Improving pre-operative planning of robot assisted nephron sparing surgery using three-dimensional anatomical model

Introduction Despite the introduction of robot-assisted surgery in daily clinical practice, complex renal masses are still challenging even for expert surgeon. In this scenario 3D anatomical models and augmented reality represent valuable tools for the surgeon. Materials and methods We present a challenging case where PN was mandatory to preserve the overall renal function. The patient was 69 years old, with indwelling catheter for BPH and Parkinson disease. After a single episode of hematuria with negative cystoscopy, a cT1N0M0 renal cancer was diagnosed (38 mm maximum diameter). Pre-operative three-dimensional (3D) model was obtained. After multidisciplinary discussion robot-assisted partial nephrectomy was proposed. The surgery was planned according to the anatomical model. Results Before the procedure a 7Ch single loop ureteral stent was placed. The surgery was carried out in 220 minutes. Selective ischaemia was perfomed for 24 minutes. Estimated blood loss was 400cc. No post-operative complications were observed. Ureteral stent was removed 4 days after the surgery. Definitive histological examination described a pG2-3 T1a Nx R0 clear cell renal carcinoma. Conclusion In selected cases 3D model result to be a useful tool for the pre-operative planning of the surgery

Segmental ureterectomy vs. radical nephroureterectomy for ureteral carcinoma in patients with a preoperative glomerular filtration rate less than 90 ml/min/1.73 m2: A multicenter study

Objectives: To compare segmental ureterectomy (SU) and radical nephroureterectomy (RNU) in terms of overall survival (OS) and impact on postoperative renal function in patients treated for upper tract urothelial carcinoma (UTUC) of the ureter with preoperatively reduced estimated glomerular filtration rate (eGFR). Materials and methods: We retrospectively collected the data of consecutive patients treated for UTUC, in 6 Italian tertiary referral centers, from 2003 to 2013, and analyzed those treated with RNU or SU for ureteral cancer and with a preoperative eGFR <90 ml/min/1.73m2. The primary outcome was to compare the postoperative eGFR variation and the OS according to the surgical technique chosen. Results: Out of 521 patients with UTUC, 228 patients had preoperative reduced eGFR. Out of these patients, 93 had ureteral cancer and were included in the primary analyses \u2013 67 (72.0%) treated with RNU and 26 (28.0%) with SU. Preoperative characteristics were similar in the 2 groups. The overall median follow-up period was 26.5 months. A nonsignificant postoperative eGFR decrease of 3.0 ml/min/1.73m2 was found overall (P = 0.094), with nonsignificant difference between the 2 groups (P = 0.735). A comparable 5-year OS was calculated for RNU and SU patients (P = 0.99). Conclusions: The type of surgery (SU vs. RNU) has a low impact on postoperative renal function and OS in patients with ureteral cancer and preoperative eGFR <90 ml/min/1.73m2. The indications for kidney sparing surgery for UTUC should be based on the surgical and oncological risks in these patients

Two-Stage Transperineal Management of Posterior Urethral Strictures or Bladder Neck Contractures Associated with Urinary Incontinence after Prostate Surgery and Endoscopic Treatment Failures

Objectives: The treatment of posterior urethral strictures or bladder neck contracture associated with severe urinary incontinence after prostate surgery and failure of endoscopic treatments is controversial. We report our experience with a transperineal approach in two steps: end-to-end urethroplasty/anastomosis and subsequent artificial urinary sphincter implantation.Methods: Between September 2001 and January 2005, we observed six patients (58-68 yr old), with a combination of severe urinary incontinence and posterior urethral stricture with anastomotic bladder neck contracture after prostate surgery. In all cases, repeated endoscopic treatments of the strictures failed. The patients underwent transperineal end-to-end urethroplasty or anastomosis followed by transperineal artificial urinary sphincter placement after 6 mo.Results: After the first surgical step, all patients were completely incontinent with absence of urethral strictures and complete anastomotic healing in all cases. Therefore, all patients underwent artificial urinary sphincter insertion. After a mean follow-up of 38 mo (range: 18-57 mo), five patients are continent with no postvoid residual urine and a perfectly functioning device, one artificial urinary sphincter was removed due to urethral erosion.Conclusions: In patients with posterior urethral strictures or bladder neck contractures associated with severe urinary incontinence, an artificial urinary sphincter implantation as a second step allows verification of the outcome of a previous end-to-end urethroplasty or anastomosis and utilizes a dedicated operative field to reduce the risks of prosthesis implants. (c) 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved

EGFr and c-erB2mRNA expression in urinary bladder superficial carcinomas.

AIM: The biological behaviour of superficial type transitional carcinomas of the urinary bladder can not be predicted. To try to differentiate those tumors that will present aggressive behaviour with infiltrative recurrences from those that will not, we studied, at the mRNA level, the expression of two membrane proteins, EGFr and c-erbB2, and of k-ras oncogene. METHODS: The mRNAs relative quantitation as performed, after RT-PCR, from histological sections cut from formalin-fixed and paraffin-embedded tissues. Twenty-three patients with urinary bladder transitional carcinoma have been studied for EGF-receptor, c-erbB2 and k-ras oncogene. The expression has been correlated with the outcomes of the follow-up period (infiltrative or superficial recurrences). RESULTS: The mRNA or EGFr was in average more expressed in tumors that continue to be superficial in the relapses, but for c-erbB2 the level of mRNA was similar in both, the more and less aggressive groups. The expression of k-ras was higher in cases associated with more infiltrative tumor relapses. CONCLUSIONS: In this preliminary study we did not identify any specific marker that can clearly predict the prognosis of superficial type transitional carcinoma of the urinary bladder; only k-ras expression is connected in some cases with the aggressiveness of the tumors. The expression of EGFr gave us intriguing results, it is in fact higher in the superficial carcinomas that do not tend to become infiltrative of the urinary bladder wall

Two-stage transperineal management of posterior urethral strictures or bladder neck contractures associated with urinary incontinence after prostate surgery and endoscopic treatment failures

Abstract OBJECTIVES: The treatment of posterior urethral strictures or bladder neck contracture associated with severe urinary incontinence after prostate surgery and failure of endoscopic treatments is controversial. We report our experience with a transperineal approach in two steps: end-to-end urethroplasty/anastomosis and subsequent artificial urinary sphincter implantation. METHODS: Between September 2001 and January 2005, we observed six patients (58-68 yr old), with a combination of severe urinary incontinence and posterior urethral stricture with anastomotic bladder neck contracture after prostate surgery. In all cases, repeated endoscopic treatments of the strictures failed. The patients underwent transperineal end-to-end urethroplasty or anastomosis followed by transperineal artificial urinary sphincter placement after 6 mo. RESULTS: After the first surgical step, all patients were completely incontinent with absence of urethral strictures and complete anastomotic healing in all cases. Therefore, all patients underwent artificial urinary sphincter insertion. After a mean follow-up of 38 mo (range: 18-57 mo), five patients are continent with no postvoid residual urine and a perfectly functioning device. One artificial urinary sphincter was removed due to urethral erosion. CONCLUSIONS: In patients with posterior urethral strictures or bladder neck contractures associated with severe urinary incontinence, an artificial urinary sphincter implantation as a second step allows verification of the outcome of a previous end-to-end urethroplasty or anastomosis and utilizes a dedicated operative field to reduce the risks of prosthesis implants

Comparison of open and laparoscopic pyeloplasty in ureteropelvic junction obstruction surgery: report of 49 cases.

This study aimed to evaluate laparoscopic dismembered pyeloplasty compared with open surgery and to determine whether the morbidity and outcome rates are different in each of these techniques. We report our 10-year experience with open and laparoscopic pyeloplasty at one istitution.From February 1999 to October 2010, 49 patients with ureteropelvic junction obstruction were assigned into two groups. 25 patients underwent open surgical pyeloplasty (period 1999-2010) and 24 underwent laparoscopic pyeloplasty (period 2004-2010). 25 patients undergoing open pyeloplasty had a retroperitoneal flank approach. Of the 24 laparoscopic cases 18 had a transperitoneal retrocolic access, 1 had a transperitoneal transmesocolic access and 5 had a retroperitoneal access. In all 49 cases an Anderson-Hynes dismembered pyeloplasty was used. We retrospectively compared the operative time, hospital stay, perioperative complications and follow-up of the two groups. Clinical symptoms were assessed before and after surgery, subjectively.Patients dermographic data were similar between the two groups with mean age of 42 years (range 6-78) and with a male/female ratio of 1:1.45. A crossing vessel could be identified in 37.5\% (9/24) with laparoscopy vs. 32\% (8/25) in open surgery. Compared with open procedures, laparoscopic procedures were associated with a longer mean operating time (274 vs 143 min), a shorter mean hospital stay (9.9 vs 15.8 day) and the perioperative complication rates were 16.7\% for laparoscopic pyeloplasties and 20\% for open pyeloplasties. The success rates were 90.5\% for laparoscopy and 90.9\% for open surgery. Average follow-up was 40.9 month for the laparoscopic group and 72.3 month for the open group. Failed procedures showed no improvement in loin pain or obstruction.The efficacy (in term of success rate and perioperative complications) of laparoscopic pyeloplasty is comparable to that of open pyeloplasty, with shorter mean hospital stay and better cosmetic results. These findings may suggest, that the laparoscopic dismembered pyeloplasty has the potential to replace open surgery and may be considered the first option for the treatment of ureteropelvic junction obstruction in expert hands

Infrequent application of intraoperative ultrasonography in urology.

Among the usual indications of intraoperative ultrasounds, we describe four infrequent applications that show how useful and powerful this technique could be for interventive urologists. The first case regards a 66 years old male who was affected by a renal metastasis from thoracic cage chondrosarcoma. The use of intraoperative ultrasounds permits to highlight atypical sonographic features of the secondary lesion that were not seen in preoperative radiologic exams and that are completely different from the usual renal lesions. The second case regards the treatment of prostatic abscess performed by echoguided transperineal puncture in which the use of transrectal ultrasound probe permits a precise and correct placement of the needle and the drainage in order to obtain a fast relief of the symptomatology. The third case shows the role of intraoperative ultrasounds in the localization of a parathyroid adenoma in a 52 years old male affected by primary hyperparathyroidism and with recurrent renal colics. In this case the blind surgical exploration of the parathyroid gland and so the possibility of iatrogenic lesions to the recurrent laryngeal nerve were avoided by the use of the intraoperative sonography for the identification of the adenoma. At the same time the operation times were reduced. The last case underlines the importance of using intraoperative ultrasounds in the real-time monitoring for the creation of the neovagina in sex reassignment surgery in male-to-female transexualism in order to avoid a dangerous postoperative complication represented by the iatrogenic lesion of the rectum during the dissection of the perineal region