Manometric evaluation of internal anal sphincter after fissurectomy and anoplasty for chronic anal fissure: a prospective study

Chronic anal fissure (CAF) is a common painful clinical disease and its pathogenesis remains poorly understood. After failure of pharmacological therapy, that is the first-line treatment, sur- gical sphincterotomy remains the treatment of choice although it is followed by a high rate of anal incontinence resulting from the sphincter damage; therefore, the research of a sphincter-saving surgical option has become an important goal. The aim of this study was to evaluate the mano- metric modifications and the incidence of anal incontinence after fissurectomy and anoplasty with advancement skin flap in patients affected by CAF with hypertonia of the internal anal sphincter (IAS). Fifteen patients affected by CAF with hypertonia of IAS, unresponsive to medical therapy, were enrolled. All subjects underwent fissurectomy and anoplasty with advancement skin flap. Anorectal manometry was performed preoperatively and after 6 and 12 months from surgery. Maximum resting pressure (MRP), maximum squeeze pressure (MSP), ultraslow wave activity (USWA), fissure healing, anal continence, and postoperative complications were recorded. All patients healed within 30 days from surgery. No intra- or postoperative complications were recorded except for a case of partial donor site break. No significant modifications of MSP were detected. Six months after surgery, MRP was higher with respect to healthy subjects but signif- icantly reduced in comparison to baseline levels. At 12 months, it was higher have versus 6-month values but significantly lower versus preoperative values. USWA was significantly represented in patients with CAF versus healthy subject. Both at 6 and 12 months, they decreased significantly with respect to preoperative values without significant differences versus healthy subjects. Both at 6 and 12 months, anal continence did not differ with respect to preoperative time. The fissurectomy with anoplasty resulted in a high healing rate without surgical sequelae or anal incontinence. Also, it was able to reduce IAS pressure in the same manner as surgical sphincterotomy or forceful dilatation

Bilateral spermatic cord en bloc ligation by laparoendoscopic single-site surgery: preliminary experience compared to conventional laparoscopy

BACKGROUND: Laparo Endoscopic Single-site Surgery (LESS) represents an evolution of minimally invasive surgery and aims to improve cosmetic outcome and reduce surgical trauma and complications associated with traditional laparoscopy. This study was performed to present our preliminary experience in bilateral spermatic cord ligation with the LESS technique and compare the results with the outcomes of conventional laparoscopic surgery. METHODS: Between June 2007 and May 2013, 24 patients were referred to our institute for bilateral varicocelectomy. The indications for this type of procedure were bilateral varicocele with impairment of semen parameters or chronic bilateral testicular pain. All procedures were performed via the same surgeon. The patients were divided into two groups according to the type of laparoscopic surgery. Group A included 10 patients underwent LESS technique while group B included the remaining 14 patients that underwent conventional laparoscopy. RESULTS: The comparison between the two techniques showed some important advantages for LESS: shorter operating time (45.4 min vs. 88.3 (P\u2009<\u2009.001), shorter hospital stay (16.6 hours vs. 51.4 hours) (P\u2009<\u2009.001), early return to the normal activity (2.3 days vs. 4.7 days) and better cosmetic outcomes. No conversions from LESS to conventional laparoscopy were necessary and blood loss was insignificant in all patients.All patients in the LESS group reported full satisfaction with the cosmetic outcome, whereas 85.7% of patients after conventional laparoscopy were fully satisfied with cosmesis. CONCLUSIONS: Bilateral spermatic cord ligation with LESS is an alternative to conventional laparoscopy. The procedure was successfully performed in all patients. The trans-umbilical approach offers the advantage of a better cosmetic result, shorter hospital stay and less postoperative pain

Double localization and multiple recurrences of dermatofibrosarcoma protuberans of the female breast: A rare clinical case

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Chronic, nonspecific, postinfectious, retroperitoneal fibrosis and ureteral obstruction

ABSTRACT Introduction: Two cases of severe ureteral obstruction following nonspecific, postinfectious, chronic retroperitoneal fibrosis are described, which both originated by a primitive intestinal pathology. Patients: This complication was observed in two women: first, 65 years old, submitted for ulcerative colitis to a total proctocolectomy, with ileo-pouch-anal anastomosis, complicated by an anastomotic fistula; and second, 66 years old, operated with an extended left hemicolectomy, for an adenocarcinoma of the recto-sigmoid colon complicated with a vaginal fistula. In these cases, computerized tomography demonstrated a unilateral hydronephrosis, secondary to a complete obstruction of the ureter; a subsequent nephro-ureterectomy became necessary. Histology demonstrated nonspecific inflammatory lesions. Discussions: Postinfectious, chronic inflammation of the retroperitoneum acts on the ureteral and peri-ureteral tissues, inducing an inflammatory and then a fibrotic process. Conclusions: We underline the opportunity of a precocious and radical treatment of every retroperitoneal infection. Keywords: Intestinal fistula, Retroperitoneal fibrosis, Retroperitoneal infection, Ureteral obstructionINTRODUCTION: Two cases of severe ureteral obstruction following nonspecific, postinfectious, chronic retroperitoneal fibrosis are described, which both originated by a primitive intestinal pathology. PATIENTS: This complication was observed in two women: first, 65 years old, submitted for ulcerative colitis to a total proctocolectomy, with ileo-pouch-anal anastomosis, complicated by an anastomotic fistula; and second, 66 years old, operated with an extended left hemicolectomy, for an adenocarcinoma of the recto-sigmoid colon complicated with a vaginal fistula. In these cases, computerized tomography demonstrated a unilateral hydronephrosis, secondary to a complete obstruction of the ureter; a subsequent nephro-ureterectomy became necessary. Histology demonstrated nonspecific inflammatory lesions. DISCUSSIONS: Postinfectious, chronic inflammation of the retroperitoneum acts on the ureteral and peri-ureteral tissues, inducing an inflammatory and then a fibrotic process. CONCLUSIONS: We underline the opportunity of a precocious and radical treatment of every retroperitoneal infection

Robot-Assisted Kidney Transplantation

Robot-assisted kidney transplantation (RAKT) has recently been introduced to reduce the morbidity of open kidney transplantation (KT). Robot-assisted surgery has been able to overcome many of the limitations of classical laparoscopy, certainly in complex and technically demanding procedures, such as vascular and ureteral anastomosis. Since the first RAKT in 2010, this technique has been standardized and evaluated in highly experienced robot and KT centers around the world. In Europe, the European Association of Urology Robotic Urology Section (ERUS) created an RAKT working group in 2016 in order to prospectively follow the outcomes of RAKT. When performed by surgeons with both robotic and KT experience, RAKT has been proven to be safe and reproducible in selected cases and yield excellent graft function with a low complication rate. Multiple institutions have now adopted RAKT, and its use will likely increase in the near future. However, structured training and proctoring will be mandatory for those embarking on RAKT in order to help them negotiate the learning curve and avoid technical mistakes. This chapter will describe RAKT from living and deceased donors and its application in kidney autotransplantation (KAT)

Advancement flap in the management of chronic anal fissure: A prospective study

Lateral internal sphincterotomy is the surgical treatment of choice of chronic anal fissure after failure of conservative measures. Several randomized trials identified an overall risk of incontinence of 10 % mostly for flatus. Fissurectomy is the most commonly used procedure to preserve the integrity of the anal sphincters. However, a possible complication is keyhole defect that may lead to faecal soiling. In this study, chronic anal fissure (CAF) was treated by fissurectomy and anal advancement flap to preserve the anatomo-functional integrity of sphincters and to reduce healing time and the risk of anal stenosis. In patients with hypertonia, surgical treatment was combined with chemical sphincterotomy by injection of botulinum toxin to enhance tissue perfusion. Forty eight patients with CAF underwent fissurectomy and anal advancement flap. In 22 subjects with hypertonia of the internal anal sphincter, intrasphincter injection of 30 UI of botulinum toxin at the completion of the surgical operation was used. All patients were followed up to 24 months. Since the first defecation, the intensity and duration of pain were significantly reduced. Two patients had urinary retention, five had infections and three had partial breakdowns. No anal stenosis, keyhole deformity or necrosis flap was recorded. At the 24 months follow-up visit, anal incontinence was similar to those detected preoperatively. Only four recurrences were detected at 18 and 20 months. After medical treatment failure, fissurectomy with advancement flap is a valid sphincter-conserving procedure for treatment of anterior or posterior CAF, regardless of hypertonia of the internal anal sphincter. © 2011 Springer-Verlag

Sodium iodide symporter (NIS) in extrathyroidal malignancies: Focus on breast and urological cancer

BACKGROUND: Expression and function of sodium iodide symporter (NIS) is requisite for efficient iodide transport in thyrocytes, and its presence in cancer cells allows the use of radioiodine as a diagnostic and therapeutic tool in thyroid neoplasia. Discovery of NIS expression in extrathyroidal tissues, including transformed cells, has opened a novel field of research regarding NIS-expressing extrathyroidal neoplasia. Indeed, expression of NIS may be used as a biomarker for diagnostic, prognostic, and therapeutic purposes. Moreover, stimulation of endogenous NIS expression may permit the radioiodine treatment of extrathyroidal lesions by concentrating this radioisotope. RESULTS: This review describes recent findings in NIS research in extrathyroidal malignancies, focusing on breast and urological cancer, emphasizing the most relevant developments that may have clinical impact. CONCLUSIONS: Given the recent progress in the study of NIS regulation as molecular basis for new therapeutic approaches in extrathyroidal cancers, particular attention is given to studies regarding the relationship between NIS and clinical-pathological aspects of the tumors and the regulation of NIS expression in the experimental models

Effect of green tea catechins in patients with high-grade prostatic intraepithelial neoplasia: Results of a short-term double-blind placebo controlled phase II clinical trial

Background and study objective: Several studies suggest a protective role of green tea catechins against prostate cancer (PCa). In order to evaluate the efficacy of green tea catechins for chemoprevention of PCa in patients with high-grade prostate intraepithelial neoplasia (HG-PIN) we performed a phase II clinical trial. Methods: Sixty volunteers with HG-PIN were enrolled to carry out a double-blind randomized placebo-controlled phase II clinical trial. Treated group took daily 600 mg of green tea catechins (Categ Plus®) for 1 year. Patients were screened at 6 and 12 months through prostatic biopsy and measurements of prostate-specific antigen (PSA). Results: Despite the statistically significant reduction of PSA observed in subjects who received green tea catechins for 6 and 12 months, we did not find any statistical difference in PCa incidence between the experimental groups neither after 6 nor after 12 months. However, throughout the one-year follow-up we observed very limited adverse effects induced by green tea catechins and a not significant improvement in lower urinary tract symptoms and quality of life. Conclusions: Although the small number of patients enrolled in our study and the relatively short duration of intervention, our findings seems to deny the efficacy of green tea catechins. However, results of our clinical study, mainly for its low statistical strength, suggest that the effectiveness of green tea catechins should be evaluated in both a larger cohort of men and longer trial

Robot-assisted kidney transplantation with regional hypothermia using grafts with Multiple Vessels After Extracorporeal Vascular Reconstruction: results from the European Association of Urology Robotic Urology Section Working Group

Background: Kidney transplantation using grafts with multiple vessels (GMVs) is technically demanding and may be associated with increased risk of complications or suboptimal graft function. To date, no studies have reported on robot-assisted kidney transplantation (RAKT) using GMVs. Objective: To report our experience with RAKT using GMVs from living donors, focusing on technical feasibility and early postoperative outcomes. Design, setting, and participants: We reviewed the multi-institutional, prospectively collected European Association of Urology (EAU) Robotic Urology Section (ERUS)-RAKT database to select consecutive patients undergoing RAKT from living donors using GMVs between July 2015 and January 2018. Patients undergoing RAKT using grafts with single vessels (GSVs) served as controls. In case of GMVs, ex vivo vascular reconstruction techniques were performed during bench surgery according to the case-specific anatomy. Intervention: RAKT with regional hypothermia. Outcome measurements and statistical analysis: Intraoperative outcomes and early (30 d) postoperative complications and functional results were the main study endpoints. Multivariable logistic regression analysis evaluated potential predictors of suboptimal renal function at 1 mo. Results and limitations: Overall, 148 RAKTs were performed during the study period. Of these, 21/148 (14.2%) used GMVs; in all cases, single arterial and venous anastomoses could be performed after vascular reconstruction. Median anastomoses and rewarming times did not differ significantly between the GMV and GSV groups. Total and cold ischemia times were significantly higher in the GMV cohort (112 vs 88 min, p = 0.004 and 50 vs 34 min, p = 0.003, respectively). Overall complication rate and early functional outcomes were similar among the two groups. No major intra-or postoperative complications were recorded in the GMV cohort. At multivariable analysis, use of GMVs was not significantly associated with suboptimal renal function at 1 mo. Small sample size and short follow-up represent the main study limitations. Conclusions: RAKT using GMVs from living donors is technically feasible and achieved favorable perioperative and short-term functional outcomes. Larger studies with longer follow-up are needed to confirm our findings. Patient summary: In this study, we evaluated for the first time in literature the results of RAKT from living donors using kidneys with multiple arteries and veins. We found that, in experienced centers, RAKT using kidneys with multiple vessels is feasible and achieves optimal results in terms of postoperative kidney function with a low number of postoperative complications. (C) 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved

Small renal masses in kidney transplantation : Overview of clinical impact and management in donors and recipients

Kidney transplantation is the best replacement treatment for the end-stage renal disease. Currently, the imbalance between the number of patients on a transplant list and the number of organs available constitutes the crucial limitation of this approach. To expand the pool of organs amenable for transplantation, kidneys coming from older patients have been employed; however, the combination of these organs in conjunction with the chronic use of immunosuppressive therapy increases the risk of incidence of graft small renal tumors. This narrative review aims to provide the state of the art on the clinical impact and management of incidentally diagnosed small renal tumors in either donors or recipients. According to the most updated evidence, the use of grafts with a small renal mass, after bench table tumor excision, may be considered a safe option for high-risk patients in hemodialysis. On the other hand, an early small renal mass finding on periodic ultrasound-evaluation in the graft should allow to perform a conservative treatment in order to preserve renal function. Finally, in case of a renal tumor in native kidney, a radical nephrectomy is usually recommended