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Introduction. Fecaluria and pneumaturia are the patognomonic signs of an abnormal communication between the bladder and the intestinal tract. Therefore, when a history of digestive signs, symptoms or digestive diseases is missing, this borderline pathology leads the patients in the care of urologists. From diagnosis to treatment the management of these cases can be difficult and challenging. Materials and Methods. A 48 year old patient, without any significant medical history, presented to the emergency room for fecaluria, pneumaturia and an episode of haematuria. He had no prior digestive symptoms. The contrast enhanced abdominal and pelvic CT scan revealed a pelvic mass involving the sigmoid colon and the dome and the posterior wall of the bladder. The cystoscopy objectifies a tumor mass involving the right postero-lateral bladder wall, with extravasation of faeces. A biopsy was taken and the frozen section found mainly uncertain inflammatory type tissue. A colonoscopy couldn’t be done because of an impassable obstacle at 15 cm from the anus. Together with general surgeons we decided for en bloc resection of the tumor with partial cystectomy, right ureterocystoneostomy and rectosigmoid resection with mechanic end to end anastomosis. Results. The postoperative period was uneventful. The histopathological examination revealed an abscessed sigmoid diverticulum with vesico-sigmoid fistula and perilesional inflammatory tissue. Two years after the surgery the patient is asymptomatic with a normal function of the right kidney and restored bladder capacity. Conclusions. Being a borderline pathology, patients with fecaluria and pneumaturia and lack of digestive symptoms are referred and managed by the urologists. Despite extensive investigations, even when preoperative biopsies reveal inflammatory tissue the patients should be treated as oncologic cases. A close cooperation with general surgeons for en bloc multiorgan resection within oncologic safety margins is mandatory.

The landscape of oligometastatic prostate cancer is constantly changing due to the development of new imaging techniques and the emergence of new therapies. Androgen deprivation therapy, combined with androgen receptor targeted therapies or with a cytotoxic agent, the main treatment strategy for metastatic prostate cancer for the last 10 years, has not improved significantly the outcomes of patients with limited metastatic burden. Good quality evidence continues to grow and support the usage of local therapies in oligometastatic disease. The strength of the available evidence lies in favor for external beam radiotherapy and several international guidelines recommend nowadays RT as a pivotal strategy in patients with limited metastatic burden. Although data assessing the efficacy of cytoreductive prostatectomy appear promising, the lack of data from prospective randomized trials restricts its usage outside clinical trials. However, cytoreductive prostatectomy or cystoprostatectomy decrease the rates of loco-regional complications, even in castrate resistant state, in patients with symptoms due to bladder or ureteric invasion. In addition, surgery presents the advantage of yielding tissue for molecular analysis, which would allow further understanding of the biology of oligometastatic disease. [ABSTRACT FROM AUTHOR]

Introduction and Objectives. Although discovered in the late 19th century by the American physician Robert F Weir, lichen sclerosus is still a condition not fully understood. Initially considered a simple skin disorder, it mainly affects the genital regions of both men and women, producing white hypomelanotic lesions, that if left untreated tend to evolve into more serious health related problems. In this paper we conducted a thorough review of the literature in order to assess the current level of knowledge of lichen sclerosus of the male genitalia, to identify its etiology, clinical presentation and diagnostic methods, and establish the main treatment options. Materials and Methods. So far a total of five etiologic factors have been considered for lichen sclerosus: autoimmunity, genetics, hormonal infiuence, repeated microtrauma and infections. As only empirical observations sustain each of them, and none alone can explain or predict lichen sclerosus, it is assumed that this condition has a multifactorial origin, and the precise appearance mechanism has yet to be determined. Regarding the lichen sclerosus of the male genitalia, four distinct clinical stages of presentation have been described, based on the extent of the disease and the complications it produces. During the first stage the white hypomelanotic lesions can be observed at the level of the prepuce, that gets scarred and brittle, and can lead to phimosis. For the second stage the lichen lesions also affect the glans of the penis, that can fuse with the phimotic prepuce. The third stage marks the involvement of the urethra, patients exhibiting stenoses and strictures, of various degrees of severity. And the fourth and most dangerous stage represents the malignant transformation of the involved tissues, resulting in squamous cell carcinoma of the penis or urethra, verrucous carcinoma of the penis, and erythroplasia of Queyrat. While definitive diagnosis is obtained after a histopathological examination of a removed specimen, the clinical presentation can often be enough to identify lichen sclerosus. Imaging like ultrasound, computed tomography or magnetic resonance is also required to correctly assess the extent of the complications. Results. Various treatment options have been employed for lichen sclerosus thus far, ranging from local ointments and creams to surgical excision and correction in the complicated cases. Some, like the revulsives and X-rays, retain only historic value, having been already abandoned. Out of the topical treatments used nowadays, meant to alleviate the symptoms and reduce the lichen affected areas, the most common are corticosteroids, calcineurin inhibitors, hormonal creams and retinoids. The same effects have been obtained with some forms of phototherapy. But when lichen sclerosus evolves beyond simple skin lesions, surgery is required in order to correct the acquired complications. If phimosis is associated, a complete circumcision of the involved tissue is needed. For the second stage, if the prepuce is fused to the glans, a restoration of lost obscured coronal sulcus procedure achieves the best results. In the third stage, when urethral strictures develop, various forms of urethroplasties are necessary to restore normal micturition, and even perineal urethrostomies are considered in cases of panurethral strictures. The fourth and most severe stage of lichen sclerosus, marked by the malignant transformation, imposes an oncologic treatment catered to the extent of the disease, from a simple excision of a prepuce or penile tumor, to complete emasculation and ilio-inguinal lymph node dissection, or even palliative chemotherapy in metastatic cases. Conclusions. Although known for almost 150 years, lichen sclerosus is still not a fully understood disease. Being considered a simple skin disorder for a long time, it's been overlooked by both patients and physicians, and its true incidence is underestimated. Only recently, after all the evolutive complications of lichen sclerosus have been identified, more effort has been invested in the diagnosis and treatment of this condition. While uncomplicated lichen sclerosus can be managed by topic therapies, advanced forms require complex surgical interventions and experienced physicians in order to achieve the best results. But further research is still needed to clarify the etiology and evolution risks. [ABSTRACT FROM AUTHOR]

Introduction and Objectives. Incidence of bladder stones is rising among women secondary to the increased number of genitourinary procedures. Materials and Methods. We report the case of a 34 years old female with history of emergency hysterectomy and cystorraphy for placenta percreta; at admission the patient had haematuria. dysuria, frequency, urgency and urinary incontinence. Spontaneously eliminated calculi containing suture material was reported. Cystoscopy revealed the large stone that was immobile, attached to the posterior bladder wall. Results. Transurethral cystolitholapaxy with ultrasonic lithotripsy was performed, and a black suture material passing through the calculus and the bladder wall was observed, incised and removed. Conclusions. With the urogenital procedures in female patients rising, it is important to bear in mind some simple principles: use of absorbable suture material, good surgical technique and cystoscopic evaluation before discharging the patient. [ABSTRACT FROM AUTHOR]

Objective: To access the feasibility of palliative cystoprostatectomy/pelvic exenteration in patients with bladder/rectal invasion due to prostate cancer (PC). Patients and methods: Twenty-five men with cT4 PC were retrospectively identified in the institutional databases of six tertiary referral centers in the last decade. Local invasion was documented by CT or MRI scans and was confirmed by urethrocystoscopy. Oncological therapies, local symptoms, previous local treatments, time from diagnosis to intervention and type of surgical procedure were recorded. Patients were divided into groups: ADT group (12 pts) and 13 pts without any history of previous local/systemic treatments for PCa (nonADT groups). Perioperative complications were classified using the Clavien–Dindo system. Overall survival (OS) was defined as the time from surgery to death from any cause. A Cox regression analysis, stratified for ISUP score and previous hormonal treatment (ADT) was also performed for survival analysis. Results: Ileal conduit was the main urinary diversion in both cohorts. For the entire cohort, complication rate was 44%. No significant differences regarding perioperative complications and complication severity between both subgroups were observed (p = 0.2). Median follow-up was 15 months (range 3–41) for the entire cohort with a median survival of 15 months (95% CI 10.1–19.9). In Cox regression analysis stratified for ISUP score, no statistically significant differences in OS in patients with and without previous ADT before cystectomy or exenteration were observed (HR 3.26, 95% CI 0.62–17.23, p = 0.164). Conclusion: Palliative cystoprostatectomy and pelvic exenteration represent viable treatment options associated with acceptable morbidity and good short-term survival outcome. [ABSTRACT FROM AUTHOR]

Introduction and Objectives. Renal cell carcinoma (RCC) represents about 3% of all cancers. The classic triad of flank pain, palpable abdominal mass and hematuria, is present in less than 10% of patients and as many as 60% of renal masses are detected incidentally. The treatment methods for renal tumors include radical nephrectomy and partial nephrectomy. Partial nephrectomy or nephron-sparing surgery (NSS) is considered the treatment of choice for localized small renal masses with oncological outcome in cases of renal cell carcinoma (RCC) similar to that of radical nephrectomy (RN). The aim of this paper is to present partial nephrectomy as a treatment method in a patient with multiple renal cell carcinoma on a solitary kidney. Materials and Methods. A 59 years old male patient who referred to our clinic with three renal masses on the left kidney. The patient had a history of right radical nephrectomy, performed 7 years prior, for a pT3aNxMx RCC. We opted for an open partial nephrectomy in order to preserve as much of the renal parenchyma as possible and avoid dialysis. After performing a left subcostal incision, we dissected the kidney and were able to identify the renal masses on the lower extremity of the kidney. After clamping the renal vessels we performed a wedge resection for all three tumors, while also being careful to keep a maximum amount of healthy renal tissue intact. We sutured the kidney and after adequate hemostasis, two drainage tubes were inserted using a small incision and the surgery was completed. Results. The operative time was 90 minutes with a warm ischemia time of 20 minutes. No major complications were encountered in the postoperative setting. The patient was discharged on the 8th postoperative day, with a subsiding creatinine level (from 3.49 mg/dL at the 48 hour mark to 1.79 mg/dL) and subsequent follow-ups have been nominal. The histopatological examination revealed clear cell renal carcinoma pT(m)3a pNx pMx. Conclusions. Nephron sparing surgery should always be considered when managing patients with renal tumors, especially in cases of solitary kidneys, in order to maintain normal renal function and avoid dialysis. While laparoscopic partial nephrectomies are feasible for patients with multiple RCCs, they should be avoided in solitary kidney cases, due to a longer warm ischemia time and higher blood loss when compared to the open approach. Open partial nephrectomy is the preferred approach for these types of patients at high risk for chronic kidney disease. [ABSTRACT FROM AUTHOR]

Introduction and Objectives. A seminal vesicle cyst is a very rare diagnosis, with a reported prevalence as low as 0.005% The cysts are usually congenital, a coexistence with Zinner syndrome being described (renal agenesis, ectopic ureteral orifice in the prostatic urethra or seminal vesicle and vas deferens stenosis). The aim of this paper is to present the management of a rare case of an acquired seminal vesicle cyst with normal upper urinary tract anatomy. Materials and Methods. A 33-yrs old male patient presented with chronic pelvic pain associated with dysuria and frequency. The ultrasound identified a right regular hypoechoic mass without Doppler signal. The imagistic diagnosis was sustained by computed tomography, revealing a high-volume (84/65/74 mm) inseparable mass from the right seminal vesicle, without contrast enhancement. The surgical approach was minimally invasive, represented by laparoscopic excision of the right seminal vesicle cyst. The patient was placed in Trendelenburg position and 4 trocars were inserted (a 12 mm optic trocar inserted 1 cm above the umbilical fold, 2 other trocars, one of 5 mm and one of 10 mm bilaterally between the umbilicus and the anterior iliac crest, and one of 5 mm on the midline below the umbilicus). A transperitoneal technique was used in order to identify the vas deferens, which guided the dissection to the cystic mass. Further, the right seminal vesicle and the cystic mass were detached from adjacent pelvic structures. The contents of the cyst were evacuated and the cystic wall was resected, the specimen removed through the 10 mm trocar. Results. The operation time was 100 minutes, with minimal blood loss. The postoperative period was uneventful and the patient was discharged on the third postoperative day, with no complications during follow-up. The pathological analysis of the specimen emphasized hyalinized fibrous tissue, ducto-acinar and seminal epithelial structures, with no evidence of malignancy. Conclusions. The proper management of seminal vesicle cyst is represented by laparoscopic excision. Whenever possible, the minimal invasive approach should be used, due to better postoperative outcomes regarding morbidity and convalescence, in comparison with open techniques. [ABSTRACT FROM AUTHOR]

Introduction. Upper urinary tract urothelial carcinomas (UTUC) are quite rare and account for only 5-10% of all urothelial carcinomas. Approximately two-thirds of patients who present with UTUCs have invasive disease at diagnosis. Studies made in the past century reported renal tumors as the most common ethiology of massive retroperitoneal bleeding, accounting for roughly 60% of cases (benign and malignant tumors being almost equally represented). Vascular disease was the next most common, with polyarteritis nodosa being most frequent, followed by other vascular conditions including aneurysm, arteriovenous malformation, portal hypertension, Wegener's granulomatosis and infarction. More rare causes are represented by severe pyelonephritis, cyst rupture, nephrosclerosis, preeclampsia, adrenal tumors. In his article about massive bleeding in the renal fossa, Lenk observed a clinical triad of sudden strong pain in the renal fossa, signs of massive hemorrhage (pallor, tachycardia, hypotension) and developing retroperitoneal mass. However, present day technology allows for complex imaging investigations which help to establish the diagnosis and course of action long before the full clinical triad of Lenk appears. We present the case of a female patient whose only symptom was an acute onset of left lumbar pain and by means of advanced imaging was found to have a large retroperitoneal hematoma and a suspected (and later proven) spontaneous renal rupture, with the underlying cause being an upper tract urothelial carcinoma obstructing and bleeding into the upper calix shaft, with subsequent dilation of the upper calices and rupture of the parenchyma. [ABSTRACT FROM AUTHOR]

obstruction and therapeutic management is a challenge for urologists. Materials and Methods. We report the case of a 46-year-old male patient investigated for left lumbar colicative pain and diagnosed on IV contrast CT scan with partially obstructive extended thrombosis in the left renal vein, reflux of contrast from the middle calyx into the left renal vein detected and grade II ureterohydronephrosis secondary to a 4 mm obstructive left ureteral stone. At admission, the patient was in good general condition, being afebrile, with blood pressure of 160/80 mmHg, white blood cells count and markers of inflammation / sepsis within normal limits. A total left nephrectomy was performed. Laboratory tests revealed the presence of an antiphospholipid syndrome. Results. The postoperative evolution was favourable, the patient being discharged from hospital 7 days after nephrectomy. The histopathological report of the nephrectomy specimen showed the presence of a renomedullary interstitial tumor with a diameter of 4 mm, nonspecific chronic focal nephritis and non-obstructive thrombosis of the left renal vein. Conclusions. We consider that the treatment of choice for calico-venous fistula secondary to ureteral obstruction with the presence of thrombus in the renal and adrenal vein is total nephrectomy. [ABSTRACT FROM AUTHOR]

Congenital urinary obstruction is one of the most frequent conditions affecting the urinary tract in children. It may lead to significant long-term health consequences and the management of these pathologies represents a major challenge for urologists.[1] In cases where the patient presents with a complex pathology and an intricate medical and surgical history, retracing and understanding this history require a thorough anamnesis. Access to a state-of-theart Imaging department is vital in order to have the highest degree of accuracy in determining the diagnosis. The doctor-patient relationship plays a very important role and all available treatment options must be discussed. The cases should be resolved through as few surgeries as possible. When the full reconstruction of the urinary tract is not feasible, as a last resort remains total nephrectomy or partial nephrectomy - when possible. The urologist's approach should always also bear in mind the patient's quality of life and it is preferable to avoid long-term indwelling catheters. Postoperative follow-up after reconstructive surgeries must be done through high-performance imaging studies of the urinary tract. In this article we will present the case of a female patient with multiple congenital anomalies of the urinary tract and iatrogenic stenoses of the ureteropelvic junction and of the ipsilateral ureterovesical reimplantation site, following the reconstructive procedures she underwent during childhood. [ABSTRACT FROM AUTHOR]

Introduction and Objectives. Bladder cancer is one of the most common malignancies in Europe. Many risk factors for bladder cancer have been identify, with tobacco smoking and exposure to environmental and occupational carcinogens being the most important ones. The objective of this study was to identify the risk factors associated with the development of bladder cancer among patients that underwent radical cystectomy. Materials and Methods. The study included 391 patients that underwent radical cystectomy from January 2017 to December 2018 in our center. According to their smoking status, patients were grouped into non-smokers (patients that didn't smoke any cigarette in the last 10 years), smokers (patients that did smoke in the last 6 months) and ex-smokers (patients that have more than 6 months and less than 10 years since they have quit smoking). Other risk factors analyzed were hereditary factors, history of external beam radiation therapy and exposure to occupational carcinogens. Results. The median age of the patients was 69 years old with 308 men (78.77%) and 83 women (21.23%) included. 170 patients were classified as smokers (43.48%), while 131 patients were ex-smokers (33.50%) and 90 patients were non-smokers (23.02%). The prevalence of occupational carcinogens exposure was 10.74%. Hereditary risk factors associated with the development of bladder cancer were identified in 17 patients (4.35%). External beam radiation therapy was identified as a risk factor in 27 patients (6.90%). Current smokers were more frequently diagnosed with T3b and T4a, while N1 and N2 lymph node stages were more often diagnosed among smokers and ex-smokers. Conclusions. Bladder cancer is a common malignancy that has a big impact on health systems and will continue to be so, due to the high prevalence of its most important risk factor, tobacco smoking. In our study, smoking was the most important risk factor, with a prevalence of 77% among patients that were classified as current smokers and ex-smokers. Prevention of smoking needs to be highlighted and cessation programs must be developed in order to lower the incidence of bladder cancer. More measures for increasing safety at work must be taken in order to decrease the exposure to occupational carcinogens. [ABSTRACT FROM AUTHOR]

Introduction and Objectives. Bilateral renal tumors have a rare occurrence, accounting for 1% to 4% of patients with renal cell carcinoma (RCC). Partial nephrectomy (PN) is the first option for treating patients with RCC especially in elective settings. While open PN is still indicated in difficult centrally located or large renal tumors, the laparoscopic approach can be as effective in standard cases. Prostate cancer (PCa) is the second most common cancer in men, accounting for 15% of all the diagnosed cancers. Laparoscopic radical prostatectomy (LRP) is a viable alternative to open prostatectomy. The aim of this paper is to present our management of a patient with bilateral renal tumors and prostate cancer. Materials and Methods. We present the case of a 65 years old patient, who was referred to our clinic for elevated PSA levels. On ultrasonography and CT examination the patient was diagnosed with a 22 mm right and 21 mm left renal tumors. Prostate biopsy at a PSA of 5 ng/ml showed acinar adenocarcinoma, Gleason score 7 (4+3), stage cT2b, classified as localized intermediary risk. The treatment strategy was to perform staged bilateral 3D LPN and then 3D LRP. Firstly we approached right kidney, then one month later the left. After another month we performed LRP, using an extraperitoneal technique. Results. We performed LPN on both sides. The operative time was 130 minutes, respectively 140 minutes, and warm ischemia time was 22 minutes, respectively 24 minutes. No major complications and no urinary fistula were encountered in the postoperative setting. Blood loss was approximately 150 ml. All surgical specimens had a minimum 1 mm safety margin of healthy renal tissue. The patient was discharged on the 4th postoperative day. The histopathological examination revealed: RCC on the right side and oncocytoma on the left. For the LRP operative time was 3.5 hours. Blood loss was 250 ml, without intraoperative complications or incidents. The Foley catheter was removed on the day 11th postoperative day. No urinary fistula was encountered in the postoperative course. The patient was discharged on the 4th day after surgery. Conclusions. In selected cases 3D LPN represents a safe and efficient alternative to open surgery in the management of renal tumors and offers earlier recovery for the patients with less pain and shorter convalescence. LRP offers similar oncologic and functional results as ORP in localized selected cases. [ABSTRACT FROM AUTHOR]

Introduction and Objectives. The most common fusion anomaly of the kidney with an incidence of approximately 1 in every 500 births is represented by the horseshoe kidney (HSK). The most common complication of HSK is kidney lithiasis. Uretero-pelvic junction obstruction (UPJO) occurs in 1 in every 1500 births, and the three conditions can be associated. The purpose of this case report is to present the 3D laparoscopic pyeloplasty as treatment for uretero-pelvic junction obstruction in horseshoe kidney and multiple renal calculi. Materials and Methods. We present the case of a 33 years old male patient, with surgical history of percutaneous nephrolithotomy 7 years prior and two ESWL procedures 1 year before, admitted for recurrent right lumbar pain. The CT scan revealed HSK with dilated right pelvi-calyceal system suggesting right UPJO and multiple secondary renal calculi. We opted for a 3D laparoscopic transperitoneal pyeloplasty and calculi extraction. The surgery was performed in a standard flank position using three ports (a 12 mm for the camera and two working trocars of 10 mm and 5 mm). After a difficult dissection due to postoperative fibrosis and vascular anomalies, the renal pelvis was suspended with a suture wire from the abdominal wall to avoid the need of an additional trocar. Then the pelvis was incised and 11 stones were removed under direct vision. We proceeded to perform a standard dismembered Anderson-Hynes pyeloplasty. A 6 Fr ureteric double-J stent was inserted in an antegrade fashion over a guidewire. The pelvi-ureteric anastomosis was performed with continuous 4-0 Vicryl suture. Results. The operative time was 90 minutes. There were no intraoperative complications or incidents encountered. The patient was discharged on the 4th postoperative day. The JJ stent was removed after 21 days. Conclusions. Although it is a high-complexity surgery due to the aberrant vessels, renal isthmus, modified anatomy of the kidney and secondary lithiasis, the 3D laparoscopic pyeloplasty could be an effective and safe procedure for treating UPJO in horseshoe kidney and secondary multiple renal calculi, even in patients with previous renal surgeries. The 3D vision system reduces the operative time as it ensures better depth perception and faster and more precise surgical gestures. In the cases of recurrent renal lithiasis UPJO should be considered and immediately managed in order to achieve long term healing. [ABSTRACT FROM AUTHOR]