P.L.E.A.T.-Preventing Lymphocele Ensuring Absorption Transperitoneally: A Robotic Technique

OBJECTIVE: To reduce the risk of symptomatic lymphocele after robotic pelvic lymph node dissection (PLND), we present a novel technique, preventing lymphocele ensuring absorption transperitoneally (P.L.E.A.T.), where the peritoneum is "pleated" along its midline, leaving 2 lateral openings and allowing lymphatic fluid to drain away from the pelvis and into the abdomen. MATERIALS AND METHODS: We analyzed a single-surgeon series of PLNDs during robotic radical prostatectomy, comparing 195 "standard" PLNDs (in which the peritoneum was "re-approximated" or left completely open) with 176 cases in which P.L.E.A.T. was performed. RESULTS: In the group without P.L.E.A.T., 8 cases of symptomatic (grade 653, according to the Clavien-Dindo Classification) lymphoceles (4.1%) were recorded. Only 1 patient in the P.L.E.A.T. group complained of symptoms because of a lymphocele (P\u2009=\u2009.039). No patient reported complications because of the procedure. CONCLUSION: The P.L.E.A.T. technique is a fast, easy-to-perform, and safe method of reducing the risk of symptomatic lymphocele after transperitoneal robotic PLND

Frailty and elderly in urology: Is there an impact on post-operative complications?

INTRODUCTION: Frailty used as predictive tool is still not carried out in daily practice, although many studies confirm the great clinical importance of the frailty syndrome in surgical outcomes. There is no standardized method of measuring the physiological reserves of older surgical patients. The aim of this study was to analyze a cohort of older urological patients according to various frailty indices, in order to evaluate whether they are predictors of post-operative complications after urological procedures. MATERIAL AND METHODS: This is a prospective observational study on 78 consecutive older ( 6570 years) patients, subjected to major urological (both endoscopic and 'open surgical') procedures. Frailty was defined according to the Edmonton Frail Scale. Several risk models and biochemical parameters were evaluated. Post-operative outcomes were surgical and medical complications, mortality and rehospitalisation within 3 months. RESULTS: An overall prevalence of frailty of 21.8% was found. Patients with complications were frailer than those without complications (univariate analysis), considering both total patients (p = 0.002) and endoscopic (p = 0.04) and 'open surgical' patients (p = 0.013). However, in multivariate analysis, a significant correlation was not found between all frailty indices tested and the risk of major complications. Limitation of the study: the small sample size (lack of statistical power), although this is a prospective study focused on older urological patients. CONCLUSIONS: New urology-tailored pre-operative assessment tools may prove beneficial when calculating the risks/benefits of urological procedures, so that objective data can guide surgical decision- making and patient counselling. Further large clinical studies specifically focusing on elderly in urology will be needed

Effect of Hypertension on Outcomes of High-Risk Patients After BCG-Treated Bladder Cancer

Immunotherapy with Bacillus Calmette Guerin (BCG) is the most efficacious treatment for high-risk bladder cancer (BC) (Ta/T1 or carcinoma in situ) to reduce the risk of recurrence. Our aim was to evaluate whether hypertension and diabetes influence the outcome of patients with noninvasive BC treated with BCG instillations. In order to collect homogeneous data, we considered as "hypertensive" only those patients who had previous diagnosed hypertension and a history of taking medical therapy with antihypertensive drugs (AHT), and as "diabetic" only those prescribed oral antidiabetics or insulin (ADT). We analyzed 343 high-risk BC patients undergoing BCG 1995 2010) with a median follow-up of 116 months (range 48-238). The distribution of various kinds of AHT and antidiabetic drugs was homogeneous, with no significant differences (p > 0.05). In both univariate and multivariate analyses, the only statistically significant parameter propostic for recurrence after BCG treatment was AHT. Recurrence-liee survival curves showed a significant correlation with AHT (p = 0.0168, hazards ratio [HR] 1.45, 95% confidence interval [CI] 1.0692-1.9619); there was no correlation ( p = 0.9040) with ADT (HR 0.9750, 95% CI 0.6457-1.4721). After stratification of AHT and A.DT according to drug(s) prescribed, there were no significant differences in the BC recurrence rate (p > 0.05). In this study with a very long-term follow-up, hypertension alone (evaluated by AHT) revealed the increased risk of BC recurrence after BCG treatment. Several hypotheses have been formulated to support these findings, but further prospective studies are needed to both evaluate the real influence of hypertension and identify a possible prognostic factor to be used in selecting poor-prognosis BC patients as early candidates for surgical treatment

Anesthesiologic effects of transperitoneal versus extraperitoneal approach during robot-assisted radical prostatectomy: results of a prospective randomized study

To compare the effects of CO(2) insufflation on hemodynamics and oxygen levels and on acid-base level during Robot-Assisted Radical Prostatectomy (RARP) with transperitoneal (TP) versus extra-peritoneal (EP) accesses

Spontaneous intra-adrenal massive hematoma: possible extreme evolution of a non-secreting untreated adrenal adenoma

The spontaneous adrenal hematoma is a rare event. An 83-year-old male patient presented a 26-cm asymptomatic retroperitoneal mass of doubtful renal-adrenal origin. He had been evaluated 10\ua0years before for an adrenal incidentaloma of 2.3\ua0cm and had refused surgery when it had reached 7\ua0cm. Later, the mass enlarged to 26\ua0cm and was surgically removed through an open anterior approach. The histopathology showed a solid 4\ua0kg mass of fibrinoid-hemorrhagic material, partially necrotic, mixed with adrenal tissue, with a well-vascularized capsule. No relapse is present at 6-month follow-up. This is the largest case described of spontaneous intra-adrenal hematoma in a case with previous non-secreting adrenal adenoma. The hematoma (a 4\ua0kg mass) developed 10\ua0years after the first diagnosis and exposed the patient to potential damage of the surrounding organs and to high-risk abdominal surgery. Long-term follow-up of non-secreting adrenal adenomas should be recommended

Il trattamento endourologico retrogrado della calcolosi cistinica multirecidivante: caso clinico paradigmatico

Presentiamo un caso clinico di calcolosi cistinica multirecidivante paradigmatico. Il paziente giungeva alla nostra osservazione dopo multipli trattamenti endourologici in altra sede con una situazione litiasica complessa: portatore di nefrostomie bilaterali e di stent ureterale destro venivano evidenziati calcoli multipli renali bilaterali e grosse calicificazioni ureterali, a destra a ridosso dello stent e a sinistra per un tratto di oltre 5 cm. Il trattamento endourologico retrogrado eseguito in più tempi, associato a una adeguata terapia medica per la cistinuria, ha portato a una bonifica completa. Riteniamo che il trattamento endourologico retrogrado rappresenti la modalità più adeguata per risolvere la calcolosi cistinica multirecidivante, al quale deve necessariamente essere associata la terapia farmacologica della cistinuria. Risulta altresi mandatario un trattamento in tempi brevi e una permanenza di eventuali endoprotesi ureterali per il tempo strettamente necessario, allo scopo di evitare calcificazioni degli stessi anche con formazioni litiasiche di ossalato di calcio. Ottenuta la bonifica, è consigliabile che anche i controlli vengano effettuati inizialmente secondo scadenze ravvicinate per poter risolvere eventuali recidive prima che raggiungano dimensioni tali da richiedere trattamenti più complessi

Peripheral primitive neuroectodermal tumor of seminal vesicles: is there a role for relatively aggressive treatment modalities?

A 50 year old white man received an incidental ultrasound diagnosis of hypoechoic mass interesting the right seminal vesicle. A CT scan showed the presence of a 7.8 cm roundish cyst, originating from the right seminal vesicle. He had been followed by the removal of the right seminal vesicle and both the cystic lesion. The histological findings of the specimen documented the presence of small round cells compatible with Ewing's sarcoma/PPNET. The patient received also adjuvant chemotherapy and radiation treatment. After 10 years, the follow-up is still negative

Robotic intracorporeal urinary diversion: practical review of current surgical techniques

In this practical review, we discuss current surgical techniques reported in the literature to perform Intracorporeal Urinary Diversion (ICUD) after Robotic Radical Cystectomy (RARC), emphasizing criticisms of single approaches and making comparisons with Extracorporeal Urinary Diversion (ECUD). Although almost 97% of all RARCs use an ECUD, ICUD is gaining in popularity, in view of its potential benefits (i.e., decreased bowel exposure, etc.), although there are a few studies comparing ICUD and ECUD. Analysing single experiences and the data from recent metanalyses, we emphasize the current critiques to ICUD, stressing particular technical details which could reduce operative time, lowering the postoperative complications rate, and improving functional outcomes. Only analysis of long-term follow-up data from large-scale homogeneous series can ascertain whether robotic intracorporeal urinary diversion is superior to other approaches

Renal colic, where is it headed? An observational study

Aim: In the last thirty years, the treatment for renal and ureteral calculi has undergone profound variations. The objective of this study has been to evaluate the existence of parameters which can affect the spontaneous expulsion of a symptomatic ureteral stone in a reasonably brief period of time and to identify whether certain parameters such as sex, age, the location and dimension of the stone, the presence of dilation in the urinary tract together with the administered therapy, can be used for a correct clinical management of the patient. Methods: In a period of 9 months, 486 cases of renal colic were registered at emergency department. Results: The cases of renal colic due to ureteral calculus were 188 (38.7%). The patients' charts, complete of all data and therefore, valid for this research, resulted to be 120 (64%). In the presence of a symptomatic ureteral stone, the correct approach must first of all, focalize on the dimension of the calculus itself; less importance instead, is given to the location, as reported in other studies, the presence of hydroureteronephrosis, sex and the side. Conclusion: In the cases when the pain symptoms cannot be solved by means of the administration of analgesics, it is then reasonable to take into consideration an immediate endourological treatment. If the pain symptoms are promptly solved, an attentive wait of 4 weeks should be considered reasonable in order to allow spontaneous expulsion of the calculus