Laparoscopic ablative techniques

Ablative techniques (AT) offer a combination of nephron-sparing and minimally invasive approaches. AT include different options and cryoablation (CA) and radiofrequency ablation (RFA) have been relatively safe and traditionally can be either performed laparoscopically or percutaneously. CA and RFA have emerged as a leading option for renal ablation, and compared with surgical techniques they offer benefits in preserving renal function with fewer complications, shorter hospitalization times, and allow for quicker convalescence. A mature dataset exists at this time, with intermediate and long-term follow up data available. Generally, laparoscopic access was the first technique used in the past, and typically for anterior and lateral mass. Afterwards, with the improvements in imaging and percutaneous techniques, laparoscopic approaches are progressively decreased and currently limited in few lesions and in relation with the surgeon’s and center’s experience. Nevertheless, laparoscopic CA and RFA could be useful techniques and currently, recommendations as a first-line therapy are made at this time in limited populations, including elderly patients, patients with multiple comorbidities, and those with imperative indications of a nephron sparing surgery. As more data emerge on oncologic efficacy, and technical experience continue to improve, the application of AT will likely be extended in future treatment guidelines and laparoscopic approaches will be a valid option in the era of tailored therapy

Saphenous-sparing laparoscopic inguinal lymphadenectomy

ABSTRACT Introduction: Inguinal lymphadenectomy is an integral part in the management of penile cancer. Video endoscopic inguinal lymphadenectomy (VEIL) is emerging as a minimally invasive treatment to reduce postoperative complications. Materials and Methods: 62 years old man underwent glansectomy for a squamous cell carcinoma (pT1b). At the physical examination one left inguinal lymph node was detectable (cN1). The chest-abdomen-pelvis CT was negative for metastasis. A 10-mm optical trocar and two 5mm operating trocar were placed. The optical trocar was placed in the apex of Scarpa's triangle after a skin incision and after the creation of a subcutaneous space by blunt finger dissection. The pCO2 was 8-10mmHg. The surgical technique involved the removal of superficial lymph nodes according to the scheme described by Deseler and of the deep lymph nodes. Sparing main venous structures and closing lymphatic vessels is important to reduce post operative complications. At the end of the procedure, a suction drain was placed per side. Results: Operative time was 90 minutes per side. Drains were removed on the seventh postoperative day. Hospital stay was 8 days and no postoperative complications occurred. The total number of nodes removed was 16 (8 per side) with 2 superficial positive nodes on the left side. Conclusion: ILND is burned by a high complication rate. VEIL provides a less invasive approach and a saphenous-sparing technique ensures a lower complication rate, reducing lymphorrhea, skin necrosis and wound complications (1–3). In experienced laparoscopic hands, VEIL is a safe and effective treatment

ProACT in the management of stress urinary incontinence after radical prostatectomy. What happens after 8 years of follow up? monocentric analysis in 42 patients

Objectives: Stress urinary incontinence is defined by a complaint of any involuntary loss of urine on effort or physical exertion or on sneezing or coughing and represents a major complication after radical prostatectomy. According to surgical technique, incidence of post-prostatectomy incontinence varies from open (7-39.5%), laparoscopic (5-33.3%) or robotic-assisted (4-31%) approaches. The ProACT® device (Uromedica, Inc., MN) is a possible surgical option for the treatment of this condition. Methods: We retrospectively analyzed surgical records of consecutive patients underwent ProACT® implantation in our department between January 2006 to November 2010. We collected data at 6 and 12 months after surgical approach about the daily pad use, International Prostatic Symptoms Score and its quality of life domain. Results: 42 patients were included in the final analysis. Most patients (92.9%) received minimally invasive surgery for treating prostate cancer. During the follow up after 6 and 12 months, the daily pad, International Prostatic Symptom Score and its quality of life domain significantly improved compared to preoperative outcomes. The logistic regression analysis found that presence of comorbidities was the only predictive factor of low satisfaction rate (PGE-I > 2) in patients who underwent ProACT® implant. Conclusions: ProACT® implant represents an effective and safe treatment for post-prostatectomy stress urinary incontinence with a high satisfaction degree and a low rate of complications

Renal angiomyolipoma with renal vein invasion

Renal angiomyolipoma is a uncommon benign tumor, considered an hamartoma. The lesion, usually benign, can be single or multiple and well-circumscribed. In letterature only few cases of infiltrating angiomyolipomas have been described. The aim of the paper is to describe a paradigmatic case of a giant kidney angiomyolipoma, not associ- ated with tuberous sclerosis, invading the pelvis and the renal vein. The lesion have been discovered incidentally during abdominal ultrasound for other pathology. Owing to the extent of the lesion and the appreciable risk of bleeding, we opted for surgical treatment

Fusion US/MRI prostate biopsy using a Computer Aided Diagnostic (CAD) system

BACKGROUND: To investigate the impact of Computer Aided Diagnostic (CAD) system on the detection rate of prostate cancer (PCa) in a series of fusion prostate biopsy (FPB).METHODS: Two prospective transperineal FPB series (with or without CAD assistance) were analyzed and PCa detection rates compared with per patient and per target analyses. Chi-Square and Mann-Whitney test were used to compare categorical and continuous variables, respectively. Univariable and multivariable regression analyses were applied to identify predictors of any and clinically-significant (cs) PCa detection. Subgroup analyses were performed after stratifying for PIRADS Score and lesion location.RESULTS: Out of 183 FPB, 89 were performed with CAD assistance. At per patient analysis the detection rate of any PCa and of cs PCa were 56.3% and 30.6%, respectively; the aid of CAD was negligible for either any PCa or csPCa detection rates (p=0.45 and p=0.99, respectively). Conversely in a per target analysis, CAD-assisted biopsy had significantly higher positive predictive value (PPV) for any PCa versus MRI-only group (58%vs37.8%, p=0.001). PI-RADS Score was the only independent predictor of any and csPCa, either in per patient or per target multivariable regression analysis (all p<0.029). In a subgroup per patient analysis of anterior/transitional zone lesions, csPCa detection rate was significantly higher in the CAD cohort (54.5%vs11.1%, respectively; p=0.028), and CAD assistance was the only predictor of csPCa detection (p=0.013).CONCLUSIONS: CAD assistance for FPB seems to improve detection of csPCa located in anterior/transitional zone. Enhanced identification and improved contouring of lesions may justify higher diagnostic performance

The microbiological profile of patients with Fournier's gangrene: A retrospective multi-institutional cohort study

Objectives: To evaluate the role of the microbiological profile and of disease-related factors in the management of patients affected with Fournier's gangrene (FG).Patients and methods: Data regarding patients admitted for FG at nine Italian Hospitals (March 2007-June 2018) were collected. Patients were stratified according to the number of microorganisms documented: Group A - one microorganism; Group B - two microorganisms; Group C - more than three microorganisms. Baseline blood tests, dedicated scoring systems, predisposing risk factors, disease's features, management and post-operative course were analyzed. UpSet technique for visualizing set intersections in a matrix layout and Cuzick's nonparametric test for trend across ordered groups were used.Results: Eighty-one patients were available for the analysis: 18 included in Group A, 32 in Group B, 31 in Group C. The most common microorganism isolated was Escherichia coli. In Group B-C, Escherichia coli was often associated to Enterococcus faecalis, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Statistically significant positive association was highlighted among the number of pathogens (Group A vs B vs C) and serum C-reactive Protein (p < 0.001), procalcitonin (p = 0.02) and creatinine (p = 0.03). Scoring systems were associated with the number of microorganisms detected (p < 0.02). A significant association between the number of microorganisms and the use of VAC therapy and need of a fecal diversion was found (p < 0.02). The number of microorganisms was positively associated with the length of stay (LOS) (p = 0.02). Ten weeks after initial debridement, wound closure was achieved in 11 (91.7%), 22 (84.6%) and 20 (80%) patients in Group A, B, and C, respectively, with no differences in overall survival.Conclusion: Polymicrobial infections in FG are positively associated with inflammatory scores, the need for fecal diversion and the LOS. This results may help the counseling and the clinical management of this rare niche of patients