A rare complication of ureteral stenting: Case report of a uretero-arterial fistula and revision of the literature

Introduction: Uretero-arterial fistulas are a rare condition. The most frequent clinical sign is hematuria. Since these bleedings occur intermittently, the diagnosis is very difficult. If not discovered, uretero-arterial fistulas involve a very high rate of mortality or even results in loss of kidney function. Case report: The clinical case we describe is an unusual one. After a radical hysterectomy and a subsequent radiotherapy, a hydronephrosis caused by ureteral fibrosis occurred on both sides. Therefore, the patient received bilateral ureteral stents. During a change of the ureteral stents 18 months later, a massive bleeding appeared in the right ureter. Initially, a clear evidence of a fistula was not possible - neither through CT scan nor through selective angiography. There were some indicators of a uretero-arterial fistula, so an endoluminal vessel stent was placed. Subsequently the fistula probably led to an erosion of the vessel stent. Discussion: A fistula between the ureter and the iliac artery (UAF) is a rare complication. The increase in known cases during the last years is linked to the possibility of ureteral stenting since 1978. Until now only 140 cases have been described in literature. The mortality rate through UAF has decreased from 69% in 1980 to 7-23% today. Its development can be traced through the pulsation of the artery and the pressure on the ureter. The most important clinical symptom is bleeding. Diagnosis is generally difficult and represents the real problem. The sensitivity of the standard angiography examination is 23- 41%; it can be improved to 63% using the “provocative” method, which means mobilizing the ureteral stent during examination. The therapy in course of the angiography consists of a simultaneous endovascular stent and/or a co-embolisation. Conclusion: Arterial or uretero-arterial fistulas (UAF) are a rare condition; the diagnosis is very difficult and most of the time the treatment requires a multidisciplinary team

An unusual case of pneumatic nail gun scrotal injury and revision of the literature

Pneumatic nail guns are hand-held tools commonly utilized in both industrial and non occupational setting. These devices facilitate production and boost efficiency but also can be a potential cause of serious injuries. Nail guns are the most frequent tool associated trauma with hospitalization among construction workers. The most common sites of injuries are the hand or fingers followed by the lower extremities. We report the first case in literature of a work nail gun injury to male external genitalia

Acute Ischemia of the Glans Penis after Circumcision Treated with Hyperbaric Therapy and Pentoxifylline: Case Report and Revision of the Literature

Acute severe ischemia of glans penis after circumcision is a very rare event and, if not treated, can lead to irreversible necrosis with severe consequences such as loss of part of the penis. The possible causes for this condition could be blood-vessel binding or cauterization, dorsal penile nerve block (DPNB), local anesthesia with vasoconstricting agents and wound dressing compression. The aim of the treatment is to provide good blood supply and thus, oxygen delivery to the ischemic penis. The therapeutic options include hyperbaric therapy (HBOT), pentoxifylline (PTX), enoxaparina, iloprost, antiplatelet, corticosteroids and peridural anesthesia. We report the case of a 24-year-old male who developed an acute severe glans penis ischemia after circumcision done under DPNB. The patient was successfully treated with HBOT in combination with PTX

Phytotherapy Might Have a Role in Reducing Unnecessary Prostate Biopsies: Results from an Exploratory, Randomized Controlled Trial of Two Different Phytotherapeutic Agents

Background: We aimed to evaluate the impact of two different phytotherapeutic agents on decision making regarding prostate biopsy for patients with higher-than-normal prostate-specific antigen (PSA) levels. Methods: From June 2022 to May 2023, all patients attending two urological institutions due to higher-than-normal PSA levels were randomized to receive either oral capsules of Curcuma Longa, Boswellia, Pinus pinaster and Urtica dioica (Group A) or Serenoa Repens 320 mg (Group B) for 3 months. At the follow-up visit after 3 months, all patients underwent PSA tests and multiparametric magnetic resonance imaging (mpMRI). Results: In the per-protocol analysis, data from 66 patients in Group A and 76 in Group B were analyzed. Fifty patients in Group A (75.7%) showed a significant reduction in total PSA compared to forty-nine in Group B (64.4%) (p p p p < 0.001). Conclusions: In conclusion, a three-month course of a combination of Curcuma Longa, Boswellia, Pinus pinaster and Urtica dioica seems to be an interesting tool to avoid unnecessary prostate biopsies among men with higher-than-normal PSA levels

INTRODUCTION OF A TAILORED ENHANCED RECOVERY PROTOCOL TO REDUCE SHORT-TERM COMPLICATIONS FOLLOWING RADICAL CYSTECTOMY AND INTESTINAL URINARY DIVERSION WITH VESCICA ILEALE PADOVANA (VIP) NEOBLADDER

INTRODUCTION AND AIM OF THE STUDY Different fast track programs for patients undergoing radical cystectomy (RC) can be found in the current literature. The aim of this article was to develop a new enhanced recovery protocol (ERP) throughout an exhaustive literature search, and to plan a pilot study to test the ERP on a small cohort of patients undergoing RC and intestinal urinary diversion for bladder cancer with the vescica ileale Padovana (VIP) neobladder. MATERIALS AND METHODS The ERP was designed after a structured literature review carried out from 1966 to December 2010 using MEDLINE via PubMed. The MEDLINE was performed including and combining the following terms, including both \u2018\u2018MeSH\u2019\u2019 (Medical Subject Heading) and \u2018\u2018free text\u2019\u2019 protocols: \u201cfast track\u201d, \u201ccystectomy\u201d and \u201cenhanced recovery\u201d. In order to test the ERP a pilot observational prospective cohort study was planned, involving all patients consecutively undergoing RC and VIP neobladder from December 2010 to June 2011 at our Urologic Unit. RESULTS The literature search rendered a total of 712 articles related to fast-track surgery, 10655 to enhanced recovery, and 8805 to cystectomy. Combining the search strings we retrieved only 2 cohort studies, and a German review article, used to develop our VIP-neobladder tailored ERP, showed in Table 1. Nine consecutive patients met inclusion criteria and participated in the pilot study. No patients died due to surgical complications. Overall 2 of 9 patients experienced complications (22.2%), none requiring surgical intervention. According to Clavien grading, complications were both grade 2. INTERPRETATION OF RESULTS We applied our enhanced recovery program to radical cystectomy and intestinal urinary diversion with vescica ileale Padovana (VIP) neobladder, assessing the results in terms of feasibility and effectiveness, but our pilot study is underpowered and unsuitable to identify predictors of any grade complications. The main problem during the application of our protocol has been the strict adherence to it by all the professional figures involved. In order to assess possible preoperative prognostic factors for the success of a ERP and to corroborate our positive preliminary results larger and specific case series and randomised controlled trials are needed. CONCLUSIONS The introduction of our ERP has been proven to be feasible and effective in the management of patients undergoing RC and intestinal urinary diversion with VIP neobladder. The quality of the postoperative course was enhanced by the absence of the nasogastric tube, the control of nausea and vomiting and early postoperative feeding. Postoperative pain relief was managed with well results, making possible an early mobilization. All these findings led to a more rapid recovery of the bowel function without the occurrence of significant complications.Our protocol was well tolerated. Table 1. Perioperative ERP. Pre-operative phase \u2013 day before RC - Hospital admission - Normal breakfast - Unrestricted clear fluids, refer to dietician for a <1500 calorie diet - Bowel preparation: enema (240 mL) at 8:00 p.m. - Antithrombotic prophylaxis with molecular weight heparin (LMWH) Pre-operative phase \u2013 day of RC - Clear fluids up to 2 h before RC, then nil by mouth - Nutritional drink (Nutricia-preOp. drink) two hours before sugery (400 mL/200 cal) - No anesthetic premedication - Elastic compressive stockings before surgery - Piperacillin/Tazobactam 4g/0.5g as prophylaxis for infection Intra-operative phase - Combined general and epidural anesthesia with an intrathecal catheter left in place to allow continuous infusion of analgesic drugs during the first postoperative days - Active prevention of hypothermia - Optimizing intra-operative intravenous fluid administration - Nasogastric tube (NGT) insertion preoperatively and removal at the end of surgery - Central venous catheter not inserted regularly - Minimizing intraoperative blood loss - Antiemetic prophylaxis with ondansetron 4mg and droperidol 1.25-2.5mg - Infiltration of the surgical wound with local anaesthetic Post-operative phase Day 1 - Female patients, remove vaginal pack - Mobilise and refer to physiotherapist - Respiratory rehabilitation exercises - 1100 calorie diet as toletated - Free clear liquids as tolerated (if not enough intravenous hydratation) - Analgesic therapy if needed (ropivacaine, paracetamol, ketorolac) - Metoclopramide regularly - Continue taking intravenous pantoprazole 40 mg - Continue taking antibiotics and LMWH as prophylaxis - Chewing gum (1 piece of gum every 2 to 4 hours) as tolerated Day 2 - 1500 calories diet as tolerated - Free clear fluids - Continue to mobilise (sitting position and deambulation) - Remove the first drain if draining <50 mL in 24 hours - Remove epidural catheter - Flush 30 mL into neobladder 6-hourly - Continue taking antibiotics as prophylaxis - Orally administration of pantoprazole 20 mg - Analgesia if needed (paracetamol, ketorolac) - Continue LMWH as prophylaxis - Metoclopramide regularly Day 3 - Continue to mobilise and encourage self care - Enema (120 mL twice per day) - Remove the second drain if draining <50 mL in 24 hours - 1650 calorie diet as tolerated - Analgesia if needed (paracetamol, ketorolac) - Metoclopramide regularly - Continue LMWH as prophylaxis - Continue pantoprazole - Flush 30 mL into neobladder 6-hourly Day 4 - Continue to mobilise and encourage self-care - 2000 calorie diet as tolerated - Analgesia if needed (paracetamol, ketorolac) - Continue LMWH as prophylaxis - Metoclopramide if needed - Continue flushing 30 mL into neobladder 6-hourly Day 5 to 7 - Free diet (dietician to eventually assess further nutritional requirements) - Start planning for discharge - Continue to mobilise and encourage self-care - If a patient is not eating or drinking after 5\u20136 days but with bowel activity, then start nasogastric feeding. If there is no bowel activity then start total parenteral nutrition. - Continue flushing 30 mL into neobladder 6-hourly Day 8 to 9 - Ureteral stents out (no stentogram) - Remove clips - Continue flushing 30 mL into neobladder 6-hourly Day 10 to 14 - Continue as previous - Cystograghy on day 13: if the cystogram finding is normal, remove the urethral catheter; patient to stay at least 24 h after stent removal - Schedule for return to hom

A new training model for robot-assisted urethrovesical anastomosis and posterior muscle-fascial reconstruction: the Verona training technique

A training model is usually needed to teach robotic surgical technique successfully. In this way, an ideal training model should mimic as much as possible the \u201cin vivo\u201d procedure and allow several consecutive surgical simulations. The goal of this study was to create a \u201cwet lab\u201d model suitable for RARP training programs, providing the simulation of the posterior fascial reconstruction. The second aim was to compare the original \u201cVenezuelan\u201d chicken model described by Sotelo to our training model. Our training model consists of performing an anastomosis, reproducing the surgical procedure in \u201cvivo\u201d as in RARP, between proventriculus and the proximal portion of the esophagus. A posterior fascial reconstruction simulating Rocco\u2019s stitch is performed between the tissues located under the posterior surface of the esophagus and the tissue represented by the serosa of the proventriculus. From 2014 to 2015, during 6 different full-immersion training courses, thirty-four surgeons performed the urethrovesical anastomosis using our model and the Sotelo\u2019s one. After the training period, each surgeon was asked to fill out a non-validated questionnaire to perform an evaluation of the differences between the two training models. Our model was judged the best model, in terms of similarity with urethral tissue and similarity with the anatomic unit urethra-pelvic wall. Our training model as reported by all trainees is easily reproducible and anatomically comparable with the urethrovesical anastomosis as performed during radical prostatectomy in humans. It is suitable for performing posterior fascial reconstruction reported by Rocco. In this context, our surgical training model could be routinely proposed in all robotic training courses to develop specific expertise in urethrovesical anastomosis with the reproducibility of the Rocco stitch

Chronic Inflammation in Prostate Biopsy Cores is an Independent Factor that Lowers the Risk of Prostate Cancer Detection and is Inversely Associated with the Number of Positive Cores in Patients Elected to a First Biopsy

bjectives: To investigate associations of chronic inflammatory infiltrate (CII) with prostate cancer (PCa) risk and the number of positive cores in patients elected to a first set of biopsies. Materials and Methods: Excluding criteria were as follows: active surveillance, prostate specific antigen (PSA) 65 30 ng/l, re-biopsies, incidental PCa, less than 14 cores, metastases, or 5-alpha reductase inhibitors. The cohort study was classified as negative (control group) and positive cores between 1 and 2 or > 2. Results: The cohort included 421 cases who did not meet the exclusion criteria. PCa was detected in 192 cases (45.6%) of which the number of positive cores was between 1 and 2 in 77 (40.1%) cases. The median PSA was 6.05 ng/ml (range 0.3-29 ng/ml). Linear regression models showed that CII was an independent predictor inversely associated with the risk of PCa. Multinomial logistic regression models showed that CII was an independent factor that was inversely associated with PCa risk in cases with positive cores between 1 and 2 (OR = 0.338; p = 0.004) or more than 2 (OR = 0.076; p < 0.0001) when compared to the control group. Conclusion: In a cohort of men undergoing the first biopsy set after prostate assessment, the presence of CII in the biopsy core was an independent factor inversely associated with PCa risk as well as with the number of positive biopsy cores (tumor extension). Clinically, the detection of CII in negative biopsy cores might reduce the risk of PCa in repeat biopsies as well as the probability of detecting multiple positive cores

Robotic bladder diverticulectomy: step-by-step extravesical posterior approach - technique and outcomes

Objective: The aim of this study was to evaluate the feasibility of robotic extravesical posterior surgical bladder diverticulectomy for treatment of symptomatic bladder diverticula (BD). Materials and methods: Data from patients with posterior BD who consecutively underwent robotic bladder diverticulectomy (RBD) from 2013 to 2016 in Azienda Ospedaliera Universitaria Integrata, Verona, were retrospectively reviewed. Baseline characteristics, perioperative outcomes including operative time (OT), estimated blood loss (EBL), postoperative transfusion rate and length of hospital stay (LOS), and early (30 days) and late (90 days) postoperative complications were recorded and analysed. Results: Six patients underwent RBD. Storage, voiding and postvoiding lower urinary tract symptoms (LUTS) were reported by 33.3%, 100% and 33.3% of patients, respectively. The median [interquartile range (IQR)] BD diameter was 7.1 (5.5\u20139.5) cm; median (IQR) preoperative postvoiding residual volume (PVR) was 300 (90\u2013395) ml. The median (IQR) OT was 112.5 (83.7\u2013133.7) min and median (IQR) EBL was 25.8 (0\u201350) ml. The median (IQR) LOS was 7 (4.7\u20139.0) days. One patient (16.7%) reported early minor postoperative complication. No patient showed early or late major postoperative complications. At 2&nbsp;month follow-up, all patients underwent a lower abdomen ultrasound and minimal or no postoperative PVR was found. At 6&nbsp;month follow-up no LUTS were reported. Conclusions: RBD appears to be a safe treatment for posterior BD with excellent perioperative and functional outcomes. The three-dimensional visualization, greater magnification and wristed instrumentation with seven degrees of freedom allow precise dissection of BD and reconstruction of the bladder wall