu R, Geavlete B. Retrograde flexible ureteroscopic approach of upper urinary tract pathology: What is the status in 2014? Int J Urol. 2014;21:1076–1084.
3. Cakiroglu B. Comparison Of SWL and RIRS In Lower Calyceal Stones. Science Journal Of Clinical Medicine. 2013;2 166.
4. Cepeda M, Amón JH, Mainez JA, Rodríguez V, Alonso D, Martínez-Sagarra JM. Flexible ureteroscopy for renal stones. Actas Urol Esp. 2014;38:571–575.
5. Ho CC, Hee TG, Hong GE, Singam P, Bahadzor B, Md Zainuddin Z. Outcomes and Safety of Retrograde Intra-Renal Surgery for Renal Stones Less Than 2 cm in Size. Nephrourol Mon. 2012;4:454–457.
6. Jung H, Osther PJ. Intraluminal pressure profiles during flexible ureterorenoscopy. Springerplus. 2015;4 373.
7. Thomsen HS. Pyelorenal backflow. Clinical and experimental investigations. Radiologic, nuclear, medical and pathoanatomic studies. Dan Med Bull. 1984;31:438–457.
8. Wilson WT, Preminger GM. Intrarenal Pressures Generated During Deflectable Ureterorenoscopy. Journal Of Endourology. 1990;4:135–141.
9. Chen S, Xu B, Liu N, Jiang H, Zhang X, Yang Y, et al. Improved effectiveness and safety of flexible ureteroscopy for renal calculi (&lt;2 cm): A retrospective study. Can Urol Assoc J. 2015;9:E273–E277.
10. Watanabe R, Inada K, Azuma K, Yamashita Y, Oka A. Case of renal subcapsular hematoma caused by flexible transurethral lithotripsy. Hinyokika Kiyo. 2013;59:565–568.
11. Campobasso D, Grande M, Ferretti S, Moretti M, Facchini F, Larosa M, Salsi P, Granelli P, Pozzoli GL, Frattini A. Subcapsular renal hematoma after retrograde ureterorenoscopic lithotripsy: our experience. Minerva Urol Nefrol. 2018 Dec;70(6):617-623.

#242: PCNL closed circuit mini-Perc Clear Petra system: our experience

Inviato da: diego.rosso@aslcn1.it

Argomenti: 

P. Mondino1, M.T. Filocamo1, D. Rosso1, P. Polledro1, P. Coppola1
  • 1 ASL CN1 Savigliano, S.O.C. Urologia (Savigliano)

Objective

Percutaneous nephrolithotomy (PCNL) was at first indicated for larger renal stones. Technological progress allowed a significant improvement of the available equipment, mostly to miniaturize the devices. However, this should not affect the stone clearance. Many different techniques arised aiming to reduce the complications of PCNL. As it becomes less invasive, the indications are greatly expanded, and a growing number of patients will benefit from this procedure in the future. This explains the significance of knowing the technique in continual development in greater detail (1). Clear Petra System consist in a closed circuit with a continuous inflow and a suction-controlled outflow that permit a clear intraoperative vision. We present our experience with this procedure.

Materials and Methods

Ten consecutive patients (mean age 54 years) affected by renal stones varied between 25 to 35 mm were treated with mini-Perc clear Petra System at our institution. All patients were positioned in Valdivia Galdakao modified. A 16 Fr Clear Petra nephrostomy sheath and a 12 Fr nephroscope in all case were used. Lithotripsy were performed used Holimium Laser. Lapaxy was performed through the aspiration linked with the later arm of the sheath. No baskets were used. In all the patients double J ureteral stent and 8 Fr nephrostomy was positioned at the end of procedure. Mean RX exposition time during surgery was 90 sec (range 70-110 sec).

Results

Operation time varied from 60 to 90 minutes, mean 72 min. All patients were stone free at the end of the procedure. Routine blood test was performed in first post-operative day and in one patients we observed a decrease in hemoglobin level because of subcapsular hematoma, without necessity of transfusion. In one case we observed fever &gt; 38°C, solved with antibiotic therapy. In all the other patients routine blood test was stable compared with preoperative. In all but one patients (fever case) nephrostomy was closed in the first post-operative day and removed in the second day. Mean Hospital stay was 3,7 days (range 3-6). After one month previous abdomen CT scan that demonstrated stone free, double J stent was removed in all patients. None patient required second look.

Discussions

The complications related to access might be the injury pleura and other visceral organs. The other complications are bleeding, infection and incomplete stone clearance (2). Complications such as perioperative bleeding, urine leak from nephrocutaneous fistula, pelvicalyceal system injury, and pain are individually graded as complications by various authors and are responsible for a significant variation in the reported overall PCNL complication rate. For this reasons comparison of morbidity between studies is almost impossible. Due to the latter, a universally accepted grading system specialized for the assessment of PCNL-related complications and standardized for each variation of PCNL technique is deemed necessary (3). Control intrarenal pelvic pressures could potential reduce the irrigation pressure-related complications (4)

Conclusion

A closed circuit PCNL clear Petra system could help the surgeon in several ways: the continuous aspiration guarantees a crystal clear vision along the procedure. The low intrarenal pressure is associated with less post-operative infective complications. The easy litholapaxy and the absence of fragments scatter may reduce operative time. Mini Perc clear Petra system is safe and effective in the treatment of large renal stone .

Reference

1) Schoofs F, Celentano G, Abboudi H, Choong S, Iselin C, Wirth G. Evolution and miniaturization of percutaneous nephrolithotomy. Rev Med Suisse. 2019 Nov 27;15(673):2198-2201. French.
2) Ganpule AP, Vijayakumar M, Malpani A, Desai MR. Percutaneous nephrolithotomy (PCNL) a critical review. Int J Surg. 2016 Dec;36(Pt D):660-664.
3) Kyriazis I, Panagopoulos V, Kallidonis P, Özsoy M, Vasilas M, Liatsikos E. Complications in percutaneous nephrolithotomy. World J Urol. 2015 Aug;33(8):1069-77.
4) Rawandale-Patil AV, Ganpule AP, Patni LG. Development of an innovative intrarenal pressure regulation system for mini-PCNL: A preliminary study. Indian J Urol. 2019 Jul-Sep;35(3):197-201.

#265: PHYSIOTHERAPY AND UROANDROSEXOLOGY TOWARDS ORGASMIC CONSCIOUSNESS AFTER RADICAL PROSTATECTOMY: AN INTEGRATED APPROACH

Inviato da: m.diambrini@tiscali.it

Argomenti: 

M. Diambrini1, A. Brizzi2, W. Giannubilo1, G. Sortino1, M. Di Biase1, A. Marconi1, R. Giampieretti2, V. Ferrara1
  • 1 Urological Department Carlo Urbani Hospital Jesi (Jesi)
  • 2 Physical Medicine and Rehabilitation Carlo Urbani Hospital Jesi (Jesi)

Objective

role of physiotherapy and sexology in the development of a new orgasmic consciousness after radical prostatectomy in order to identify individual and couple sexual well-being

Materials and Methods

Integrated physiotherapeutic and uroandrosexological pathway which includes: a) physiotherapy pathway: activation and relaxation of the perineal floor in both individual and group sessions, electrostimulation of the perineal floor and biofeedback, b) urosandrosessuological pathway: first individual visit one month after surgery with progressive awareness of the new body configuration, clinical evaluation of erectile dysfunction and first interview about the new orgasmic configuration, followed by a first therapeutic pharmacological approach; continuation of the relational path with first individual then couple scheduled visits

Results

January 2018 October 2019, 90 single incision videolaparoscopic prostatectomies were performed ; 71 (78.8%) of them presented for the first visit in the uroandrosexological path . 15 of them (21.1%) followed the full relational path with particular attention to the climacturia
16 patients were subjected to physiotherapy for stress incontinence: 6 were evaluated to the integrated approach with concomitant uroandrosessuological pathway.
Of the 10 patients who did not follow the uroandrosessuological path : 5 drop out, out of the remaining 5: 4 problems of anxiety inherent to the disease, 1 relationship problems with division by the Partner; out of the 6 enrolled in the integrated approach: only 1 case (16%) reported climacturia ; the remaining 5 patients without climacturia 2 reached full orgasmic consciousness with satisfaction reporting "orgasm as if ejaculating" and 1 patient had a new partner. All 6 patients experienced penetrative success not necessarily mandatory for patient satisfaction. Only in 1 case the partner was involved
Out of the total 15 cases subjected to the uroandrosexologiac pathway The climacturia was referred in 46.6%

Discussions

The percentage of patients who accepted the uroandrosusuological path is still low, demonstrating that there are still resistances in communications in sexology.
Patients undergoing physiotherapy had a lower incidence of climacturia.
Patients undergoing an integrated approach showed a better quality of life with the goal of “orgasmic consciousness"

Conclusion

The sample is initial and small, but the successes obtained are the basis for the continuation of the experience

Reference

Neglected Side Effects After Radical Prostatectomy: A Systematic Review
lA. Ullmann, FJ Sønksen M Fode Jou Sex Med Volume 11, Issue 2, February 2014, Pages 374-385

#246: ORGASMIC CONSCIOUSNESS AFTER RADICAL PROSTATECTOMY: BEYOND SURGERY TOWARD SEXUAL WELLNESS

Inviato da: m.diambrini@tiscali.it

Argomenti: 

M. Diambrini1, W. Giannubilo1, G. Sortino1, M. Di Biase1, A. Marconi1, V. Ferrara1
  • 1 Urological Department Carlo Urbani Hospital Jesi (Jesi)

Objective

the development of a new orgasmic consciousness after radical prostatectomy for identifying sexual wellness both for individual and for couple

Materials and Methods

Proposal of an androsexological pathway that includes a first visit one month after surgery with a clinical evaluation of erectile dysfunction and the first individual interview with progressive awareness of personal body configuration after the intervention , orgasmic consciousness with a first therapeutic pharmacological approach.Continuation with a relational path projecting first individual then couple scheduled visits, for a minum of 4 visits

Results

January 2018 October 2019 : 90 single-incision videolaparo prostatectomies were performed : 71 (78.8%) presented at the first androsexological visit . 15 of them (21.1% ) followed the relational path with particular attention to climacturia. 7 out of 15 (46.6% ) had climacturia. Of the remaining 8 patients without climacturia : 4 they reached full orgasmic consciousness with satisfaction reporting "the sensation it is like before but nothing comes out "1 paz has had a new partner, everyone has experienced a penetrative success not necessarily related to the patient's satisfaction . Of the 7 patients with climacturia 2 full orgasmic consciousness were reported with satisfaction in the muscular contractions itself and with masturbation itself with or without involvement of the partners. Only 3 out of 15 (20%) involved the partners

Discussions

The percentage of patients who accepted the uroandrosusuological path is still low, demonstrating that there are still resistances in communication in sexology

Conclusion

The successes obtained in patients following androsexological pathway are the basis for the continuation of the experience

Reference

Neglected Side Effects After Radical Prostatectomy: A Systematic Review
lA. Ullmann, FJ Sønksen M Fode Jou Sex Med Volume 11, Issue 2, February 2014, Pages 374-385

#226: First prospective randomized study comparing HoLEP and MoLEP in a cohort of 140 patients

Inviato da: yasser.doc@gmail.com

Y. Hussein M I1, F. Ceresoli1, R. Milesi1, M. Bellangino1, S. Bassi1, I. Vavassori1
  • 1 ASST Bergamo Ovest (Treviglio )

Objective

BPH is a common condition in older men.Several techniques use laser energy to resect, enucleate or ablate hyperplastic prostate tissue. Holmium laser is used for HoLEP (H). MoLEP(M) is a usage of HoLEP technique that endorsea modified laser pulse with Moses™ technology (Lumenis®).
We did a prospectie randomized trial on H vs.M to expand assess data on safety and efficacy of M enucleation in BPH treatment.

Materials and Methods

This is a single-centre trial was a single-centre open-label phase 3 trial, approved by our local committee and conducted in Treviglio (BG), Italy.
Patients were men with moderate to severe BPH-associated symptoms refractory or intolerant to medical therapy or with acute or chronic urinary retention and prostate volume of &gt;80 ml, and enroled if they agreed to participate the trial; were excluded if had previous surgery, or suspected for prostate cancer, untreated urinary infection, of neurological bladder or had severe cardiovascular.
140 patients(70/70 H/M) patients were randomized preoperatively in a 1:1 fashion to H-arm or M-arm. All the procedures were performed by a single experienced operator using the traditional 3 lobes technique, the only difference was the use of MOSES™technology in M’s arm.
Primary endpoints were the evaluation of the difference in operation time and laser time, The secondary endpoints was safety.
Comparisons of means in the paired sample was performedwith a two-tail T-test(α power of 0.05 to observe a 10% difference in time of enucleation).

Results

Median age, basal PSA and prostate volume were similar. Mean laser duration was 5 minute shorter in arm M (36.4 vs 31.5 min.; P=.01) There was also a reduced laser fiber consuming (P&lt;.01).
Perioperative hemoglobin and hematocrit variations were similar. The hospital stay was the same: 2.7 vs 2.8 days.

Discussions

This trial demostrate significant that MoLEP outperformed HoLEP in term of laser timing duration due to a 5 minutes shorter laser timing, laser duration was 5 minute shorter in M’s arm and this is primarily due to a brief enucleation time in M’s arm (30.5 vs 27.1 min.; P=.03) maintaining the safety guaranteed by the surgical technique as prooven by similar bleeding, complications and hospital stay.

Conclusion

These data provide demonstration that MoLEP is safe and the most effective treatment for BPH and HoLEP with MOSES™ technology can be proposed as the new standard for HoLEP.

Reference

1) Fraundorfer, M. R., &amp; Gilling, P. J. (1998). Holmium: YAG laser enucleation of the prostate combined with mechanical morcellation: preliminary results. European urology, 33(1), 69-72.
2) GILLING, P. J., KENNETT, K., DAS, A. K., THOMPSON, D., &amp; FRAUNDORFER, M. R. (1998). Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience. Journal of endourology, 12(5), 457-459.
3) ELZAYAT, Ehab A.; ELHILALI, Mostafa M. Holmium laser enucleation of the prostate (HoLEP): the endourologic alternative to open prostatectomy. European urology, 2006, 49.1: 87-91.
4) ELZAYAT, Ehab A.; ELHILALI, Mostafa M. Holmium laser enucleation of the prostate (HoLEP): long-term results, reoperation rate, and possible impact of the learning curve. european urology, 2007, 52.5: 1465-1472.
5) ELZAYAT, Ehab A.; HABIB, Enmar I.; ELHILALI, Mostafa M. Holmium laser enucleation of the prostate: a size-independent new “gold standard”. Urology, 2005, 66.5: 108-113.
6) Beaghler M, Leo M, Gass J, March J, Sandoval S, et al. (2017) Initial Experience with New High Powered 120 W Holmium for Vaporization of the Prostate. Urol Nephrol Open Access J 4(2): 00119. DOI: 10.15406/unoaj.2017.04.00119
7) Ibrahim, A., Carrier, S., Andonian, S., &amp; Elhilali, M. (2017). Evaluation of the New Moses technology of Holmium laser lithotripsy: Initial clinical experience. European Urology Supplements, 16(3), e393-e394.
8) Elhilali, M., Badaan, S., Ibrahim, A., &amp; Andonian, S. (2017). PD30-11 Use Of Moses Pulse Modulation Technology To Improve Holmium Laser Lithotripsy Outcomes: A Preclinical Study. The Journal of Urology, 197(4), e582.
9) Elhilali, M. M., Badaan, S., Ibrahim, A., &amp; Andonian, S. (2017). Use of the Moses technology to improve holmium laser lithotripsy outcomes: a preclinical study. Journal of endourology, 31(6), 598-604.
10) Aldoukhi, A. H., Roberts, W. W., Hall, T. L., &amp; Ghani, K. R. (2017). Holmium Laser Lithotripsy in the New Stone Age: Dust or Bust?. Frontiers in surgery, 4, 57.
11) Ibrahim, A., Fahmy, N., Carrier, S., Elhilali, M., &amp; Andonian, S. (2018). Double-blinded prospective randomized clinical trial comparing regular and moses modes of holmium laser lithotripsy: Preliminary results. European Urology Supplements, 17(2), e1390.
12) MULLERAD, Michael, et al. Initial Clinical Experience with a Modulated Holmium Laser Pulse—Moses Technology: Does It Enhance Laser Lithotripsy Efficacy?. Rambam Maimonides medical journal, 2017, 8.4.
13) Ibrahim, A., Badaan, S., Elhilali, M. M., &amp; Andonian, S. (2018). Moses technology in a stone simulator. Canadian Urological Association Journal, 12(4), 127.
14) John Michalak, David Tzou, Joel Funk: HoLEP: the gold standard for the surgical management of BPH in the 21st Century Am J Clin Exp Urol 2015;3(1):36-42
15) Holmium Laser Enucleation of the Prostate; Results at 6 Years, Gilling PJ, Aho, TF, Frampton CM, et al. Eur Urol 2008 Apr:53(4):744-9
16) Mark Cynk, Holmium Laser Enucleation of the Prostate is More Efficient with More Laser Power, abstract #MP7-01, Moderated Poster Session 7: BPH/LUTS, WCE 2016

#251: Occasional finding of a giant renal artery aneurysm: case report

Inviato da: fmele@mauriziano.it

F. Mele1, M. Barale1, H. Ghabin1, A. Gaggiano2, G. De Rosa3, R. Migliari1
  • 1 AO Ordine Mauriziano, S.C. Urologia (Torino)
  • 2 AO Ordine Mauriziano, S.C. Chirurgia Vascolare (Torino)
  • 3 AO Ordine Mauriziano, S.C. Anatomia Patologica (Torino)

Objective

The renal artery aneurysms (RAA) was mentioned for the first time in 1770 by Rouppe, who described the death of a sailor due to rupture of a large false aneurysm. Renal artery aneurysms are often diagnosed by ultrasound examination for the screening of hypertension. Many small aneurysms are repairable, in other large aneurysms nephrectomy may be required for the increased wall shear stress and the destruction of renal parenchyma. In recent years, coil embolization or stent-graft with the coil embolization was successful for treating RAAs This paper will deal with the accidental diagnosis and treatment of one giant asymptomatic renal artery aneurysm.

Materials and Methods

A 73-year-old female patient presented at the emergency department due to accidental fall. Left lombar pain was present since a week. The patient had general good health and BMI was 23. At the arrival, left thighbone fracture was diagnosed, the patient was stable and the routine blood tests were normal, with creatinine 0.83 mg/dL and Hb 13.5 g/dL.

Results

FAST Ultrasonography (US) revealed a left abdominal mass with a big surrounding haematoma. A computed tomography (CT) revealed a pseudo-cystic lesion of the left kidney with enhanchement during the arterial phase.
Renal angiography showed a swirling flow of the pseudo-cystic formation which turned out to be a left renal artery giant aneurism. The aneurism was not susceptible of percutaneous endovascular treatment due to the high angle and dimensions. So the patient underwent an laparotomy resection of the aneurysm and a left nephrectomy.
She had an uneventful recovery and a healthy status.
Histological examination revealed a large aneurysm of the renal artery size of 9 cm, with compression of the renal parenchyma, with diffuse glomerulosclerosis, interstitial inflammation and diffuse atrophy.

Discussions

There are a lot of studies about renal artery aneurysms, but little exists on treatment plans for giant renal artery aneurysm. It seems that most Giant RAAs are discovered when they are close to 10 cm in diameter and are usually part of the renal parenchyma and simptomatics. Arterial reconstruction or arterial embolization are not always an option since the dimensions and because these patients may be elderly and have significant comorbidities.

Conclusion

This report confirms that nephrectomy could be mandatory in some case of RAA not suitable for conservative management.

Reference

1. Rouppe DL. Renalarteryaneurys. NovaActaPhysico-Medica Academiae Caesareae Leopoldino-Carolinae Naturae Curiosorum. 1770; 4:76.
2. Hageman JH, Smith RF, Szilagyi E, Elliott JP. Aneurysms of the renal artery: problems of prognosis and surgical management. Surgery. 1978; 84:563-72.
3. Jibiki M, Inoue Y, Kudo T, Toyofuku T. Surgical Procedures for Renal Artery Aneurysms. Annals of Vascular Diseases. 2012; 5:157-160.

#239: Supine Percutaneous Nephrolithotomy in Horseshoe Kidneys? Results of a Multicentric Study

Inviato da: omaugeri@gmail.com

Argomenti: 

F. Vicentini1, E. Mazzucchi 2, M. Gokce 3, M. Sofer4, Y. Tanidir5, T.E. Sener 5, P. de Souza Melo 2, B. Eisner6, T. Batter 6, T. Chi7, M. Armas Phan 7, C.M. Scoffone 8, C. Cracco8, B. Manzo 9, O. Angerri10, E. Emiliani10, O. Maugeri11, K. Stern 12, C. Batagello 12, M. Monga12
  • 1 Endourology Section, Clinics Hospital, University of Sao Paulo (Sao Paulo )
  • 2 Endourology Section, Hospital Brigadeiro (Sao Paulo)
  • 3 Ankara University School of Medicine (Ankara, Turkey)
  • 4 Endourology Section, Tel-Aviv Sourasky Medical Center (Tel-Aviv)
  • 5 Marmara University School of Medicine, Istanbul (Istanbul)
  • 6 Kidney Stone Program, Massachusetts General Hospital, Harvard Medical School (Boston)
  • 7 UCSF School of Medicine (San Francisco)
  • 8 Cottolengo Hospital (Torino)
  • 9 Hospital Regional de Alta EspecialidaddelBajío (Leon)
  • 10 FundacióPuigvert, UniversitatAutònoma de Barcelona (Barcelona)
  • 11 Cannizzaro Hospital / Santa Croce e Carle Cuneo Hospital (Catania)
  • 12 Glickman Urological and Kidney Institute, Cleveland (Cleveland, Ohio)

Objective

To report on the outcomes of Percutaneous Nephrolithotomy (PCNL) in Horseshoe Kidneys (HSK) in 12 different institutions worldwide and evaluate the impact of positioning during surgery.

Discussions

Our study shows that PCNL in HSK is a relatively low frequency procedure. However, it is a safe and effective treatment with a low rate of complications. Higher BMI and stone size impacted negatively outcomes and supine positioning was associated to a lower operative time.

Conclusion

Moreover, it breaks the paradigm that PCNL in HSK should only be done in prone positioning through the upper pole, since supine and prone groups had similar outcomes. Patient positioning during PCNL in HSK could be chosen according surgeon preference.

Reference

1.​Weizer AZ, Silverstein AD, Auge BK, et al. Determining the incidence of horseshoe kidney from radiographic data at a single institution. J Urol. 2003;170(5):1722-1726.
2.​Pawar AS, Thongprayoon C, Cheungpasitporn W, Sakhuja A, Mao MA, Erickson SB. Incidence and characteristics of kidney stones in patients with horseshoe kidney: A systematic review and meta-analysis. Urol Ann. 2018;10(1):87-93.
3.​Raj GV, Auge BK, Assimos D, Preminger GM. Metabolic abnormalities associated with renal calculi in patients with horseshoe kidneys. J Endourol. 2004;18(2):157-161.
4.​Kartal I, Cakici MC, Selmi V, Sari S, Ozdemir H, Ersoy H. Retrograde intrarenal surgery and percutaneous nephrolithotomy for the treatment of stones in horseshoe kidney; what are the advantages and disadvantages compared to each other? Cent European J Urol. 2019;72(2):156-162.
5.​Gokce MI, Tokatli Z, Suer E, Hajiyev P, Akinci A, Esen B. Comparison of shock wave lithotripsy (SWL) and retrograde intrarenal surgery (RIRS) for treatment of stone disease in horseshoe kidney patients. Int Braz J Urol. 2016;42(1):96-100.
6.​Türk C, Petřík A, Sarica K, et al. EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis. Eur Urol. 2016;69(3):468-474.
7.​Assimos D, Krambeck A, Miller NL, et al. Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART I. J Urol. 2016;196(4):1153-1160.
8.​Li J, Gao L, Li Q, Zhang Y, Jiang Q. Supine versus prone position for percutaneous nephrolithotripsy: A meta-analysis of randomized controlled trials. Int J Surg. 2019;66:62-71.
9.​de Souza Melo PA, Vicentini FC, Beraldi AA, Hisano M, Murta CB, de Almeida Claro JF. Outcomes of more than 1 000 percutaneous nephrolithotomies and validation of Guy&#039;s stone score. BJU Int. 2018;121(4):640-646.
10.​Satav V, Sabale V, Pramanik P, Kanklia SP, Mhaske S. Percutaneous nephrolithotomy of horseshoe kidney: Our institutional experience. Urol Ann. 2018;10(3):258-262.
11.​Etemadian M, Maghsoudi R, Abdollahpour V, Amjadi M. Percutaneous nephrolithotomy in horseshoe kidney: our 5-year experience. Urol J. 2013;10(2):856-860.
12.​Osther PJ, Razvi H, Liatsikos E, et al. Percutaneous nephrolithotomy among patients with renal anomalies: patient characteristics and outcomes; a subgroup analysis of the clinical research office of the endourological society global percutaneous nephrolithotomy study. J Endourol. 2011;25(10):1627-1632.
13.​Sohail N AA, Abdelrahman KM, Bhatti KH. Supine percutaneous nephrolithotomy in horseshoe kidney. Journal of Taibah University Medical Sciences. 2017;12:261-264.
14.​Vicentini FC, Marchini GS, Mazzucchi E, Claro JF, Srougi M. Utility of the Guy&#039;s stone score based on computed tomographic scan findings for predicting percutaneous nephrolithotomy outcomes. Urology. 2014;83(6):1248-1253.
15.​Osther PJ, Razvi H, Liatsikos E, et al. Percutaneous nephrolithotomy among patients with renal anomalies: patient characteristics and outcomes; a subgroup analysis of the clinical research office of the endourological society global percutaneous nephrolithotomy study. J Endourol. 2011;25(10):1627-1632.
16.​Skolarikos A, Binbay M, Bisas A, et al. Percutaneous nephrolithotomy in horseshoe kidneys: factors affecting stone-free rate. J Urol. 2011;186(5):1894-1898.
17.​Shokeir AA, El-Nahas AR, Shoma AM, et al. Percutaneous nephrolithotomy in treatment of large stones within horseshoe kidneys. Urology. 2004;64(3):426-429.
18.​Kuntz NJ, Neisius A, Astroza GM, et al. Does body mass index impact the outcomes of tubeless percutaneous nephrolithotomy? BJU Int. 2014;114(3):404-411.
19.​Zhou X, Sun X, Chen X, et al. Effect of Obesity on Outcomes of Percutaneous Nephrolithotomy in Renal Stone Management: A Systematic Review and Meta-Analysis. Urol Int. 2017;98(4):382-390.
20.​Tzou DT, Metzler IS, Usawachintachit M, Stoller ML, Chi T. Ultrasound-Guided Access and Dilation for Percutaneous Nephrolithotomy (PCNL) in the Supine Position: a step-by-step approach. Urology. 2019.
21.​Vicentini FC, Perrella R, Souza VMG, Hisano M, Murta CB, Claro JFA. Impact of patient position on the outcomes of percutaneous neprolithotomy for complex kidney stones. Int Braz J Urol. 2018;44(5):965-971.

#262: Adjustable single incision slings for female stress urinary incontinence: a single center study

Inviato da: rlombardo@me.com

Argomenti: 

R. Giulianelli1, R. Lombardo1, B.C. Gentile1, L. Mavilla1, A.L. Lopes Mendes1, G. Tema1, L. Albanese1
  • 1 Nuova Villa Claudia (Roma)

Objective

Stress urinary incontinence (SUI) is a common problem worldwide. The aim of this study is to assess middle-term results of the adjustability single incision TOT sling (Altis) in patients with of stress urinary incontinence.

Materials and Methods

A consecutive series of female patients with SUI were enrolled from 2014 to 2016. Patients with neurogenic UI were excluded from the analysis. All patients underwent Altis Single Incision Sling System with or without O. Patient-reported cure rate, objective cure rate and complications were reported at 1 and 2 years.

Results

Overall 30 patients with a mean age of 55 years (Range: 36-79) were enrolled. Mean operating time of sling procedure alone was 11 minutes All patients completed the follow up period of 24 months. Overall success rate was 83%, improved rate was 4% and failure rate was 3%. Complications included 3 patients with mesh extrusion solved with estrogens while no voiding difficulties and no dysuria were recorded.

Discussions

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Conclusion

SIMS-Altis is safe and effective in the treatment of female stress urinary incontinence. The results of the study suggest that the adjustability single incision sling (Altis) can be considered a minimally invasive TOT with no-needles and maintaining similar cure rates. Further randomized clinical trials should confirm our results.

Reference

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#263: Bipolar plasma enucleation of the prostate vs open prostatectomy in large benign prostatic hyperplasia: a single centre 3-year comparison

Inviato da: rlombardo@me.com

R. Giulianelli1, A.L. Lopes Mendes1, G. Tema1, B.C. Gentile1, L. Albanese1, L. Mavilla1
  • 1 Nuova Villa Claudia (Roma)

Objective

Aim of our study is to compare surgery outcomes and safety of button bipolar enucleation of the prostate vs open prostatectomy in patients with large prostates (&gt;80g) in a single center cohort study.

Materials and Methods

All patients with lower urinary tract symptoms due to benign prostatic enlargement undergoing button bipolar enucleation of the prostate (B-TUEP) or open prostatectomy (OP) between May 2012 and December 2013 were enrolled in our study. Data on clinical history, physical examination, urinary symptoms, erectile function, uroflowmetry and prostate volume were collected at 0,1,3 6, 12, 24 and 36 months. Early and long-term complications were recorded.

Results

Overall, 240 patients were enrolled. Out of them 129/240 (54%) performed an OP and 111/240 (46%) performed a B-TUEP. In terms of efficacy both procedures showed durable results at three years with a reintervention rate of 7.5% in the OP group and of 5% in the B-TUEP group. In terms of safety B-TUEP presented less high-grade complications when compared to OP.

Discussions

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Conclusion

In our single center study, B-TUEP represents a valid alternative to OP with excellent outcomes at three years. Further multicentre studies should confirm our results.

Reference

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#264: DEPTH OF INVASION AS A POTENTIAL PREDICTOR OF RECURRENCE IN PATIENTS TREATED WITH ENBLOC-TRANSURETHRAL RESECTION OF THE BLADDER: A FEASIBILITY STUDY

Inviato da: rlombardo@me.com

R. Giulianelli1, L. Albanese1, A.L. Lopes Mendes1, L. Mavilla1, L. Albanese1, R. Lombardo1, B.C. Gentile1
  • 1 Nuova Villa Claudia (Roma)

Objective

As for other tumors it is likely that depth of invasion is a prognostic factor for disease recurrence and progression in high grade pT1 urothelial bladder cancer. To date nor anatomy based neither dimensional subclassification proved reliable correlation with recurrence and progression, mainly considering the high interobserver variability in pT1 diagnosis, based by the TURB resection technique intrinsic artifact. Aim of this study is to assess the feasibility of measuring depth of invasion of urothelial carcinoma in patients undergoing EB-TURB for pT1HG disease.

Materials and Methods

27 patients undergoing EB-TURB with Collins knife and with pT1-HG disease were included. A second TURB was performed after 4-6 weeks from the first one. A dedicated pathologist assesses the feasibility of depth of invasion measurement

Results

Overall 32 patients with pT1HG disease were enrolled. EB-resection was adequately performed in 27/32 (85%) of the patients. Overall 40 lesions were identified with a median tumour size of 2 cm (1/4).
Median depth of invasion was 1.35 mm (0.48/3.5). Deepness measurement was feasible in 100% of the patients and in 100% of the lesions. As well on re TURB 8/27(29%) patients presented residual disease and in 100% of these patients it was possible to measure depth of invasion with a median value was 1.1 mm (0.43/2.3). Limitations include number of patients.

Discussions

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Conclusion

In specimen obtained from EB-TURB measurement assessment proved to be easy and highly reproducible. Recruitment of patients is still ongoing to evaluate an eventual prognostic value of neoplastic invasion in recurrence and progression.

Reference

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#266: Narrow Band Imaging reduces persistence of cancer in patients with pT1 high grade bladder cancer

Inviato da: rlombardo@me.com

R. Giulianelli1, B.C. Gentile1, A.L. Lopes Mendes1, G. Rizzo1, R. Lombardo1, L. Albanese1, L. Mavilla1, G. Tema2
  • 1 Nuova Villa Claudia (Roma)
  • 2 Sapienza University of Rome (Roma)

Objective

To evaluate persistence rate on repeated transurethral resection of the bladder (re-TURB) 6 weeks after the first TURB in patients with pT1HG disease undergoing resection of the margins and bed on Narrow Band Imaging.

Materials and Methods

A consecutive series of patients undergoing TURB and a diagnosis of pT1 high grade disease were prospectively enrolled. On initial TURB patients underwent classic white light resection of the tumour followed by narrow band image (NBI) resection of margins and bed. After 6 weeks from the initial TURB, patients underwent a re-TURB under white light. Persistence rates on re-TURB were recorded.

Results

Overall 797 patients underwent TURB, out of them 126 patients with pT1 high grade disease were included in the study. The total number of lesions was 226 meaning 1.79 lesions per patient. On re-TURB 24/126 (19%) of the patients presented residual disease with a total of 28/226 (12%) lesions identified. All these patients presented a pTa residual disease. Out of them 8/21 (38%) presented bladder cancer on the resection bed and 13/21 (62%) presented bladder cancer on margins.

Discussions

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Conclusion

Narrow Band Imaging trans-urethral resection of the bladder is an oncological effective procedure in the treatment of pT1HG disease. The procedure has a 19% of persistence rate which is inferior when compared to the available evidence on white light TURB. Further multicenter studies are needed in order to validate our results.

Reference

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#267: iXip for the prediction of prostate cancer

Inviato da: rlombardo@me.com

B.C. Gentile1, A.L. Lopes Mendes1, G. Tema1, R. Giulianelli1, G. Rizzo1, L. Albanese1, L. Mavilla1
  • 1 Nuova Villa Claudia (Roma)

Objective

iXip has been recently introduced for the prediction of prostate cancer. The aim of our study was to analyze the performance iXip for the prediction of prostate cancer patients undergoing prostate biopsies.

Materials and Methods

A consecutive series of men undergoing prostate biopsies were enrolled in two centers. Indications for prostate biopsy included abnormal Prostate specific antigen levels (PSA&gt;4ng/ml) and/or abnormal DRE. Demographic and clinical characteristics of the patients were recorded. All patients underwent iXip test before prostate biopsy. Prostate biopsy was performed transperineally and all patients underwent 12 core biopsy. Performance of Xip was analyzed using receiver operator characteristics curve (ROC curve).

Results

Overall 60 patients with a median age of 65 (59/72) years were enrolled. Median PSA was 6.8 (4.8/10.0) ng/ml and median prostate volume was 48 (35/68) ml. Overall median iXip was 0,33 (0,28-0,51). 35/60 patients based on iXip levels (&lt;0,5), PSA levels and MRI data after discussion with the patient were scheduled for a 6 months control because of low suspicion of cancer. Overall 11/25 (44%) presented PCa and out of them 7/11 (63%) presented a prostate cancer. The test presented an AUC of 0,71 (0,50-0,91, p=0,045) for the prediction of prostate cancer while PSA presented an AUC of 0,60 (0,37-0,83).

Discussions

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Conclusion

In our experience the use of iXip may help clinicians in the diagnostic pathway of prostate cancer avoiding unnecessary biopsies. Although the numbers are small the accuracy of iXip outstands PSA one.

Reference

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#268: En Bloc transuretral resection of the bladder

Inviato da: rlombardo@me.com

R. Giulianelli1, R. Lombardo1
  • 1 Nuova Villa Claudia (Roma)

Abstract

We present technical aspects of en-bloc transurethral resection of the bladder all in different zones of the bladder.

#271: Open simple prostatectomy with Pfannenstiel incision

Inviato da: rlombardo@me.com

M. Vermiglio1, R. Giulianelli1, R. Lombardo1
  • 1 Nuova Villa Claudia (Roma)

Abstract

We present technical aspects of open simple prostatectomy using Pfannenstiel incision.

#270: BIPOLAR ENERGY LESS ENUCLEATION OF THE PROSTATE WITH WOLF BUTTO AND BOWA GENERATOR

Inviato da: rlombardo@me.com

R. Lombardo1, R. Giulianelli1
  • 1 Nuova Villa Claudia (Roma)

Abstract

We present technical aspects of bipolar energy less enucleation of the prostate using wolf button and BOWA generatori.

#269: LAPAROSCOPIC SIMPLE PROSTATECTOMY: TECHNICAL ASPECTS

Inviato da: rlombardo@me.com

R. Giulianelli1, R. Lombardo1
  • 1 Nuova Villa Claudia (Roma)

Abstract

A consecutive series of men with lower urinary tract symptoms and large prostates (>80cc) prospectively enrolled between November 2015 and December 2017 in one center. All patients underwent laparoscopic simple prostatectomy. Outcomes were evaluated considering the trifecta favourable outcome which was defined as a combination of the following items: (1) no perioperative complications, (2) postoperative IPSS 15 ml/s. Complications were evaluated according to the modified Clavien classification system. Univariate and multivariate binary logistic regression was performed to identify predictors of a positive
Overall 272 patients were enrolled. At three months after surgery median IPSS total score was 4 (IQR:3/7), median IPSS Qol was 1 (IQR:1/2), median PSA was 0.53 (IQR:0.33/1.00) ng/ml and median Qmax was 23 (17/30) ml/s. All these parameters improved statistically when compared to baseline (p<0.001). The overall complication rate was 21 % however most of the complications were low grade complications according to modified Clavien Dindo classification (Grade ≤2). Overall, 68% of the patients presented a positive trifecta outcome. On multivariate analysis only preoperative Haemoglobin and hospital stay were confirmed predictors of positive trifecta outcome.
LSP represents a safe and effective procedure in the treatment of large adenomas.

#150: Eccezionale caso di trattamento chirurgico Robot - asssitito in un paziente con diagnosi di tumore alla prostata associato a tumore renale sincrono bilaterale (doppio al rene di sinistra e singolo al rene di destra)

Inviato da: dott.alessandro.izzo@gmail.com

Argomenti: 

A. Izzo1, G. Grimaldi1, G. Quarto1, R. Muscariello1, L. Castaldo1, M. Perra1, D. Franzese1, S.. Perdonà1
  • 1 Istituto Nazionale dei Tumori di Napoli - IRCCS - Fondazione "G. Pascale" (Napoli)

Abstract

Riportiamo il recente caso di un uomo di 73 anni con diagnosi di adenocarcinoma prostatico GS 8 (4+4), PSA 8.7 ng/mL che, in corso degli esami di stadiazione (TC e scintigrafia ossea total body), ha avuto la diagnosi incidentale di tre tumori renali sincroni (due a sinistra – RENAL SCORE 6p e 4 p; ed uno a destra – RENAL SCORE 5a).
Tecnica chirurgica utilizzata:
Primo tempo: preventivo posizionamento dei trocar robotici per i diversi interventi e prostatectomia radicale (RARP) associata a linfoadenectomia estesa (patologia ad alto rischio).
Il secondo tempo: enucleoresezione renale robot assistita (RAPN) sinistra "clampless" di entrambe le lesioni, che come illustrato dalla TC nel video risultavano essere contigue. Il terzo tempo: RAPN destra, con paziente in decubito laterale sinistro. Il tempo di console è risultato essere, rispettivamente:
54' per la RARP e per la Linfoadenectomia estesa.
50' per la duplice RAPN di sinistra
36' per la RAPN di destra.
Le perdite ematiche complessive: 220 cc
I giorni di degenza: 3
Il tempo di cateterizzazione: 3 giorni.
Dati patologici:
RARP: pT3s R1 pN0, Adenocarcinoma GS7 (4+3).
RAPN destra: carcinoma renale a cellule chiare grado 2.
RAPN sinistra: carcinoma a cellule renali papillare grado 2 + carcinoma renale a cellule chiare grado 2.

#157: Linfoadenectomia Retroperitoneale Robot-assistita per massa residua post chemioterapia in paziente trattato per neoplasia germinale mista (carcinoma embrionale + teratoma post-puberale) del testicolo sinistro

Inviato da: dott.alessandro.izzo@gmail.com

A. Izzo1, G. Grimaldi1, G. Quarto1, R. Muscariello1, L. Castaldo1, D.. Franzese1, M. Perra1, S. Perdonà1
  • 1 Istituto Nazionale dei Tumori di Napoli - IRCCS - Fondazione "G. Pascale" (Napoli)

Abstract

Il video descrive la tecnica utilizzata presso il nostro Istituto per il trattamento chirurgico Robot-assistito per masse residue post-chemioterapia per tumore a cellule germinali del testicolo. Il caso rappresentato riguarda un uomo di 23 anni sottoposto a ottobre 2018 a orchifunicolectomia sinistra diagnosi istologica di neoplasia germinale mista (carcinoma embrionale 50% e teratoma maturo post-puberale 50%) con presenza di invasione linfovascolare. TAC e PET-FDG post-operatorie negative.
Sottoposto a tre cicli di PEB.
Al follow-up esibisce FDG PET/TC con evidenza di due lesioni ipodense a contenuto colliquativo necrotico in sede paraortica sinistra entrambe di circa 3 x 2 cm di diametro. Markers negativi.
Il paziente è stato sottoposto il 7 novembre 2019 a Linfoadenectomia Retroperitoneale Robot-assistita attraverso il Sistema Robotico Davinci Xi secondo il template dello Weissbach study che include, a sinistra, l'asportazione dei linfonodi pre-aortici, para-portici e retro-aortici, interaorto-cavali. Il limite craniale è rappresentato dalla vena renale di sinistra, quello caudale dall'arteria mesenterica inferiore, il limite laterale dall'uretere. La linfoadenectomia comprende anche i linfonodi iliaci comuni di sinistra.
Il tempo di console è stato di 76'.
Le perdite ematiche: 100 cc. Il paziente è stato dimesso in seconda giornata.
In attesa di esito istologico.

#149: Laparoscopic management of complex ureteropelvic junction obstruction

Inviato da: francescok86@gmail.com

M. Fabiano1, F. Chiancone2, M. Fedelini2, V. Altieri1, C. Meccariello2, P. Fedelini2
  • 1 University Hospital of Salerno (Salerno)
  • 2 Urology Department, A.Cardarelli Hospital (Napoli)

Abstract

This video shows the management of some complex cases of ureteropelvic junction obstruction performed at the “Urology Department” of A.Cardarelli Hospital (Naples). We present a minimally invasive approach with laparoscopic access. Open access technique is used for primary trocar. All procedures were performed with transperitoneal approach using three operative trocars. We used these laparoscopic instruments: 1 bipolar grasp, 1 scissor, 2 needle drivers,1 grasp and 1 suction device. In some cases a fourth trocar was placed for a grasp to elevate the liver. The patients were placed in lateral position. We present a pyeloplasty in ptosic kidney, in ectopic kidney and the ureteropelvic junction reconstruction in a horseshoe kidney. Moreover we show the pyeloplasty in a double incomplete collecting system and a case of repyeloplasty after failed laparoscopic repair of UPJ obstruction by crossing vessels. A double J stent was placed intraoperative with a laparoscopic-endoscopic procedure in all cases. The remodelling of the junction was performed using 5/0 Vicryl suture. No patients experienced compications and no failure of the procedures were seen at post-operative follow-up. Mini-invasive treatment of complex ureteropelvic junction obstruction is a feasible and safe procedure if performed in highly experienced laparoscopic centres.

#258: High-Frequency Dusting using a 120-W Holmium Laser during flexible ureteroscopy: a single-centre experience

Inviato da: omaugeri@gmail.com

Argomenti: 

O. Maugeri1, D. Peretti2, F. Venzano3, L. D'Arrigo4, M. Pennisi4, R. Biancolini5, E. Dalmasso5
  • 1 Ospedale Cannizzaro (Catania)/Ospedale Santa Croce e Carle (Cuneo)
  • 2 AOU San Luigi Gonzaga – Scuola di Specializzazione Urologia (Orbassano )
  • 3 Ospedale Villa Scassi (Genova )
  • 4 Ospedale Cannizzaro (Catania)
  • 5 ospedale Santa Croce e Carle (Cuneo)

Abstract

In this video to present a detailed report of our experience about Low Energy (LE)/High Frequency (HF) lithotripsy (settings 0.2-0.5J / 50-80Hz – 10-40W) by using a 120-W high-power Ho:YAG system and to propose our technique.
Our technique consists in 3 phases: 1) Contact Laser lithotripsy (LE/HF/LPW dusting – 0,5 J/50 Hz or 02 J/70 Hz in relation to stone Hardness), 2) Extraction of main fragments (both for treatment and for stone analysis), 3) Non-contact Laser lithotripsy (LE/HF/Short Pulse Width Pop Dusting – 0,5 J /80Hz). From December 2017 to January 2019 104 LE/HF/LPW RIRS had been performed in Cuneo Hospital. Follow-up was conducted with a CT scan performed at 3 months after RIRS and the procedure success was defined as stone-free or presence of ≤4 mm fragments (CIRF). All patients underwent a 3 months post-operative therapy with potassium citrate (3025,4 mg/100 ml/die) and magnesium citrate (1136,4 mg/100 ml/die). Overall success rate at 3 months CT scan was 88,5% (71,2% stone-free and 17,3% CIRF). Early post-operative complications were reported in 4,6%. The application of LE/HF/LPW RIRS for the treatment of renal stones seems to be safe and effective, in terms of positive success rate, low number of complications and reduced operative time.

#259: RIRS PERFORMED IN SITU FOR LOWER POLE RENAL STONES: CAN WE ACHIEVE A GOOD OUTCOME?

Inviato da: omaugeri@gmail.com

Argomenti: 

O. Maugeri1, D. Peretti2, F. Venzano3, L. D'Arrigo4, R. Baincolini5, E.. Dalmasso5
  • 1 Ospedale Cannizzaro (Catania) / Ospedale Santa Croce e Carle (Cuneo)
  • 2 AOU San Luigi Gonzaga – Scuola di Specializzazione Urologia (Orbassano )
  • 3 Ospedale Villa Scassi (Genova)
  • 4 Ospedale Cannizzaro (Catania)
  • 5 Ospedale Santa Croce e Carle (Cuneo)

Abstract

When performing RIRS for lower pole stones dislocation of the stone is usually suggested. The main reason of that is the high risk of ureteroscope damaging due the extreme and prolonged flexion. Less is known about real efficacy of lithotripsy if performed in situ. In this video to present a detailed report of our experience about the efficacy of RIRS with lithotripsy performed in situ in case of non dislocable stones or favorable anatomy.
RIRS performed in a single Center from 2011 to 2016 were retrospectively analyzed. Single stones ≤ 15 mm in the lower pole were selected. We created 2 groups: in group A stones were treated in situ, in group B stones were dislocated before before lithotripsy. Success was considerd in case of stone free or residual fragments ≤ 4 mm.
Complete data were available for 93 patients. Stones were treated in situ in 61 cases (group A) and after dislocation in 32 (group B). RIRS performed in situ for lower pole renal stones have a low success rate, even if the caliceal anatomy allows an easy access to the stone. Success rate is low for smaller stones as well. When the preoperative evaluation suggests poor chance of displacing, patient is informed about mini or Ultramini ECIRS.

#240: Mini percutaneous nephrolithotomy (MiniPCNL) with ClearPetra™ Nephrostomy Sheath

Inviato da: fmele@mauriziano.it

Argomenti: 

F. Mele1, M. Barale1, A. Rocca1, R. Migliari1
  • 1 A.O. Ordine Mauriziano, SC Urologia (Torino)

Abstract

Percutaneous nephrolithotomy (PCNL) is the gold standard surgical modality in the management of large kidney stones. Recently, with raising popularity of PCNL procedures, multiple modifications were proposed to the surgical techniques and instrumentation. Reducing the gauge of the instrument reduces the morbidity associated with the procedure. There are many retrospective studies demonstrating safety and efficacy of different mini versions of PCNL.

The ClearPetra™ System is a new device designed for enhance the renal stones lithotripsy using a negative pressure aspiration. It improves stone clearance rate, reduces the intra-luminal pressure, prevents stone retropulsion, improves visual field, obviates the need of accessory device (baskets, forceps,…) and saves operating time.

In this video we show a case of miniPCNL procedure in a patient with a 3.5 cm left staghorn stone. The procedure was done with a modified 10-14 Ch access sheath with a suction-evacuation function and a Storz MiniNephroscope 12 Ch with a 3.5 Ch operative channel for stone Ho-laser lithotripsy.

#234: The Anatomical Low-power En-bloc Thulium Laser Enucleation of the Prostate (ALE-ThuLEP) technique

Inviato da: fmele@mauriziano.it

A. Rocca1, F. Mele1, M. Barale1, R. Migliari1
  • 1 A.O. Ordine Mauriziano, SC Urologia (Torino)

Abstract

The use of lasers for benign prostatic hyperplasia (BPH) is currently considered a safe and effective therapeutic option.
In 1998 Gilling firstly describe the classical technique for holmium laser enucleation of the prostate (HoLEP), adapted in 2010 by Herrmann for thulium laser (ThuLEP).
The traditional three-lobe technique is continuously being refined and evolving. A few modifications of the original technique have been developed, and several en-bloc enucleation methods have been introduced.

In this video we present a step-by-step description of our anatomical low-power en-bloc ThuLEP (ALE-THULEP) technique.

Key points of ALE-THULEP are: to do a coronal incision of the mucosa at the level of the apex, identify the capsular plane only once, laterally to the veru montanum at 5 o'clock, enucleation is continued circularly from the apex to the bladder neck mainly using the tip of the instrument for mechanical dissection and limiting the use of laser which can be set to low-power (20W) reducing energy supply to the capsule.
At the end of the en-bloc enucleation the bladder neck is fully respected and the prostatic loggia is smooth and homogeneous, similar to that of a surgical adenomectomy but with a high control of bleeding and the possibility of removing the catheter in the first postoperative day in most cases.

#229: Mini percutaneous nephrolithotomy (MiniPCNL) is the ideal solution for medium-sized renal calculi

Inviato da: fmele@mauriziano.it

Argomenti: 

F. Mele1, M. Barale1, D. Surleti1, R. Migliari1
  • 1 A.O. Ordine Mauriziano, SC Urologia (Torino)

Abstract

Percutaneous nephrolithotomy (PCNL) is the gold standard surgical modality in the management of large kidney stones. Recently, with raising popularity of PCNL procedures, multiple modifications were proposed to the surgical techniques and instrumentation. Reducing the gauge of the instrument reduces the morbidity associated with the procedure. There are many retrospective studies demonstrating safety and efficacy of different mini versions of PCNL.
The 16 Ch Miniperc tract offers low morbidity in terms of blood loss and maintains stone clearance comparable to larger 24 Ch tract size. It should be the ideal size used for medium (15 – 30mm) sized renal stones.

In this video we show a case of miniPCNL procedure in a patient with a 2.0 cm left pyelic stone, detailed step by step from the US-guided puncture to the exit strategy. The procedure was done through a 16 Ch Mini Amplatz cannula mounted on a 14 Ch metallic shaft dilator. A Storz MiniNephroscope 12 Ch with a 3.5 Ch operative channel is used for stone Ho-laser lithotripsy.

#227: Transvaginal Vesicovaginal fistula (VVF) repair using a Martius Flap

Inviato da: fmele@mauriziano.it

F. Mele1, M. Barale1, P. Gamba1, R. Migliari1
  • 1 A.O. Ordine Mauriziano, SC Urologia (Torino)

Abstract

Vesicovaginal fistula (VVF) are among the most distressing complications of gynecologic and obstetric procedures and it is still a major cause for concern in many developing countries. The diagnosis of the condition has traditionally been based on clinical methods and dye testing but CT or MRI of the pelvis are have also been proposed to depict the fistolous tract.

The best chance of a successful repair is at the first attempt. The arguments about the most appropriate route for repair continue and are not clarified by the publications so far.

In the video we show a VVF repair technique using a Martius flap.
This technique represents our consolidated experience in 19 cases.
17 patients developed a VVF after gynecologic surgery and 5 out of 17 were recurrent fistula after previous transvaginal attempt of repair. One patient developed a fistula following a radical cystectomy with a continent ortotopic urinary diversion and one patients had a VVF after previous multiple surgery for recurrent uretrahral diverticula.
Successful surgical repair was obtained in 18 out of 19 patient while in one patient was necessary to perform a urinary diversion.

#231: Retrograde intrarenal surgery with single-use digital devices: what's the best?

Inviato da: fmele@mauriziano.it

Argomenti: 

F. Mele1, M. Barale1, D. Surleti1, R. Migliari1
  • 1 A.O. Ordine Mauriziano, SC Urologia (Torino)

Abstract

Retrograde intrarenal surgery (RIRS) using a flexible ureteroscope (fURS) has become gold standard for the
first line treatment of upper urinary tract stones (<1.5 cm) and conservative management for upper tract urothelial tumors. However, common problems associated with the use of flexible endoscopes include scope performance deterioration, costly repairs and the need for dedicated sterilization equipment.

To improve the performance of fURS, disposable devices have recently been developed.
The LithoVue™ (Boston Scientific), introduced in 2015, is the first single-use digital disposable fURS. Recent publications have confirmed its usefulness and competitiveness in comparison to other reusable devices.
Other single-use fURSs have been lately introduced aiming to offer solutions to the sterilization, fragility and cost issues of the reusable ureteroscopes.

In this video we confront different scopes feature of single-use digital fURS: LithoVue™ (Boston Scientific), WiScope™ (OTU Medical), EU-Scope™ (Shanghai Anquing) and PU3022A™ (Zhuhai Pusen Medical).
In order to provide surgeons the best disposable device we have compared size, deflection and irrigation abilities, image quality and ergonomic handling.

#222: Hydronephrosis as an unusual presentation for metastatic lobular breast cancer

Inviato da: hpyl@hotmail.it

C. Introini1, A. Di Domenico1, M. Ennas1, M. Beverini1, F. Campodonico1, M. Rutigliani1, F. Paparo1
  • 1 E. O. Ospedali Galliera (Genova)

Abstract

We present here the first-reported case of tubal metastasis from lobular breast cancer diagnosed by the incidental finding of hydronephrosis.
A 61-year-old woman suffering from left hydronephrosis was referred to us 4 years after she underwent a right radical mastectomy and subsequent radiotherapy for lobular breast carcinoma.
The CT scan revealed a left hydronephrosis with dilated ureter up to the proximal third, where thickening of the walls was not excluded.

An exploratory laparoscopy was performed and the definitive histopathology examination showed a recurrence of the initial carcinoma with a right tubal metastasis and peritoneal carcinosis.
The eventuality of such an unusual site of metastasis should be remembered.

#139: LAPAROSCOPIC RADICAL PROSTATECTOMY AFTER PREVIOUS OPEN RETROPUBIC PROSTATIC ADENOMECTOMY

Inviato da: paolo.parma@asst-mantova.it

P. Parma1, M. Nidini1, A. Samuelli1, L. Cappellaro1, V. Galletta1, S. Guatelli1, F. Croce1, E. Deluise1, L. Marco1, B. Dall'Oglio1
  • 1 Ospedale Carlo Poma Mantova (Mantova)

Abstract

This video presents a successfully performed LRP after previous open retropubic adenomectomy.
A 70-years-old patient was submitted to open retropubic adenomectomy of the prostate in 2009
The PSA was 6.4 ng/ml, the histologic examination of the biopsies revealed a prostatic adenocarcinoma Gleason 7 (4+3) at the apex of the left lobe and at the base of the right lobe.
The patient was submitted to transperitoneal laparoscopic radical prostatectomy with extended pelvic limphoadenectomy.
We began the laparoscopic surgery performing a difficult blunt dissection between the anterior bladder wall and the abdominal wall.
The anterior face of the prostate is not visible due to the adhesions of the prostate with the pubis caused by the previous surgery.
The isolation of the bladder neck after open retropubic adenomectomy is difficult as the bladder neck is wide and the ureteral orifices could be very close to it. The presence of fibrous tissue made difficult the development of the posterior plane of the vas deferens and seminal vesicles. Section of prostatic vascular pedicles without nerve sparing technique.
Section of the prostatic apex and the urethra with adeguate lenght of the urethral stump.
The urethral vesical anastomosis was performed with a single 3-00 double needle barbed suture 35 cm length with posterior reconstruction.

#136: 3D RETROPERITONEAL LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR COMPLEX RENAL TUMORS

Inviato da: paolo.parma@asst-mantova.it

Argomenti: 

P. Parma1, M. Nidini1, A. Samuelli1, L. Cappellaro1, V. Galletta1, S. Guatelli1, F. Croce1, E. Deluise1, M. Luciano1, B. Dall'Oglio1
  • 1 Ospedale Carlo Poma Mantova (Mantova)

Abstract

In the video we show 3 cases of partial nephrectomy for complex renal masses (PADUA score 10-11) we availed the retroperitoneal approach using 3 D laparoscopic technique.
First case: 63 years old obese male with a mass of 6 cm at the upper pole of the right kidney.
After clamping two renal arteries, we proceed to the enucleation of the neoformation.
Renorrhaphy is performed with a double layers suture: a continuos 2/0 polygactin suture of the tumor bed and subsequent unclamping of the renal artery and interrupted sutures of the renal parenchyma (warm ischemia 15 minutes).
Second case: 72 years old female with a 4,5 cm tumor at the third medium-superior of the right kidney that reaches both renal sinus and superior caliceal group . We performed an enucleoresection with
opening of the calix. Renorrhaphy is performed with a double layer suture with a running sliding-clip suture (warm ischemia time 18 minutes).
Third case: 64 years old male with a tumor of 6,5 at the lower pole of the left kidney (PADUA score 10). The patient is affected by chronic renal failure
We opt for a partial nephrectomy with a selective clamping. Hemostasis is performed with two continuous sutures of the tumor bed and a pre rolled tachosil patch.

#219: CONFEZIONAMENTO DI NEOVESCICA ILEALE ORTOTOPICA SEC HAUTMAN MODIFICATA APPROCCIO TOTALMENTE LAPAROSCOPICO CON RICOSTRUZIONE MANUALE ( V- LOCK SUTURE)

Inviato da: giuseppe.ruoppo@ausl.re.it

G. Ruoppo1, F. Bergamaschi1, D. Viola1, F. Borgatti1, D. Biferi1, G. Bonfante1
  • 1 Arcispedale S. Maria Nuova (Reggio Emilia)

Abstract

IL VIDEO MOSTRA LA TECNICA DI CONFEZIONAMENTO DI NEOVESCICA ILEALE CON APPROCCIO LAPAROSCOPICO TOTALMENTE INTRACORPOREO A DUE OPERATORI.
TERMINATA LA FASE DEMOLITIVA E LA LINFECTOMIA, ISOLATO UN TRATTO DI ILEO DI CIRCA 60 CM SI PROCEDE PRIMA AD ANASTOMOSI URETRO-ILEALE SU FOLEY 20 CH SILICONATO CON DUE EMICONTINUE DI PDS 3/0. A SEGUIRE, AVENDO UN PUNTO FISSO URETRALE, SI REALIZZA LA DETUBULARIZZAZIONE ILEALE AL VERSANTE ANTIMESENTERICO E SUCCESSIVAMENTE LA RICONFIGURAZIONE MEDIANTE SUTURE DEL TIPO V-LOCK CONVIDIEN 3/0. SI RICONFIGURA PRIMA LA PARETE POSTERIORE (3 SUTURE), POI A NEOVESCICA ANCORA "APERTA" SI PROCEDE ALLE ANASTOMOSI URETERO ILEALI. A TAL PROPOSITO LA TIPOLOGIA DI NEOVESICA LA DEFINIAMO DI HAUTMAN MODIFICATA PER LA PRESENZA DI DUE CAMINI NON DETUBULARIZZATI AI DUE CAPI DELLA W-SHAPE AL FINE DI RENDERE PIU' AGEVOLI LE ANASTOMOSI URETERO ILEALI DIRETTE. COMPLETATE LE ANASTOMOSI URETERALI SI PROCEDE ALLA CHIUSURA DEL SERBATOIO ILEALE ORTOTPICO NELLA PARETE ANTERIORE E A LIVELLO DELLA "CUPOLA" DA CUI FUORIESCONO I TUTORI URETERALI ESETERIORIZZATI DALLA PARETE ADDOMINALE ATTRAVERSO UN PORTA DA 5 MM. LA METODICA SEPPUR INDAGINOSA E RICHIDENTE UN LIVELLO AVANZATO SULLA CURVA DI APPRENDIMENTO PUO' ESSERE UNA ALTERNATIVA MINIVASIVA ALLO STANDARD OPEN IN PAZIENTI SELEZIONATI.

#217: CISTECTOMIA RADICALE VIDEOLAPAROSCOPICA PROSTATE-SEMINAL SPARING CON ILEOCAPSULOANASTOMOSI

Inviato da: giuseppe.ruoppo@ausl.re.it

G. Ruoppo1, F. Bergamaschi1, M. Spagni1, R. Andrea1, A. Domenico1, S. Spatafora1
  • 1 Arcispedale S. Maria Nuova (Reggio Emilia)

Abstract

LA CISTECTOMIA RADICALE LAPAROSCOPICA PROSTATE – SEMINAL SPARING E' PROPONIBILE SOLO A PAZIENTI ACCURATAMENTE SELEZIONATI E CANDIDABILI AL CONFEZIONAMENTO DI NEOVESCICA ORTOTOPICA. NEL VIDEO PROPONIAMO IL CASO DI UN CINQUANTENNE, EX SPORTIVO AGONISTA, CON DIAGNOSI DI NEOPLASIA VESCICALE INFILTRANTE (T2) ALTO GRADO, DELLA PARETE VESCICALE POSTERIORE , PRIMA MANIFESTAZIONE, SINGOLA. IPSS 3 PSA 1.5, Q MAX 23 PROSTATA 25 CC, NON SOSPETTA. MOTIVATO NELLA PRESERVAZIONE DELLA FUNZIONE SESSUALE. IL VIDEO PONE IN RISALTO COME L'APPROCCIO LAPAROSCOPICO NELLA FASE DEMOLITIVA DIFFERISCE DALLO STANDARD SIA IN FASE DI DISSEZIONE POSTERIORE CHE ANTERIORE. PIU'ARTICOLATA LA PRIMA PER LA NECESSITA' SVILUPPARE UN PIANO DI CLIVAGGIO TRA VESCICOLE SEMINALI LASCIATE IN SEDE E LA PARETE VESCICALE POSTERIORE RETRO-SOVRA TRIGONALE. CIO' CONSENTE LA PRESERVAZIONE SIA DEI BUNDLE VASCOLO NERVOSI CHE DELLA RETE DEL PLESSO PELVICO PRESENTE A TALE LIVELLO. LA DISSEZIONE ANTERIORE E LA PREPARAZIONE DEL COLLO VESCICALE E DELLA BASE PROSTATICA DEVONO CONSENTIRE LA DELMITAZIONE DELLA CAPSULA E DELL' URETRA PROSTATICA SOVRA COLLICOLARE. NON ESEGUITA TURP PRELIMINARE PER LE ESIGUE DIMENSIONI PROSTATICHE IN PAZIENTE GIOVANE SENZA SINTOMI DI RILIEVO. LA NEOVESCICA CONFEZIONATA CON STAPLER INTRACORPOREA E' UNA CAMEY II. ANASTOMOSI URETERALI DIRETTE NON ANTIREFLUSSO. A DISTANZA DI 3 ANNI IL PAZIENTE E' POTENTE CON EIACULAZIONE, CONTINENTE. NON EVIDENZA DI RECIDIVE PELVICHE E A DISTANZA.

#201: URETRAL- RECTUM FISTULA REPAIR. OUR EXPERIENCE

Inviato da: stefano.masciovecchio@hotmail.com

S. Masciovecchio1, A.B. Di Pasquale1, G. Zasa2, G. Romano1, G. Ranieri1, L. Di Clemente1
  • 1 P.O. "San Salvatore", U.O.C. Urologia (L'Aquila)
  • 2 Università degli Studi - L'Aquila (L'Aquila)

Abstract

MALE PATIENT 57 YEARS OLD, PREVIOUS SURGERY VIDEOLAPAROSCOPIC RADICAL PROSTATECTOMY. HE CAME TO OUR CENTER WITH RECCURENT UTI AND URINARY SPILLAGE FROM THE RECTUM. WE PERFORMED A CISTOGRAPHY THAT SHOWED URETHRAL-RECTUM FISTULA AT THE ANASTOMOSIS LEVEL. IN OPERATORY ROOM WE PERFORMED A STANDARD CYSTOSCOPY WITH CYSTOSCOPE 17 CH 30 DEGREE OPTICS: THE ANTERIOR URETHRA WAS REGOLAR. THERE WAS A FISTOLOSE CONNECTION AT SEVEN O'CLOCK AT THE LEVEL OF THE URETHRAL BLADDER ANASTOMOSIS. URETERAL ORIFICE WERE IN SITE AND COMPETENT. POSITIONING OF URETERAL CATHETERINE 5CH IN THE FISTULOUS VIA. FOLEY CATHETER 16 CH IN BLADDER. PERINEAL INCISION. EXPOSURE OF THE BULBOSPONGIUS MUSCLE. ISOLATION OF THE SAME WITH SECTION OF THE CENTRAL TENDON OF PERINEUM, IDENTIFICATION AND OPENING OF THE FISTULA WITH EXPOSURE OF THE URETERAL CATHETER PREVIOUSLY POSITIONED. REGULARIZATION OF THE FISTULA MARGINS BOTH ON THE RECTUM AND ON THE BLADDER. CLOSURE OF THE VESICAL OPENING WITH TWO SEMICONTINUOS SUTURES IN VYCRIL 4-0. LEAK TEST UP TO 120 ML OF NACL SOLUTION IN THE BLADDER. CLOSURE OF THE INTESTINAL OPENING WITH DETACHED SUTURE IN VYCRIL 3-0. SEAL CONTROL WITH AIR IN THE RECTUM. CONTROL OF HEMOSTASIS. ABUNDANT WASHING WITH NACL SOLUTION. APPOSITION OF EVICEAL ON THE SUTURES. LAYERED SYNTHESIS OF THE WALL. RECTAL PROBE.

#195: A very challenging scrotoplasty for a large scrotum as consequence of penile amputation with inguinal lymphnodes dissection

Inviato da: francescok86@gmail.com

Argomenti: 

M. Carrino1, L. Pucci2, F. Chiancone2, M. Fasbender Jacobitti1, M. Fabiano2, R. Giannella2, P. Fedelini2
  • 1 Andrology Department, AORN “A. Cardarelli” (Naples)
  • 2 Urology Department, AORN “A. Cardarelli” (Naples)

Abstract

A 60-year-old was referred to our attention for a large scrotum showing spontaneous exudation in standing position. Past medical history included depression due to the enormous scrotum that prevented him from a normal social life, hypertension (treated with ACE inhibitors). Urological medical history included benign prostatic hyperplasia (BPH) treated with alpha-blockers, previous partial penile amputation for carcinoma in situ of the glans (2013) and subsequent inguinal lymphnodes dissection (ILND). Both surgeries were not performed at our hospital. A scrotoplasty was performed at our Andrology department in collaboration with the plastic surgery operative unit. The procedures required an excision of about 3 kilograms of imbibed lymphatic skin tissue respecting the funiculus and testicles that appear enormously increased in volume due to lymphostasis. A double flap reconstruction is performed with large excision of exceeding tissue. The pathology report of the skin flap (35 x 20 x 10 cm) described a morphological picture consisting of an epidermal line with hyperkeratosis and papillomatosis. A reactive myofibroblastic proliferation associated with a marked edema with small vessels with thickened walls and bundles of hyperplastic dartos is observed in the dermis and hypodermis. Scrotal lymphedema is confirmed. No postoperative complications occurred. At one month follow-up the scrotum resulted very reduced in size and patient solved his depression.

#130: Enucleoresezione transuretrale della prostata con biplare (TUEB o BipoLEP) vs TULEP, esperienza iniziale

Inviato da: rnucciotti@gmail.com

R. Nucciotti1, C. Gulia1, E. Santini1, F.M. Costantini1, A. Bragaglia1, F. Viggiani1
  • 1 Ospedale della misericordia (Grosseto)

Abstract

Da anni eseguiamo l'enucleoresezione della prostata con ansa bipolare Gyrus nei casi di ipertrofia prostatica benigna associata a sintomatologia ostruttiva.
La tecnica è semplice, riproducibile e permette di affrontare adenomi prostatici voluminosi fino a 80/100 gr. Il miglior risultato si ottiene nelle prostata con voluminoso terzo lobo.
Si eseguono due solchi a lato del terzo lobo dal collo vescicale al veru montanum ad ore 4 ed ad ore 8, quindi dal veru in senso retrogrado si procede allo scollamento del terzo lobo scollandolo meccanicamente con la robusta ansa bipolare plus, coagulando i capillari fino al collo vescicale. A tale livello invece di proseguire lo scollamento del lobo in vescica si procede alla resezione, semplice e veloce. Stessa manovra viene ripetuta per il lobo di dx e poi per quello di sn. I vantaggi rispetto alla TURP: emostasi più accurata e resezione dei lobi una volta allontanati dal veru montanum quindi minor rischio di danneggiare lo sfintere.
Vogliamo portare la nostra iniziale esperienza mostrando il percorso formativo che abbiamo deciso di intraprendere nell'utilizzo del laser al tullio per il trattamento dell'ipertrofia prostatica benigna.

#127: Neovescica ileale robotica: un intervento cucito su misura

Inviato da: rnucciotti@gmail.com

R. Nucciotti1, C. Gulia1, E. Santini1, F.M. Costantini1, A. Bragaglia1, F. Viggiani1
  • 1 Ospedale della misericordia (Grosseto)

Abstract

L'approccio mininvasico, laparoscopico o robotico, alla cistectomia radicale offre indubbi vantaggi nel recupero clinico nel post operatorio, basti pensare alla riduzione delle perdite ematiche intraoperatorie e alla conseguente riduzione di emotrasfusioni, alla riduzione del dolore da ferita chirurgica quindi alla precoce mobilizzazione e alla precoce canalizzazione intestinale soprattutto se viene eseguita la resezione ileale per il confezionamento di una derivazione ortotopica o eterotopica. L'approccio mininvasivo associato al fast track chirurgico permette la canalizzazione fin dal POD#3. Il sondino nasogastrico viene rimosso la mattina successiva all'intervento e il pz inizia a sorseggiare acqua e mangiare del gelato mattina e sera fin dal post operatorio. Non viene somministrata nutrizione parenterale. La mobilizzazione è in prima giornata post operatoria.
Il video mostra le fasi salienti della fase ricostruttiva, isolamento dell'ansa mediante suturatrici meccaniche laparoscopiche , riconfigurazione dell'ansa ileale, anastomosi ileouretrale e anastomosi degli ureteri.
Il vantaggio dell'approccio robotico sta nella semplificazione della riconfigurazione con sutura continua della neovescica ortotopica e nella maggior facilità di esecuzione della anastomosi neovescicouretrale. I risultati clinici nel post operatorio ci incoraggiano a perseguire questo approccio.

#125: Prostatectomia radicale robotica: steps chirurgici per mantenere la continenza

Inviato da: rnucciotti@gmail.com

R. Nucciotti1, C. Gulia1, E. Santini1, F. Viggiani1, F.M. Costantini1, A. Bragaglia1
  • 1 Ospedale della misericordia (Grosseto)

Abstract

La prostatectomia radicale robotica è diventato il gold standart terapeutico per il trattamento del tumore prostatico organo confinato. Oltre alla radicalità oncologica è fondamentale assicurare al paziente un ottimo recupero della continenza urinaria e se possibile il risparmio del fascio vascolo nervoso.
Per il recupero precoce della continenza è importante eseguire una corretta neck sparing, cioè risparmiare le fibre del collo vescicale in modo da renderlo congruente con il diametro dell'uretra membranosa. Di fondamentale importanza il rispetto della lunghezza anatomica e funzionale dell'uretra membranosa quindi l'approccio chirurgico all'apice prostatico.
Dopo la fase demolitiva passiamo alla fase ricostruttiva caratterizzata dalla ricostruzione posteriore del rabdomiosfintere, importante per il supporto posteriore delle fibre dello sfintere, e dall'anastomosi vescicouretrale che ha il compito di ripristinare la lunghezza funzionale dell'uretra assicurandola al governo della pressione endoaddominale.
Il video mostra gli steps chirurgici salienti spiegandone il razionale e mostando i dettagli tecnici, dettagli che possono fare la differenza nel risultato funzionale di un intervento riproducibile e in apparenza semplice ma costellato di tanti passaggi che possono avere risvolti critici nel recupero funzionale del paziente.

#126: Cistectomia laparoscopica con confezionamento di Bricker intracorporea

Inviato da: rnucciotti@gmail.com

R. Nucciotti1, C. Gulia1, E. Santini1, F.M. Costantini1, F. Viggiani1, A. Bragaglia1
  • 1 Ospedale della misericordia (Grosseto)

Abstract

L'approccio mininvasico, laparoscopico o robotico, alla cistectomia radicale offre indubbi vantaggi nel recupero clinico nel post operatorio, basti pensare alla riduzione delle perdite ematiche intraoperatorie e alla conseguente riduzione di emotrasfusioni, alla riduzione del dolore da ferita chirurgica quindi alla precoce mobilizzazione e alla precoce canalizzazione intestinale soprattutto se viene eseguita la resezione ileale per il confezionamento di una derivazione ortotopica o eterotopica. L'approccio mininvasivo associato al fast track chirurgico permette la canalizzazione fin dal POD#3. Il sondino nasogastrico viene rimosso la mattina successiva all'intervento e il pz inizia a sorseggiare acqua e mangiare del gelato mattina e sera fin dal post operatorio. Non viene somministrata nutrizione parenterale. La mobilizzazione è in prima giornata post operatoria.
Il video mostra gli steps laparoscopici più salieni. Con scopo descrittivo viene mostrata la cistectomia radicale e la linfoadenectomia iliaco otturatoria estesa. Con finalità didattica, e quindi soffermandosi sui particolari, viene mostrato l'utilizzo delle suturatrici meccaniche laparoscopiche e la gestione della anastomosi ureteroileale intracorporea.
Il condotto ileale secondo Bricker rappresenta a nostro giudizio la migliore derivazione dopo cistectomia radicale per qualità di vita nei pazienti per i quali è improponibile la neovescica ileale ortotopica. L'approccio laparoscopico permette un più rapido recupero post operatorio.

#171: Purely off-clamp Robot-assisted partial nephrectomy for totally endophytic renal tumors: mid-term outcomes from a single-center series

Inviato da: puldet@gmail.com

Argomenti: 

G. Tuderti1, U. Anceschi1, S. D'Annunzio2, M. Ferriero1, A. Bove1, A. Brassetti1, M. Costantini1, S. Guaglianone1, M. Gallucci3, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Ospedale Sant'Andrea (Roma)
  • 3 Università "Sapienza" (Roma)

Abstract

The case of a 73-yr old male with a 3.3cm endophytic left renal tumor was reported. Surgical steps were highlighted, focusing on identification of the mass and margins scoring, simultaneous use of two suction devices combining irrigation and suction to maintain a bloodless and clear operative field, enucleative strategy and finally a selective renorraphy to avoid any unintentional injury to hilar branches of main vessels. Potential use of near infrared fluorescence was showed, including intravenous injection to ensure maximal preservation of healthy and functioning renal parenchyma and preoperative transarterial delivery to optimize tumor identification and resection strategy. Baseline, perioperative, oncologic and functional data were reported.

#158: Neovescica Ileale ortotopica con approccio Robot-assistito: quale scegliere?

Inviato da: dott.alessandro.izzo@gmail.com

A.. Izzo1, G. Grimaldi1, G. Quarto1, R. Muscariello1, L. Castaldo1, D. Franzese1, M. Perra1, S. Perdonà1
  • 1 Istituto Nazionale dei Tumori di Napoli - IRCCS - Fondazione "G. Pascale" (Napoli)

Abstract

Il video descrive le tre tecniche utilizzate presso il nostro Istituto per il confezionamento della neovescica ileale ortotopica intracorporea con approccio robot-assistito: la VIP (Vescica Ileale Padovana), la "Y shaped" e la FloRIN.
Nel dettaglio da gennaio 2017 ad Aprile 2019 sono stati trattati 37 pazienti (28 M e 9 F):
28 VIP
6 "Y" shaped
3 FloRIN
I dati relativi ai tempi operatori, perdite ematiche, degenza e tempi di cateterizzazione sono riportati nel video.
Nei pazienti sottoposti a VIP si sono registrati due casi di infezione complicata delle vie urinairie, un caso di osteomielite pubica, un caso di fistola urinaria esitata in stenosi dell'anastomosi neo-vescico-ureterale.
Non ci sono state complicanze, ad oggi, nei pazienti trattati con le altre due derivazioni intracorporee.
Ulteriori dati patologici e funzionali vengono riportati nelle tabelle del video.
Sulla base della nostra esperienza preliminare possiamo concludere che la neovescica più anatomica è la VIP. Nei casi in cui gli ureteri siano corti o il meso non complicante, la "Y" shaped, grazie alla sua versatilità e facilità di esecuzione è la più indicata. La giusta via di mezzo potrebbe essere la FloRIN.
La nostra esperienza supporta la fattibilità delle 3 tecniche descritte nel video e dimostra la loro somiglianza e sicurezza in termini con risultati.

#214: Diagnostic accuracy of 68Ga-PSMAHBED PET/CT and pelvic mp-3Tesla MRI in primary staging of patients with intermediate/high-risk prostate adenocarcinoma

Inviato da: monica.celli@irst.emr.it

M.. Celli1, R. Gunelli2, F. Ferroni 1, A. Vici2, P.. Caroli1, U.. Salomone2, L. Fantini1, E.. Fragalà2, V.. Rossetti1, V.. Di Iorio1, M.. Costantini2, D. Barone1, F. Matteucci1
  • 1 Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (Meldola)
  • 2 Policlinico Morgagni-Pierantoni (Forlì)

Objective

To evaluate the diagnostic accuracy of whole-body 68Ga-PSMAHBED PET/CT (PSMA PET) and pelvic multi-parametric 3TeslaMRI (mpMRI) in primary staging of patients with intermediate/high-risk prostate adenocarcinoma (PCa).

Materials and Methods

We prospectively enrolled 13 patients (age range: 49-72 years; median: 61 years) with biopsy-proven PCa (ISUP: 1 to 4; PSA range: 2.2-28.3ng/ml; biopsy T: T2a-T2c) scheduled for radical prostatectomy. PSMA PET-CT and mpMRI were performed within six weeks prior to surgery and independently reported. Concordance between PSMA PET and mpMRI findings was assessed. A rigid co-registration of PSMA PET to T2-weighted MRI reporting all suspected PCa lesions onto the 12-segment prostate map was carried out. Post-prostatectomy pathology was the standard of truth for T and N staging; abdomen CT and bone scan for M staging.

Results

Pathologic prostate findings were documented in all 13 patients on mp-MRI and in 12 patients on PSMA PET. PCa tumour laterality (bilateral in 12 cases; monoloteral in 1 case) was correctly identified in nine patients by PSMA PET and in 10 patients by mpMRI. On a 12-prostate segment basis PSMA PET and mpMRI results were concordant in 115/156 segments (73.7%) being both positive for PCa in 30 segments and both negative for PCa in 85 segments. Concordant positive findings on PSMA PET and mpMRI resulted true positive (TP) on pathology in 80% (24/30 segments); concordant negative findings on both PSMA PET and mpMRI resulted true negative (TN) on pathology in 68% (58/85 segments).Discordant results were observed in 41 segments. Of these, 19 segments were positive on PSMA PET only (10 TP; 9 false positives); 22 segments were positive on mpMRI only (18 TP, 4 false positives). All patients resulted negative for nodal metastases on PSMA PET and mpMRI. Pelvic node dissection confirmed the N0 status. No distant metastases were demonstrated on PSMA PET and on pelvic mpMRI, nor suspicious lesions were documented on clinical bone scans and abdomen CTs. Tumours with ISUP 1, ISUP 2, ISUP 3 and ISUP 4 had a median SUVmax of 5.1, 10.3, 4.1 and 15.0, respectively. Median PCa SUVmax was 4.6 and 4.3 in patients with PSA starter 10ng/ml, respectively.

Conclusion

Our preliminary results suggest that PSMA PET might have a role in PCA pre-operative staging. Obviously a larger number of patients is needed to understand the accuracy of PSMA PET compared to mpMRI.

Reference

1) Tulsyan S et Al. Comparison of 68Ga-PSMA PET/CT and multiparametric MRI for staging of high-risk prostate cancer. Nucl Med Commun. 2017 Dec;38(12):1094-1102;

3) Zhang Q. et Al. Comparison of 68Ga-PSMA-11 PET-CT with mpMRI for preoperative lymph node staging in patients with intermediate to high-risk prostate cancer. J Transl Med (2017) 15, 230;

4) Park S.Y. et Al. Gallium 68 PSMA-11 PET/MR imaging in patients with intermediate- or high-risk prostate cancer. Radiology 2018; 288: 495–505;

5) Yilmaz B et Al. Comparison of preoperative locoregional Ga-68 PSMA-11 PET-CT and mp-MRI results with postoperative histopathology of prostate cancer. Prostate 2019; 79: 1007–17;

2) Meißner S et Al. Accuracy of standard clinical 3T prostate MRI for pelvic lymph node staging: Comparison to 68Ga-PSMA PET-CT. Sci Rep. 2019 Jul 24;9(1):10727.

#207: After 6 years, Study comparing GreenLight ™ XPS 1800 W laser and transurethral resection of the prostate for the treatment of benign prostatic hyperplasia

Inviato da: afandella@libero.it

A. Fandella1, S. Guazzieri1
  • 1 Casa di Cura Rizzola (San Donà di Piave)

Objective

Transurethral resection of the prostate (TURP) is still considered the gold standard surgical treatment for symptomatic benign prostatic hyperplasia (BPH). However, photoselective vaporization of the prostate (PVP) has gained widespread global acceptance in national guidelines as a safe and effective alternative option. Nevertheless, further evidence is required to assess the durability of Greenlight PVP. Herein, we report our six years of PVP experience with the Greenlight 180W XPS laser system. We compared Green laser PVP with transurethral resection of the prostate (TURP) in subjects with symptoms of lower urinary tract secondary to benign prostatic hyperplasia.

Materials and Methods

We compared the clinical course of patients operated with PVP to a group of patients similar in age, prostate volume and symptomatology evaluated with IPSS, before and after surgery. The trial was designed as a non inferiority trial, and the primary outcome was IPSS to 6 months. A margin of 3 IPSS was chosen to assess non-inferiority PVP as this is the accepted limit in which patients can feel the difference. Other key endpoints were pre-specified Qmax, incidence of complications, PVR, PSA, and the reduction of prostate volume. 180 patients were enrolled between October 2013 and October 2019 of which 88 PVP, 92 TURP

Results

All 180 subjects who completed 6 months of follow-up visits. The two treatment groups were similar with respect to demographic and baseline characteristics. The median procedure Rates for PVP and TURP were 46.0 minutes and 36.0 minutes, respectively. The mean difference in IPSS at 6 months was 2 (mean values of 6.8 for the PVP arm and 5.5 for the TURP arm, 95% CI for the mean difference, 0.1 to 2.6). Since the upper limit of the 95% confidence was under 3, the statistical criterion for the non-inferiority was reached (p = 0.004). Mean Qmax was not significantly different at 6 months (23.3 vs. 24.4 PVP to TURP, 95% CI for the mean difference -3.9-1.8), satisfy the criterion of non-inferiority for Qmax with p = 0.003. Freedom from complication rate was similar between the two groups (87.9% vs 82.8% for the PVP to TURP; 95% CI for the group difference of -3.6% to 13.8%) and PVP criterion for non-inferiority was reached (p = 0.012). secondary noteworthy endpoints have shown that PVP has resulted in fewer serious bleeding events (macroscopic hematuria, clot retention, hemorrhage) 2.2% as against 6.8% for TURP, low short-term re-intervention rate (2.9% vs. 9.8%) and, sometimes catheterization median (22.0 hours. vs. 46.7 hours.) and reduced average length of hospital stay (39.3 hours. vs. 78.2 hours).

Discussions

According to the American and other international guidelines, surgery should be suggested as an option to patients having one or more of the following: urinary symptoms refractory to maximal medical therapy, gross hematuria, recurrent infections, bladder stones, or deterioration of kidney function.(1–3) Transurethral resection of the prostate (TURP) remains the gold standard treatment for LUTS secondary to BPH.1 However, this intervention is associated with safety issues, particularly in patients taking anticoagulation therapy and those with larger prostates (&gt;80 cc).(4,5)

Over the past decades, Greenlight (GL) 532 nm laser photo selective vaporization of the prostate (PVP) has gained widespread acceptance as a safe and effective alternative to TURP.(3,6) This technology is based on a 532 nm length laser that vaporizes the highly vascularized transitional prostatic zone by selectively heating the hemoglobin.(7,8)
the Goliath study is the only prospective, randomized clinical trial comparing 180 W XPS and TURP with an exclusion of any patient in urinary retention. (6) At two years, they reported an IPSS score of 6.9, which suggests a drop of 14.3 points (67.5%) form baseline (21.2 points).
Despite its merits, our study has certain limitations that need to be mentioned. Results are obtained from a retrospective analysis of a prospectively maintained database of a single surgeon in a single institution.

Conclusion

In conclusion, in this large PVP RCTs they have demonstrated efficacy comparable to TURP with fewer serious side effects, decreased time of catheterization and shorter length of stay in hospital.

Reference

1. American Urological Association Education and Research Inc. American Urological Association Guideline: Management of benign prostatic hyperplasia (BPH) 2018. . http://www.auanet.org/benign-prostatic-hyperplasia.
2. Nickel JC, Mendez-Probst CE, Whelan TF, et al. 2010 Update: Guidelines for the management of benign prostatic hyperplasia. Can Urol Assoc J. 2010;4:310–6.
3. Gratzke C, Bachmann A, Descazeaud A, et al. EAU guidelines on the assessment of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol. 2015;67:1099–109.
4. Ahyai SA, Gilling P, Kaplan SA, et al. Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. Eur Urol. 2010;58:384–97.
5. Reich O, Gratzke C, Bachmann A, et al. Morbidity, mortality, and early outcome of transurethral resection of the prostate: A prospective, multicentre evaluation of 10 654 patients. J Urol. 2008;180:246–9.
6. Thomas JA, Tubaro A, Barber N, et al. A multicentre randomized non-inferiority trial comparing GreenLight-XPS laser vaporization of the prostate and transurethral resection of the prostate for the treatment of benign prostatic obstruction: Two-year outcomes of the GOLIATH study. Eur Urol. 2016;69:94–102.
7. Chughtai B, Te A. Photoselective vaporization of the prostate for treating benign prostatic hyperplasia. Expert Rev Med Devices. 2011;8:591–5.
8. Muller G, Bachmann A, Wyler SF. Vaporization techniques for benign prostatic obstruction: GreenLight all the way? Curr Opin Urol. 2014;24:42–8.

#193: Treatment of 1258 bulbar urethral strictures using graft urethroplasties: multivariable statistical analysis

Inviato da: mirko.preto@unito.it

E. Palminteri1, M. Preto2, G. Ferrari3, L. Gatti3, P. Bove4, V. Iacovelli4, M. Falcone5, O. Sedigh5, P. Gontero5
  • 1 Centro di Chirurgia Uretrale e Genitale – Humanitas Cellini Torino (Torino)
  • 2 Centro di Chirurgia Uretrale e Genitale – Humanitas Cellini Torino; Clinica Urologica Torino, Presidio Molinette (Torino)
  • 3 Hesperia Hospital, Centro C.U.R.E, Modena (Modena)
  • 4 Ospedale S. Carlo di Nancy, Roma (Roma)
  • 5 Clinica Urologica Torino, Presidio Molinette (Torino)

Objective

We investigated the success rate of different surgical grafting techniques for bulbar stricture repair. Our aim is to retrospectively evaluate a large series analyzing the success rates and the independent predictive factors for failure.

Discussions

Success rates of the analyzed techniques do not show significant differences neither at 12 nor at 60 months. This result is in agreement with the available data, currently no specific technique is superior. TTpreserving+Ventral grafting offers inferior results. However we emphasize that the choice of the technique depends on the stricture characteristics. Dorsal or Ventral grafting can be used for non sub-obliterative strictures where the remaining urethral lumen could be adequately augmented by using a single graft. Otherwise double Dorsal+Ventral grafting or dorsal TTpreserving+Ventral grafting are necessary for sub-obliterative or obliterative cases.
Stricture length has proved to be an independent predictor of failure. Two other predictive factors have been identified: patient age and the post-operative voiding flow (Qmax &lt;13mL/sec) that could be useful during clinical follow-up. A significant difference in terms of success among those who had never undergone any treatment compared to previously treated patients was recorded (95.3%vs83.1%). Considering that, the clinical management should lead to earlier surgical indications instead of periodic dilations or repeated urethrotomies. MB has been confirmed as gold standard tissue. Patients must be followed for a minimum period of 5 years.

Conclusion

Grafting techniques for bulbar strictures have shown a high success rate at medium-long followup.
Predictive factors for failure are age, stricture length and previous treatments. BM graft showed the better results. Long followup is mandatory.

Reference

1. Barbagli G, Montorsi F, Balò S, Sansalone S, Loreto C, Butnaru D, Bini V, Lazzeri M; Treatments of 1242 bulbar urethral strictures: multivariable statistical analysis of results; World J of Urol 2019;37:1165–1171

2. Chapple CR, Goonesinghe SK, Nicholson T, De Nunzio C. The importance of endoscopic surveillance in the follow up of patients with urethral stricture disease. J Urol 2002;167(Suppl):16.

3. Barbagli G, Palminteri E, Bartoletti R, Selli C, Rizzo M. Long-term results of anterior and posterior urethroplasty with actuarial evaluation of the success rates. J Urol 1997;158:1380–2.

#183: The impact of age and diabetes on chronic kidney disease worsening after partial or radical nephrectomy for high nephrometry score renal masses

Inviato da: puldet@gmail.com

Argomenti: 

U. Anceschi1, A. Brassetti1, G. Tuderti1, M. Costantini1, R. Mastroianni1, A. Bove1, M. Ferriero1, M. Gallucci2, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Università "Sapienza" (Roma)

Objective

The potential functional benefits of partial nephrectomy (PN) versus radical nephrectomy (RN) for patients with anatomically complex or large renal masses must be counterbalanced by the potential increased risks of preoperative complications. The aim of this study was to assess the impact of surgical treatment on renal functional outcomes for renal masses with RENAL nephrometry score ≥9.

Materials and Methods

Our institutional renal cancer dataset was queried for “radical nephrectomy”, “partial nephrectomy”, “RENAL score≥9”. Between January 2008 and October 2019, a total of 229 patients matched the inclusion criteria (134 ocRAPNs; 95 LRNs). Newly onset of any CKD stage (3a,3b,4,5) after surgery was computed by Kaplan-Meier curve and compared for surgical approach with the log-rank test. Univariable and multivariable Cox regression analyses were performed to identify predictors of CKD progression. For all statistical analyses, a two-sided p &lt; 0.05 was considered significant.

Results

At a median follow-up of 13 months (IQR 13-25), the newly onset of CKD3a and CKD-3b,4,5 stages in the ocRAPN group were 11.9 and 6% respectively, while in the LRN group the progression to CKD-3a and CKD-3b,4,5 was 27,4%, respectively. At Kaplan-Meier analysis, LRN was associated with a significantly higher risk of CKD progression. (Figure 1; p&lt;0.01). On multivariable analysis age (HR 1.03, 95%CI 1-1.06; p=0.02) and RN (HR 0.17, 95%CI 0.09-0.33; p&lt;0.01) were independent predictors of any CKD stage migration (Table 1). When including in the model ΔeGFR at discharge, ΔeGFR (HR 1.04, 95%CI 1-1.07; p=0.013) and diabetes (HR 4.1, 95%CI 1.44-11.6; p=0.008) were independent predictors of renal function deterioration (Table 2).

Conclusion

PN confirmed to have a significant protective role on renal functional outcomes, notwithstanding, when running the analysis adjusting for ΔeGFR, simulating a scenario when RN must be performed, diabetes was an independent predictor or CKD stage migration during follow-up. Potential impact of proper versus suboptimal medical treatment of diabetes requires further studies.

#182: The impact of ischemia on chronic kidney disease progression after robotic partial nephrectomy in patients over 75 years old: results of a multinstitutional collaborative series (ROSULA)

Inviato da: puldet@gmail.com

Argomenti: 

U. Anceschi1, A. Brassetti1, G. Tuderti1, A. Minervini2, A. Mari2, A. Grasso2, M. Carini2, U. Capitanio3, A. Larcher3, F. Montorsi3, R. Autorino4, A. Veccia4, C. Fiori5, D. Amparore5, F. Porpiglia5, I. Derweesh6, D. Eun7, J. Lee7, M. Gallucci8, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Ospedale Careggi (Firenze)
  • 3 IRCCS Ospedale San Raffaele (Milano)
  • 4 Virginia Commonwealth University (Virginia)
  • 5 Ospedale San Luigi (Orbassano)
  • 6 UC San Diego Health System (San Diego)
  • 7 Lewis Katz School of Medicine at Temple University (Philadelphia)
  • 8 Università "Sapienza" (Roma)

Objective

Partial nephrectomy (PN) in elderly patients (over 75 years) is certainly underused with concerns regarding risk of major complications and a negligible impact on renal function. The aim of this study was to compare the progression to chronic kidney disease (CKD) of purely off-clamp vs on-clamp robotic partial nephrectomy in patients ≥ 75 years in a multinstitutional series.

Materials and Methods

A collaborative multicentric minimally-invasive renal surgery dataset (ROSULA) was queried for “partial nephrectomy” and “age≥75 years”. Between May 2008 and October 2019, a total of 207 patients who underwent robotic partial nephrectomy (RAPN) matched the inclusion criteria. Newly onset of any CKD stage (3a,3b,4,5) after surgery was computed by Kaplan-Meier curve and compared for surgical approach (purely-off clamp vs on-clamp) with the log-rank test. Univariable and multivariable Cox regression analyses were performed to identify predictors of CKD progression. For all statistical analyses, a two-sided p &lt; 0.05 was considered significant.

Results

Mean age of the cohort considered was 77 years (IQR 76-81). At a median follow-up of 25 months (IQR 12-42.2) newly onset of CKD-3a and CKD-3b stages were observed in 7.2% and 8.7% of patients, respectively. At Kaplan-Meier analysis, on-clamp approach was associated with a significantly higher risk of developing a CKD progression, while a purely-off clamp approach was associated with a significantly lower risk of renal decline in patients ≥ 80 years old. (Figure 1; p=0.04 – Figure 2; p=0.03). On univariable analysis surgical approach (HR 4.22 – 95% CI 1.52-11.6; p=0.006) warm ischemia time (HR 1.05 – 95% CI 1.02-1.08; p=0.01) and tumor size (HR 1.05 -95% CI 1.01-1.09) were all significant predictors of renal function decline. On multivariable analysis warm ischemia time (HR 1.04 – 95% CI 1.01-1.08; p=0.006) was the only independent predictor of any CKD stage progression.

Conclusion

Robotic partial nephrectomy in the elderly population may achieve acceptable mid-term functional outcomes. Ischemia time during robotic partial nephrectomy remains the only modifiable surgical factor to avoid a significant progression of CKD even at the oldest age.

#178: Retrospective comparison of perioperative and 1-yr self-reported functional outcomes between Millin, Freyer and Madigan Robot assisted simple prostatectomy: single center series

Inviato da: puldet@gmail.com

A. Bove1, G. Tuderti1, M. Ferriero1, U. Anceschi1, A. Brassetti1, M. Gallucci2, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Università "Sapienza" (Roma)

Objective

Robot assisted simple prostatectomy (RASP) is an established surgical procedure for the management of obstructive symptoms caused by large adenomas. Traditionally this is performed according to the Freyer (trans-vescically) or Millin (trans-capsular) technique. These are known to cause retrograde ejaculation which limits their application in younger patients. We have recently described a novel urethra sparing (Madigan) technique which has shown some promising preliminary results. In this study we compare the above techniques for perioperative and intermediate term functional outcomes.

Materials and Methods

We retrospectively collected data from patients who underwent RASP across the three techniques in our center. Baseline demographic, clinical and perioperative data were collected. Standardized indications to the available three techniques were: bladder diverticula or stones and/or large median lobe for Freyer technique, patients’ desire to preserve antegrade ejaculation in absence of any of the above mentioned criteria for Freyer procedure, Millin procedure in all other cases. Baseline and one-yr functional outcomes assessed by means of self-reported validated questionnaires (IPSS, IIEF, ICIQ short form, MSHQ Short Form) were analyzed. Categorical and continuous variables were compared with chi square and Student t test, respectively.

Results

Between June 2012 and September 2019, 45 patients underwent RASP: 23 (51%) Millin, 8 (18%) TVA, and 14 (31%) Madigan. The median follow-up was 37 months (18–63.5). Demographic and clinical data were homogeneous for BMI, prostate volume and ASA score (p=0.34, 0.23, 0.57 respectively), while patients who underwent Madigan were younger (median 66) compared to the Millin (72) and Freyer (74) cohorts (p=0.013). Baseline IPSS, IIEF, ICIQ, or MSHQ scores were comparable between groups (all p&gt;0.17). Similarly, operative time, hospital stay and complication rates were comparable between groups (p=0.28, 0.27 and 0.32, respectively). The Madigan procedure provided higher 1-yr MSHQ score (median 10.5), mostly based on preserved antegrade ejaculation, compared with Millin (median 2) and Freyer (median 2) cohorts (p=0.04) and also a trend towards significantly higher IIEF score (p=0.05).

Conclusion

Our study has demonstrated how the Madigan technique is a promising surgical approach to preserve the ejaculatory function while ensuring resolution of obstructive symptoms comparable to the traditional techniques, regardless of the prostate size.

#177: Assessing the impact of multiparametric MRI and fusion biopsy on upgrading & upstaging during active surveillance

Inviato da: puldet@gmail.com

M. Ferriero1, V. Panebianco2, M. Pecoraro3, R.. Mastroianni1, C. De Nunzio4, A. Bove1, G. Tuderti1, U. Anceschi1, A. Brassetti1, S. Guaglianone1, G. Malossini5, M. Puglisi5, M. Gallucci2, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Università "Sapienza" (Roma)
  • 3 Unversità "Sapienza" (Roma)
  • 4 Ospedale Sant'Andrea (Roma)
  • 5 Ospedale di Trento (Trento)

Objective

Active surveillance (AS) is a viable but expensive option for low risk prostate cancer. Multiparametric (mp) Magnetic Resonance Imaging (MRI) has been introduced as an optional tool in many surveillance protocols with the aim of improving staging process and consequently of early detecting any potential disease progression. In this study, we assessed the impact of mpMRI and of ultrasound (US)-MRI fusion biopsies on upgrading &amp; upstaging risks in patients under AS.

Conclusion

This study support integration of mp-MRI into AS protocols together with established prognosticators, such as PSA density. Identification of patients at significant risk for progression can be useful to proper counsel patients at enrollment, as well as to early identify Us or Ug during AS and to switch patients to radical treatment.

#176: Retrospective comparison of perioperative and 1-yr self-reported functional outcomes between Millin, Freyer and Madigan Robot assisted simple prostatectomy: single center series

Inviato da: puldet@gmail.com

A. Bove1, G. Tuderti1, R. Mastroianni1, M. Ferriero1, U. Anceschi1, A. Brassetti1, M. Gallucci2, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Università "Sapienza" (Roma)

Abstract

The video shows our surgical techniques for three different approaches of RASP: Freyer, Millin and Madigan. Standardized indications to the available techniques were: bladder diverticula or stones and/or large median lobe for Freyer technique, patients’ desire to preserve antegrade ejaculation in absence of any of the above mentioned criteria for Madigan procedure, Millin procedure in all other cases. Baseline and one-yr functional outcomes assessed by means of self-reported validated questionnaires (IPSS, IIEF, ICIQ short form, MSHQ Short Form) were analyzed. Categorical and continuous variables were compared with chi square and Student t test, respectively.

#175: ICG-guided robotic-assisted Partial Adrenalectomy

Inviato da: puldet@gmail.com

M. Ferriero1, R. Mastroianni1, G. Tuderti1, U. Anceschi1, A. Bove1, A. Brassetti1, S. Guaglianone1, M. Gallucci2, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Università "Sapienza" (Roma)

Abstract

We present a case of a 54-year old female patient with a 1 cm left adrenal aldosterone-secreting lesion. Patient was symptomatic and required hypotensive treatment. Serum aldosteron levels were increased. Patient was placed in extended flank position and side docking. A transperitoneal five-port access was performed using a 30° scope. Once the adrenal gland was identified, under NIFI, the adrenal nodule appeared hyperintense compared to the adrenal parenchyma.
The lesion was progressively mobilized following the pseudocapsule plane. A blunt and sharp dissection using monopolar scissors was employed to maximize adrenal parenchyma preservation. Blood pressure was carefully monitored intraoperatively to ensure hemodynamic stability during the procedure. The dissection was carried out without any isolation of adrenal vessels, in order to avoid accident or injury to adrenal vessels. The remnant adrenal margins were approximated with a sliding-clip running suture (3/0 Monocryl).

ICG-guided RPA is a safe and feasible procedure, providing excellent functional outcomes. The real time feed-back of ICG technology is best suited for small lesions to improve visualization of resection margins and to minimize unintended resection of healthy parenchyma.

#174: Pushing the limits of robot-assisted partial nephrectomy: off-clamp approach for bilateral, hilar and totally endophytic renal masses

Inviato da: puldet@gmail.com

Argomenti: 

M. Ferriero1, R. Mastroianni1, G. Tuderti1, U. Anceschi1, A. Bove1, A. Brassetti1, S. Guaglianone1, M. Gallucci1, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)

Abstract

The video highlights surgical steps of purely off-clamp robotic partial nephrectomy in different scenarios: docking and patient positioning, surgical equipment, three consecutive videos of bilateral tumors, purely hilar tumor and totally endophytic renal tumors.
The first case was a patients with synchronous bilateral tumors (cT2 on right side and cT1b on right side). A single session bilateral robotic partial nephrectomy was performed (right side shown). The second case was a 3.3 cm purely hilar tumor in touch with main renal artery and renal pelvis. The last case was a 3.3 cm totally endohytic renal tumor with baseline stage 3b chronic kidney disease who underwent preoperative transarterial ICG marking and subsequent off-clamp robotic partial nephrectomy.Purely off clamp robotic partial nephrectomy is a challenging technique. Its feasibility in challenging surgical scenarios is demonstrated. Despite the potential functional benefits in patients with baseline impairment of renal function, this technique requires advanced surgical skills, therefore selective referral to high volume centers should be considered.

#173: Nerve-sparing Robot-Assisted Radical Cystectomy with intracorporeal Neobladder in male patients: surgical technique, perioperative, oncologic and functional outcomes

Inviato da: puldet@gmail.com

G. Tuderti1, R. Mastroianni1, U. Anceschi1, S. D'Annunzio2, M. Ferriero1, A. Bove1, A. Brassetti1, S. Guaglianone1, M. Gallucci3, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Ospedale Sant'Andrea (Roma)
  • 3 Università "Sapienza" (Roma)

Abstract

Prospectively maintained IRB approved bladder cancer database was queried for “male”, “RARC”, “iN” and “Nerve-sparing”. Inclusion criteria were: organ confined disease, without involvement of prostate, prostatic urethra or bladder neck, and strong motivation to preserve sexual function. Key surgical steps are: isolation of the ureters; preparation of Douglas space and athermal isolation of seminal vesicles; development of posterior intrafascial dissection plane, endopelvic fascia incision and antegrade intrafascial dissection of neurovascular bundles up to prostatic apex; assessment of distal ureter vascularity before and after LND with near-infrared fluorescence imaging. Hypogastric and presacral nodes were not involved in the dissection, in order to avoid any injury to the pelvic plexus. Finally, intracorporeal Padua ileal neobladder was performed. Baseline demographic, clinical, perioperative, oncologic and functional data were collected and reported. Kaplan-Meier method was performed to assess survival outcomes and day & night-time continence recovery probabilities.

#172: Transarterial ICG delivery before purely off-clamp robot-assisted Partial Nephrectomy for totally endophytic renal tumors: technique and outcomes

Inviato da: puldet@gmail.com

Argomenti: 

G. Tuderti1, R. Mastroianni1, U. Anceschi1, S. D'Annunzio2, M. Ferriero1, A. Bove1, A. Brassetti1, M. Costantini1, S. Guaglianone1, M. Gallucci3, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Ospedale Sant'Andrea (Roma)
  • 3 Università "Sapienza" (Roma)

Abstract

In this video we present two cases of ICG- guided off-clamp RPN. The first one is a 54-yr old female with a 3-cm endophytic “8 shaped” right renal tumor. The second is a 64-yr old male with a 2.5 cm endophytic left renal tumor. Between October 2017 and March 2019, patients with totally endophytic renal masses were scheduled for this procedure. Baseline, perioperative, pathologic, oncologic and functional follow-up data were prospectively collected.

#170: Liquid biopsy in clear cell Renal Cell Carcinoma: urinary miR-210-3p as emerging specific biomarker

Inviato da: puldet@gmail.com

Argomenti: 

M. Costantini1, V. Petrozza2, C. Tito3, L.M. Giammusso3, V. Sorrentino2, J. Cacciotti2, N. Porta2, A. Iaiza3, A.L. Pastore2, A. Di Carlo3, G. Simone1, M. Gallucci3, A. Carbone2, F. Fazi3
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 I.C.O.T - Latina Università "Sapienza" (Latina)
  • 3 Università "Sapienza" (Roma)

Objective

The most common subtype of renal cell carcinoma (RCC) is clear cell RCC (ccRCC) that accounts for 70-80% of all renal malignancies. To date, no useful markers are available in clinical practice for early diagnosis and for optimal patient stratification. MicroRNAs, a class of small non-coding RNA, are emerging as promising molecules in the management of urological tumors suggesting the possibility of using them as non-invasive biomarkers. The aim of this study is to evaluate whether miR-210-3p may be an accurate non invasive diagnostic and prognostic biomarker for ccRCC patients.

Materials and Methods

This study includes a cohort of 21 ccRCC cases underwent radical or partial nephrectomy. We analyzed by RTpPCR miR-210-3p levels in neoplastic and healthy tissues and in urine specimens collected at surgery and during follow-up visits (from 3 to 24 months) of all ccRCC cases, of which 18 disease-free patients and a small subgroup presenting metastatic progression. Urine samples were also collected from 16 healthy donors with similar demographic features. The specimens were frozen within 30 minutes from collection and stored at -80°C until RNA extraction and microRNA expression analysis.

Results

miR-210-3p was upregulated in ccRCC frozen tissues compared to matched normal counterparts. Next, we evidenced that miR-210-3p resulted significantly up-regulated in urine specimens collected from ccRCC patients at the time of surgery, compared to healthy samples. Of note, miR- 210-3p levels resulted significantly reduced in urine samples from disease-free patients during follow-up, compared to the baseline levels (time of surgery). In a small subgroup of patients presenting metastases, the urine levels of miR-210-3p increased and, interestingly, again decreased when responding to medical treatments.

Conclusion

This pilot study highlights the relevance of secreted miR-210-3p as powerful non invasive diagnostic and prognostic biomarker for ccRCC patients, with potential clinical applications from diagnosis to treatment.

#160: A nomogram to predict disease-free survival after partial nephrectomy: development and internal validation

Inviato da: puldet@gmail.com

Argomenti: 

A. Brassetti1, L. Benecchi2, R. Lombardo3, U. Anceschi1, A. Bove1, M. Costantini1, M. Ferriero1, S. Guaglianone1, R. Mastroianni1, G. Tuderti1, M. Gallucci4, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Ospedale di Cremona (Cremona)
  • 3 Ospedale Sant'Andrea (Roma)
  • 4 Università "Sapienza" (Roma)

Objective

The best follow-up (FU) strategy following partial nephrectomy (PN) remains unclear. The Mayo Clinic Algorithm (MCA), developed in 2003 on a series of 1671 radical nephrectomies, has not been validated specifically in PN cohorts. We developed a nomogram to predict cancer recurrence after PN.

Materials and Methods

Our prospectively maintained database on 1744 partial nephrectomies was queried for “cT1-2N0”, “clear-cell renal cell carcinoma” (ccRCC). Uni/Multivariable Cox regression analyses identified predictors of disease-free survival (DFS) which were used to generate a nomogram. The discrimination accuracy was measured by concordance index (CI). Calibration plot was generated with 200 bootstraps resampling to explore nomogram performance and decision curve analyses assessed the net benefit of the model.

Results

Overall, 806 patients were included in the analysis. At 12, 24, 36 and 60 months, DFS probabilities were 96±1, 92±1, 88±2, 84±2, respectively. On multivariable Cox analysis (Table 1), age, male gender, pathologic tumor size, Fuhrman grade, tumor necrosis and positive surgical margins were significant predictors of DFS probabilities. The developed nomogram (Figure 1) had a 0.72 CI and was perfectly calibrated (Figure 2). On decision curve analyses, the net benefit of using the model was evident for probabilities between 10%-50% (Figure3).

Conclusion

This nomogram efficiently estimates DFR probabilities at 12, 24, 36 and 60 months after PN. It could be useful in designing a patient-tailored follow-up schedule based on his individual risk of cancer recurrence, thus avoiding

#161: 15 years outcomes of laparoscopic partial nephrectomy: single center experience

Inviato da: puldet@gmail.com

Argomenti: 

A. Brassetti1, U. Anceschi1, A. Bove1, M. Costantini1, M. Ferriero1, S. Guaglianone1, R. Mastroianni1, G. Tuderti1, M. Gallucci2, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Università "Sapienza" (Roma)

Objective

Although robotic surgery is gaining acceptance, laparoscopic partial nephrectomy (LPN) still remains a viable options to treat patients with cT1-2N0 renal tumors. To minimize ischemic injury to the healthy parenchyma, we pioneered the off-clamp approach and first proposed the preoperative superselective embolization of tumor vessels (SETV)1 in order to decrease intraoperative bleeding. We herein present long term oncologic and functional outcomes after 15 years of LPN.

Materials and Methods

Our prospectively maintained institutional database was queried for patients undergone off-clamp LRP with or without SETV before October 2004. Baseline demographic, clinical, pathologic surgical and survival data were collected. Patients with clear cell (ccRCC) and non-clear cell renal cell carcinomas (non-ccRCC) were stratified into risk groups according to the Mayo Clinic Risk Stratification System (MCRSS)2 and the University of California Integrated Staging System (UCISS)3, respectively.

Results

Overall,73 consecutive patients were included in the analysis. Most of them were men (60%) with a median age of 63 yrs (IQR: 53-70) and BMI of 24.7(IQR: 21.8-28); 3 (4%) presented with a solitary kidney (Table1). Median tumor size was 3 cm (IQR:2-4). SETV was performed in 27 cases (37%). While 23 patients (32%) were diagnosed with a benign tumor, 41 (56%) and 9 (12%) harbored clear cell and non-clear cell cancers, respectively; 6 (8%) of these malignancies were intermediate/high risk (IR/HR) diseases. The positive surgical margins rate was 4% (n=3) and an acute kidney injury occurred in 22% of cases; a new onset CKD ≥ IIIa was observed in 28% (n=21) of patients overall.
At 15 yrs, disease-free (DFS), cancer-specific (CSS) and overall-survival (OS) probabilities were 72±6%, 90±4% and 65±8%, respectively. Overall, the rates of distant metastases and recurrence at the tumor bed or at the contralateral kidney were 16±5%, 1.5±1% and 20±6%, respectively (Figure 1-2). At the same timepoint the chances to develop a CKD ≥ IIIa were 22±2% and these were not affected by SETV (Figure 3; Log Rank p&gt;0.240). On Cox analysis, age was the only predictor of long-term functional deterioration (OR:1.066, 95%CI:1.006-1.129; p=0.031). Kaplan Meier analysis identified MCRSS and UCISS as predictor of DFS, CSS and OS probabilities (Figure 1; all p&lt;0.001).

Conclusion

We reported 15-yr oncologic and functional outcomes of the largest cohort of patients undergone off-clamp LPN, at a single referral center. According to this report, preoperative SETV seems not to affect long-term kidney function.

Reference

1 Gallucci M, Guaglianone S, Carpanese L, Papalia R, Simone G, Forestiere E et al. Superselective Embolization as First Step of Laparoscopic Partial Nephrectomy. Urology 2007; 69: 642–645.
2 Leibovich BC, Blute ML, Cheville JC, Lohse CM, Frank I, Kwon ED et al. Prediction of progression after radical nephrectomy for patients with clear cell renal cell carcinoma. Cancer 2003; 97: 1663–1671.
3 Zisman A, Pantuck AJ, Dorey F, Said JW, Shvarts O, Quintana D et al. Improved prognostication of renal cell carcinoma using an integrated staging system. J Clin Oncol 2001; 19: 1649–57.
4 Wang G, McKenney JK. Urinary Bladder Pathology: World Health Organization (WHO) Classification and American Joint Committee on Cancer (AJCC) Staging Update. Arch Pathol Lab Med 2018; : arpa.2017-0539-RA.

#167: Assessing the impact of absence of detrusor muscle in Ta-LG urothelial carcinoma of the bladder on recurrence free survival

Inviato da: puldet@gmail.com

R. Mastroianni1, A. Brassetti1, Y. Al Salhi2, U. Anceschi1, A. Bove1, A. Carbone3, C. De Nunzio4, A. Fuschi3, M. Ferriero1, A. Nacchia4, A. Pastore3, G. Tema4, G. Tuderti1, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 I.C.O.T. Latina - Università "Sapienza" (Latina)
  • 3 I.C.O.T. Latina - Università "Sapienza" (Roma)
  • 4 Ospedale Sant'Andrea (Roma)

Objective

Obtaining detrusor muscle in TURBt specimen is recommended by European Association of Urology guidelines. Few studies assessed this specific topic in the setting of Ta low-grade (LG) urothelial carcinoma (UC) of the bladder. The aim of this study was to assess if the absence of detrusor muscle at pathologic report has a negative impact on recurrence free probability in patients with a Ta LG UC of the bladder.

Materials and Methods

A multicenter TURBt database was queried for: “low-grade Ta, UC of the bladder”. All patients treated between 2008 and 2018 with tumor grade assessed according to both ISUP and WHO grading systems and with a minimum follow-up of 1-yr were included. Patients with previous history of high-grade UC were excluded. Baseline demographic, clinical and pathologic data were analyzed. EORTC risk group was recorded. Kaplan-Meier analysis was performed to assess the predictive role of clinical and pathologic data on Recurrence-Free Survival (RFS) probability, computed at 12, 36, 60 months after TURBt.

Results

Overall, 203 consecutive patients were included. Most of them were men (84%), median age was 69 yrs (IQR: 61-77). Patients and tumors characteristics were reported in Table1. At Kaplan-Meier analysis low-risk EORTC cohort displayed a significantly higher RFS probability compared with intermediate-risk cohort (5-yr probability 89.5% vs 72.4%, respectively; log-rank p=0.011. Figure 1a).
At univariable Cox regression multiple tumors (HR 1.36, 95%CI 1.02-1.82; p=0.037), tumor diameter ≥3cm (HR 2.8, 95%CI 1.01-7.9; p=0.049), previous history of UC ≤1 yr (HR 1.96, 95%CI 1.02-3.75; p=0.043) and combined EORTC risk group (HR 3.15, 95%CI 1.23-8; p=0.017) were significant predictors of recurrence. Absence of detrusor muscle at pathologic report (HR 1.45, 0.61-3.45; p=0.4. Figure 1b) and adjuvant intravesical treatments (HR 0.95, 95%CI 0.5-1.78; p=0.87) had negligible impacts on RFS probabilities (Table 2).

Conclusion

EORTC risk group is a strong predictive tool to assess the risk of recurrences in patients with Ta-LG UC of the bladder. Absence of detrusor muscle in the TURBt specimen has negligible role on recurrence of patients with Ta-LG tumors, therefore it should no longer be considered as a mandatory data to assess prognosis or treatment schedule.

#169: Highly-Trained Dogs’ Olfactory System don’t discriminate low and high risk prostate cancer in urine samples

Inviato da: matteo.zanoni@materdomini.it

G. Taverna1, L. Tidu2, F.. Grizzi3, A. Mandressi1, P.. Sardella2, G. La Torre2, M. Zanoni1, P. Vota1, M.. Justich1, G.. Toia1, G. Malagola1, G. Guazzoni4
  • 1 Department of Urology, Humanitas Mater Domini (Castellanza)
  • 2 Italian Ministry of Defences, Military Veterinary Center, CEMIVET (Grosseto)
  • 3 Department of Immunology and Inflammation (Rozzano)
  • 4 Department of Urology, Humanitas Clinical and Research Center, Rozzano (Rozzano)

Objective

To establish the diagnostic accuracy, in term of sensitivity and specificity at which a
rigorously trained canine olfactory system can discriminate High Risk Prostate Cancer (HPC) versus Low Risk Prostate Cancer (LPC) specific volatile organic compounds (VOCs) in urine samples(1-2-3).

Materials and Methods

Two female and one male German Shepherd Explosive Detection Dogs were trained to identify HPC-specific VOCs in urine samples and tested on 550 subjects (165 with HPC vs 385 with LPC. This cross sectional design for diagnostic accuracy involved Humanitas Mater Domini and the Italian Ministry of Defense’s, Military Veterinary Center.

Results

The dogs achieved the following performances: Dog 1 achieved a sensitivity of 1% and specificity of 0,7% Dog 2 achieved a sensitivity of 0,2% and specificity of 0,1% Dog3 achieved a sensitivity of 0,1% and specificity of 0,7%

Discussions

A trained canine olfactory system don’t discriminate between HPC and LPC

Conclusion

Evidently, for Highly-Trained Dogs’ Olfactory System, high risk cases do not differ in terms of VOCs compared to LPC. Apparently, the VOCs metabolism is the same for HPC and LPC.

Reference

1) Sniffing out prostate cancer: a new clinical opportunity
Taverna G, Tidu L, Grizzi F.
Cent European J Urol. 2015;68(3):308-10. doi: 10.5173/ceju.2015.593. Epub 2015 Oct 15

2) Olfactory system of highly trained dogs detects prostate cancer in urine samples.
Taverna G, Tidu L, Grizzi F, Torri V, Mandressi A, Sardella P, La Torre G, Cocciolone G, Seveso M, Giusti G, Hurle R, Santoro A, Graziotti P.
J Urol. 2015 Apr;193(4):1382-7. doi: 10.1016/j.juro.2014.09.099. Epub 2014 Sep 28

3) Highly-trained dogs' olfactory system for detecting biochemical recurrence following radical prostatectomy
Taverna G, Tidu L, Grizzi F, Stork B, Mandressi A, Seveso M, Bozzini G, Sardella P, Latorre G, Lughezzani G, Buffi N, Casale P, Fiorini G, Lazzeri M, Guazzoni G.
Clin Chem Lab Med. 2016 Mar;54(3):e67-70. doi: 10.1515/cclm-2015-0717

#168: SERPINB3: a novel histopathological biomarker of prostate cancer aggressiveness

Inviato da: matteo.zanoni@materdomini.it

G. Taverna1, F. Grizzi2, M. Zanoni1, P. Vota1, M. Justich1, G. Toia1, G. Malagola1, A. Mandressi1, G. Guazzoni3
  • 1 Department of Urology (Castellanza)
  • 2 Department of Immunology and Inflammation, Humanitas Clinical and Research Center (Rozzano)
  • 3 Department of Urology, Humanitas Clinical and Research Center (Rozzano)

Objective

SERPINB3, also known as Squamous Cell Carcinoma Antigen-1 or SCCA1 is a member of the family of serine-protease inhibitors(1). SERPINB3 protects cells from oxidative stress conditions, but in chronic damage this serpin may lead to cancerous lesions through different strategies, including inhibition of apoptosis, induction of epithelial to mesenchymal transition and decrease of desmosomal junctions, cell proliferation and invasiveness(2). The aim of the present study was to investigate the protein expression of SERPINB3 in a series of prostate cancer specimens and benign prostatic hyperplasia (BPH) following transurethral resection of the prostate (TURP).

Materials and Methods

Sixty prostate specimens were investigated. Fifty specimens were diagnosed as prostate carcinoma and 15 as benign prostate hyperplasia. The samples were fixed in 10% formaldehyde and paraffin-embedded. Two-micrometer thick sections were cut and processed for immunohistochemistry with primary antibodies raised against SERPINB3 (Proteintech, Rosemont, IL, USA). This was followed by 30 min incubation with the Envision system (Dako). 3,3’-Diaminobenzidine tetrahydrochloride was used as a chromogen to yield brown reaction products.

Results

SERPINB3 expression was detected in a high percentage of prostate cancer tissues (80%), but to a much lesser extent in adjacent non-malignant tissues (20%) or tissue affected by benign prostatic hyperplasia (p &lt;0.001). High levels of SERPINB3 expression were found in advanced prostate tissue specimens.

Discussions

These results suggest that SERPINB3 may be a potential prognostic marker for prostate cancer

Conclusion

the down-regulation of SERPINB3 may be a therapeutic target in the suppression of prostate cancer growth.

Reference

1) Hyperdynamic circulatory syndrome in a mouse model transgenic for SerpinB3.
Villano G, Verardo A, Martini A, Brocco S, Pesce P, Novo E, Parola M, Sacerdoti D, Di Pascoli M, Fedrigo M, Castellani C, Angelini A, Pontisso P, Bolognesi M.
Ann Hepatol. 2019 Sep 18. pii: S1665-2681(19)32233-1. doi: 10.1016/j.aohep.2019.06.021

2) Urinary biomarkers for the diagnosis of cervical cancer by quantitative label-free mass spectrometry analysis.
Chokchaichamnankit D, Watcharatanyatip K, Subhasitanont P, Weeraphan C, Keeratichamroen S, Sritana N, Kantathavorn N, Diskul-Na-Ayudthaya P, Saharat K, Chantaraamporn J, Verathamjamras C, Phoolcharoen N, Wiriyaukaradecha K, Paricharttanakul NM, Udomchaiprasertkul W, Sricharunrat T, Auewarakul C, Svasti J, Srisomsap C.
Oncol Lett. 2019 Jun;17(6):5453-5468. doi: 10.3892/ol.2019.

#148: Carbon and zeolite impregnated polyester fabric inhibits urine odour: a randomized experimental study

Inviato da: matteo.zanoni@materdomini.it

Argomenti: 

G. Taverna1, F. Grizzi2, M. Zanoni1, P. Vota1, M. Justich1, G. Toia1, L.. Thiel3, B.. Stork4, D.L. Miller5, L. Tidu6, A. Mandressi1, G. Guazzoni7
  • 1 Department of Urology, Humanitas Mater Domini (Castellanza)
  • 2 Department of Immunology and Inflammation, Humanitas Clinical and Research Center (Rozzano)
  • 3 McAuley School of Nursing, College of Health Professions, University of Detroit Mercy (Detroit)
  • 4 West Shore Urology (Muskegon)
  • 5 Mercy Health Visiting Nurses Services and Hospice Services (Muskegon)
  • 6 Italian Ministry of Defences, Military Veterinary Center, CEMIVET (Grosseto)
  • 7 Department of Urology, Humanitas Clinical and Research Center (Rozzano)

Objective

Bladder cancer ranks fifth as the most common cancer in the world. Many individuals with bladder cancer have undergone a surgical urostomy and often complain of being self-conscious of the unpleasant smell of their own urine. The focus of this study was to test the efficacy of a pouch cover made of a carbon and zeolite containing polyester material to inhibit the smell of urine by comparing two trained dogs’ response time in detecting volatile organic compounds (VOCs) in urine(1-2), with and without the fabric covering the samples.

Materials and Methods

This study used a randomized, blinded experimental design to evaluate the efficacy of a fabric to interfere with two highly trained dogs’ ability to detect specific VOCs present in the urine of prostate cancer patient. Ninety urine samples were analysed in this study.

Results

Prior to the experiment, both dogs accurately detected VOCs in the uncovered test urine samples of men with prostate cancer with a sensitivity and specificity of nearly 100%. Both dogs recognized the “uncovered” urine samples of men with prostate cancer within two seconds. When the test sample was covered with the study fabric, the test urine samples were detected within 30-40 seconds and in some instances the dogs were not able to identify the covered samples, whatsoever.

Discussions

The findings of this study demonstrate that the carbon and zeolite containing polyester fabric did significantly interfere with the ability of the dogs to detect VOCs in urine of men with prostate cancer

Conclusion

The fabric may show promise as a pouch cover in controlling offensive urine odour which many ostomates experience.

Reference

1. Sniffing out prostate cancer: a new clinical opportunity.
Taverna G, Tidu L, Grizzi F
Cent European J Urol. 2015;68(3):308-10. doi: 10.5173/ceju.2015.593. Epub 2015 Oct 15. Review.
2. Highly-trained dogs' olfactory system for detecting biochemical recurrence following radical prostatectomy.
Taverna G, Tidu L, Grizzi F, Stork B, Mandressi A, Seveso M, Bozzini G, Sardella P, Latorre G, Lughezzani G, Buffi N, Casale P, Fiorini G, Lazzeri M, Guazzoni G
Clin Chem Lab Med. 2016 Mar;54(3):e67-70. doi: 10.1515/cclm-2015-0717

#165: Near-infrared fluorescence imaging technology applications in urologic surgery

Inviato da: puldet@gmail.com

R. Mastroianni1, G. Tuderti1, U. Anceschi1, A. Bove1, A. Brassetti1, M. Ferriero1, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)

Abstract

In this video we collected multiple clinical applications of NIRF technology: ICG-marking of totally endophytic renal tumors selected for partial nephrectomy, assessment of thrombus extent during level III IVC tumor thrombectomy, identification of functioning adenomas during adrenal surgery, assessment of ureteral vascularization during robot assisted radical cystectomy and during ureteral reimplantation, identification of urethra and ejaculatory ducts during Madigan prostatectomy.

#164: TOTALLY INTRACORPOREAL ROBOT-ASSISTED ILEAL URETERIC REPLACEMENT FOLLOWING AN URETERAL INTUSSUSCEPTION

Inviato da: puldet@gmail.com

R. Mastroianni1, G. Tuderti1, U. Anceschi1, M. Ferriero1, A. Brassetti1, S. Guaglianone1, M. Gallucci2, G. Simone1
  • 1 "Regina Elena" National Cancer Institute (Roma)
  • 2 Università "Sapienza" (Roma)

Abstract

We report the case of a 50 yr-old man admitted from Emergency Room for a right ureteral intussusception, occurred using a Dormia basket during an operative ureteroscopy. An antegrade pyelography demonstrates a proximal ureteral injury, about 4 cm caudal to the right renal pelvis, and a 17cm ureteral defect. Therefore, patient underwent a totally intracorporeal robot-assisted ileal ureteric replacement. The first step was the medialization of the right colon and the isolation of the ureter. In the video, is clearly evident the proximal damaged ureter, of which only the serosa is visible. The proximal ureter was transected and spatulated. Then, the segment of ileum nearest the proximal ureter was isolated, at least 20 cm distant from the ileocecal valve and transected using Endo-GIA. The proximal uretero-ileal anastomoses was performed using two running sutures of 4-0 monocryl, each in a semicircular configuration. The robot was redocked in Trendelenburg position. The right robotic port and the left laparoscopic port are closed and three additional ports are placed. A side to side ileal anastomosis was performed with motorized staplers. Afterwards, the bladder dome was opened, and the intussuscepted ureter, identified into the bladder lumen, transected and excised. Ileovesical anastomosis was completed with two 4-0 monocryl running sutures, each in a semicircular configuration.

#140: Thulium laser enucleation versus transurethral prostate resection: impact on erectile function

Inviato da: matteo.zanoni@materdomini.it

G. Taverna1, M. Zanoni1, P. Vota1, M. Justich1, G. Toia1, G. Malagola1, A. Mandressi1, F. Grizzi2, G. Guazzoni3
  • 1 Department of Urology, Humanitas Mater Domini (Castellanza)
  • 2 Department of Immunology and Inflammation, Humanitas Clinical and Research Center (Rozzano)
  • 3 Department of Urology, Humanitas Clinical and Research Center (Rozzano)

Objective

In this study, we compared the results of sexual function in patients with benign prostatic hyperplasia (BPH) treated with transurethral prostate resection (TURP) or laser thulium enucleation (ThuLEP) (1-2).

Materials and Methods

We performed a retrospective analysis of patients undergoing transurethral resection and endoscopic enucleation of the prostate for BPH; the inclusion criteria were the presence of bladder obstruction (IPSS&gt; 20, Qmax &lt;10 mL/s). Erectile function (EF) was evaluated using the International Erectile Function Index (IIEF-5) both before the endoscopic examination and after six months.

Results

A total of 650 patients with BPH were included in the study; of these, 350 underwent ThuLEP and 300 TURP. Preoperative IIEF-5 in the TURP and ThuLEP groups was 11.7 (± 4.5) and 11.1 (± 5.0), respectively (p = 0.17). At six months the IIEF-5 score was unchanged (p = 0.26 ep = 0.08) and comparable in both groups (p = 0.49). However, the mean score of IIEF-5 showed a significant increase of 0.72 in the ThuLEP group, compared to a decrease of 0.24 in patients with TURP (p &lt; 0.001).

Discussions

Both TURP and ThuLEP are effective methods in managing bladder obstruction due to BPH. At six months follow-up after surgery, both techniques lead to a comparable IIEF-5 score.

Conclusion

Our results have shown that ThuLEP is more likely to preserve erectile function with an increase of IIEF-5 at six months than TURP which results in a slight decrease in the IIEF-5 score.

Reference

1. A prospective study to compare changes in male sexual function following holmium laser enucleation of prostate versus transurethral resection of prostate.
Pushkar P, Taneja R, Agarwal A.
Urol Ann. 2019 Jan-Mar;11(1):27-32

2. Impact of endoscopic enucleation of the prostate with thulium fiber laser on the erectile function.
Enikeev D, Glybochko P, Rapoport L, Okhunov Z, O&#039;Leary M, Potoldykova N, Sukhanov R, Enikeev M, Laukhtina E, Taratkin M. BMC
Urol. 2018 Oct 12; 18(1):87. Epub 2018 Oct 1

#137: Thulium laser enucleation (ThuLEP) versus transurethral bipolar prostate resection (TURP): prospective randomized study: early intra- and postoperative results

Inviato da: matteo.zanoni@materdomini.it

G.. Taverna1, M. Zanoni1, P. Vota1, M. Justich1, G. Toia1, G. Malagola1, A. Mandressi1, F. Grizzi2, G. Guazzoni3
  • 1 Department of Urology, Humanitas Mater Domini (Castellanza)
  • 2 Department of Immunology and Inflammation, Humanitas Clinical and Research Center (Rozzano)
  • 3 Department of Urology, Humanitas Clinical and Research Center (Rozzano)

Objective

Comparison of early intra- and postoperative clinical results between transurethral enucleation of the prostate with thulium laser (1) (ThuLEP) and transurethral bipolar resection of the prostate (TURP) for the treatment of benign prostatic hyperplasia(2) (BPH) in a prospective randomized trial

Materials and Methods

In the study 650 consecutive patients with BPH were randomized: ThuLEP (n = 350) and TURP (n = 300). The parameters evaluated were: blood loss, catheterisation time, irrigation volume, hospital stay and operating time. At 3 months after surgery they were evaluated: International Prostate Symptom Score (IPSS), maximum flow (Qmax) and postmintional residue (RPM)

Results

Patients in each study arm did not show any significant differences in preoperative parameters compared to TURP, ThuLEP required the same operating time (53.69 ± 31.44 vs 61.66 ± 18.7 minutes, P = .123) but resulted in a reduction in lower hemoglobin values (0.45 vs 2.83 g/dL, P = 0.005). ThuLEP also determined less non statistically significant catheterisation time, lower irrigation volume (29.4 vs 69.2 L, P = 0.002) and lower non-significant hospital stay (1.7 vs 2.5 days). During the 3-month follow-up, procedures did not show a significant difference in Qmax, IPSS, PVR and QOLS.

Discussions

ThuLEP and TURP reduce both symptoms of the lower urinary tract with efficacy and safety (2-3)

Conclusion

ThuLEP is statistically superior to TURP in terms of blood loss, irrigation volume. However, procedures do not differ significantly in Qmax, IPSS, RPM and QOLS for up to 3 months of follow-up.

Reference

1. Safety and feasibility of thullium laser transurethral resection of prostate for the treatment of benign prostatic enlargement in overweight patients.
Carmignani L, Clementi MC, Signorini C, Motta G, Nazzani S, Palmisano F, De Lorenzis E, Catellani M, Mistretta AF, Conti A, Tringali V, Costa MB, Vizziello D.
Asian J Urol. 2019 Jul;6(3):270-274. doi: 10.1016/j.ajur.2018.05.004. Epub 2018 May 17.
2. Lasers versus bipolar technology in the transurethral treatment of benign prostatic enlargement: a systematic review and meta-analysis of comparative studies.
Gu C, Zhou N, Gurung P, Kou Y, Luo Y, Wang Y, Zhou H, Zhen C, Yang J, Tian F, Wu G.
World J Urol. 2019 Jun 17. doi: 10.1007/s00345-019-02852-1.
3. Novel Thulium Fiber Laser for Enucleation of Prostate: A Retrospective Comparison with Open Simple Prostatectomy.
Enikeev D, Okhunov Z, Rapoport L, Taratkin M, Enikeev M, Snurnitsyna O, Capretz T, Inoyatov J, Glybochko P.
J Endourol. 2019 Jan;33(1):16-21. doi: 10.1089/end.2018.079

#141: Robotic assisted prostatectomy (RARP): autologous Sling with the Denonvilliers muscular portion and subsequently early continence. Preliminary Data

Inviato da: matteo.zanoni@materdomini.it

G. Taverna1, M. Zanoni1, P. Vota1, M. Justich1, G. Toia1, G. Malagola1, A. Mandressi1, F. Grizzi2, G. Guazzoni3
  • 1 Department of Urology, Humanitas Mater Domini (Castellanza)
  • 2 3Department of Immunology and Inflammation, Humanitas Clinical and Research Center (Rozzano)
  • 3 Department of Urology, Humanitas Clinical and Research Center (Rozzano)

Objective

Urinary continence (UC) recovery remains bothersome for patients even after RARP(1). Analyzing the results published by the group of Cestari(2) we have developed a technique of Sling (3) using the Denonvilliers muscular portion. We describe our new surgical technique for retropubic suburethral autologous sling created during RARP using the Denonvilliers muscular portion. The surgical technique and preliminary data regarding its effectiveness in improving early UC recovery are presented.

Materials and Methods

Between september and november 2019, 50 patients who underwent RARP at a single high-volume center were prospectively randomized into sling and non sling groups. Early UC was assessed at 7 days (time of catheter removal), 15 days, and 30 days postoperatively by the daily number of pads used and the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) score. Sling-related operative time and urethral erosion were also analyzed.

Results

Complete data were available for all patients. Mean ± standard deviation (SD) numbers of pads used daily in nonsling and sling groups, respectively, were 1.9 ± 1.2 versus 1.7 ± 1.4 (P = 0.5) at 7 days, 1.8 ± 1.3 versus 1.3 ± 1.3 (P = 0.1) at 15 days, and 1.1 ± 1.2 versus 0.4 ± 0.8 (P = 0.01) at 30 days.
At 1 month, mean ± SD ICIQ-UI-SF scores in nonsling and sling groups, respectively, were 4.8 ± 4.6 versus 1.8 ± 3.4 (P = 0.01); sling patients were associated with pad-free status (76% vs 46%, P = 0.03).
Surgical time did not differ between groups, and in sling patients, no cases of urethral erosion or uroflowmetry suggestive of urinary obstruction were found. Limitations included the small cohort of patients.

Discussions

The suburethral autologous sling is technically feasible and may improve early UC recovery after RARP

Conclusion

Our new surgical technique for retropubic suburethral autologous sling created during RARP using the Denonvilliers muscular portion is simple and easily reproducibile. These preliminary results should be confirmed in a larger sample of patients

Reference

1) Urinary incontinence after robot-assisted radical prostatectomy: pathophysiology and intraoperative techniques to improve surgical outcome.
Kojima Y, Takahashi N, Haga N, Nomiya M, Yanagida T, Ishibashi K, Aikawa K, Lee DI.
Int J Urol. 2013 Nov; 20(11):1052-63. Epub 2013 Jul 10

2) Intraoperative Retrograde Perfusion Sphincterometry to Evaluate Efficacy of Autologous Vas Deferens 6-Branch Suburethral Sling to Properly Restore Sphincteric Apparatus During Robot-Assisted Radical Prostatectomy.
Cestari A, Soranna D, Zanni G, Zambon A, Zanoni M, Sangalli M, Ghezzi M, Fabbri F, Sozzi F, Dell'Acqua V, et al.
J Endourol. 2017 Sep; 31(9):878-885. Epub 2017 Jul 31.

3) A Randomized Study of Intraoperative Autologous Retropubic Urethral Sling on Urinary Control after Robotic Assisted Radical Prostatectomy.
Nguyen HG, Punnen S, Cowan JE, Leapman M, Cary C, Welty C, Weinberg V, Cooperberg MR, Meng MV, Greene KL, et al.
J Urol. 2017 Feb; 197(2):369-375. Epub 2016 Sep 28.

#145: Extracellular collagenic type and structural organization changes in prostate cancer and benign prostatic hyperplasia

Inviato da: matteo.zanoni@materdomini.it

G.. Taverna1, F. Grizzi2, M. Zanoni1, P. Vota1, M. Justich1, G. Toia1, G. Malagola1, A. Mandressi1, G. Guazzoni3
  • 1 Department of Urology, Humanitas Mater Domini (Castellanza)
  • 2 Department of Immunology and Inflammation, Humanitas Clinical and Research Center (Rozzano)
  • 3 Department of Urology, Humanitas Clinical and Research Center (Rozzano)

Objective

It is now ascertained that stromal-epithelial interactions play a crucial and poorly understood role in carcinogenesis and prostate cancer progression(1). Tumor stroma is a complex and dynamic set of cells that includes a fibroblastic component often referred to as cancer-associated fibroblasts and a collagenic and non-collagenic extracellular reactive matrix(2).

Materials and Methods

In the present study we investigate the collagenic extracellular reactive matrix in a series of prostate cancer biopsy specimens and benign prostatic hyperplasia (BPH) following transurethral resection of the prostate (TURP). Particularly the study focused on the type of collagen composition and its spatial organization. Sixty prostate specimens were investigated. Fifty specimens were diagnosed as prostate carcinoma and 15 as benign prostate hyperplasia. The samples were fixed in 10% formaldehyde and paraffin-embedded. Two-micrometer thick sections were cut and stained with Sirius red staining to distinguish type I and III collagen using a polarized light microscopy. The ratios of collagen I/III were automatically evaluated using a computer-aided image analysis system. The spatial organization was evaluated on unstained tissue sections by combining a multi-photon microscopy and an open-source MATLAB software framework that includes two separate but linked packages "CurveAlign" and "CT-FIRE". All of the data were analyzed using Statistica software (StatSoft, Inc., Tulsa, OK, USA) and GraphPad Prism 5 (San Diego, California, USA). P-values of ≤ 0.05 were considered to be statistically significant.

Results

By observing the stained sections with Picro-Sirius Red we found different conformations of the collagenic extracellular matrix. Collagen matrix is characterized by a set of highly irregular fragments with different size, size and roughness. In particular, the tumor microenvironment consists of thin collagen fibers while dense plaques have been observed in the microenvironment that characterizes BPH status. Additionally, we found that in BPH type III collagen is less represented if compared to the low and high-grade tumoral tissues. A statistically significant difference was identified between BPH and biopsies of patients with low-grade tumor and in whose fragment no neoplastic cells were observed (p&lt;0.001). In addition, the alignment of collagen fibers is much more pronounced in biopsy of prostate cancer patients than in tissues of patients with BPH. Collagen type (type I versus type III) composition and its spatial organization i.e. alignment is different when evaluated in tumoral versus inflammatory state.

Discussions

Collagen type (type I versus type III) composition and its spatial organization i.e. alignment is different when evaluated in tumoral versus inflammatory state.

Conclusion

Given the dynamical process of tissue matrix remodeling, our findings first demonstrated that stromal collagen alignment might provide additional, clinically relevant information about prostate cancer and underscores the importance of stroma-cancer interactions.

Reference

1) Lanni C, Bottone MG, Bardoni A, Dyne K, Soldani C, Pellicciari C, Caporali R, Montecucco C.
Proliferation characteristics and polyploidization of cultured myofibroblasts from a patient with fibroblastic rheumatism.
Eur J Histochem. 2003;47(3):257-62

2)Vieira CP, Viola M, Carneiro GD, D&#039;Angelo ML, Vicente CP, Passi A, Pimentel ER.
Glycine improves the remodeling process of tenocytes in vitro.
Cell Biol Int. 2018 Jul;42(7):804-814. doi: 10.1002/cbin.10937

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