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INTRODUCTION AND OBJECTIVE:Endoscopic Combined IntraRenal Surgery (ECIRS) involves simultaneously a percutaneous and endoscopic access for the treatment of large renal stones or for multiple large ...

Background Percutaneous nephrolithotomy (PCNL), the gold standard for the management of large and/or complex urolithiasis, is conventionally performed with the patient in the prone position, which has several drawbacks. Of the various changes in patient positioning proposed over the years, the Galdakao-modified supine Valdivia (GMSV) position seems the most beneficial. It allows simultaneous performance of PCNL and retrograde ureteroscopy (ECIRS, Endoscopic Combined Intra-Renal Surgery) and has unquestionable anaesthesiological advantages. Objective To prospectively analyse the safety and efficacy of endoscopic combined intrarenal surgery (ECIRS) in GMSV position for the treatment of large and/or complex urolithiasis. Design, setting, and participants From April 2004 to December 2007, 127 consecutive patients who were followed in our department for large and/or complex urolithiasis were selected for surgery (American Society of Anesthesiologists [ASA] score 1–3, no active urinary tract infection [UTI], any body mass index [BMI]). Intervention All the patients underwent ECIRS in GMSV position. Technical choices about percutaneous access, endoscopic instruments and accessories, and postoperative renal and ureteral drainage are detailed. Measurements Patients' mean age plus or minus standard deviation (± SD) was 53.1 yr±14.2. Of the 127 patients, 5.5% had congenital renal abnormalities, 3.9% had solitary kidneys, and 60.6% were symptomatic for renal colics, haematuria, and recurrent UTI. Mean stone size±SD was 23.8mm±7.3 (range: 11–40); 33.8% of the calculi were calyceal, 33.1% were pelvic, 33.1% were multiple or staghorn, and 4.7% were also ureteral. Results and limitations Mean operative time±SD was 70min±28, including patient positioning. Stone-free rate was 81.9% after the first treatment and was 87.4% after a second early treatment using the same percutaneous access during the same hospital stay (mean±SD: 5.1 d±2.9). We registered overall complications at 38.6% with no splanchnic injuries or deaths and no perioperative anaesthesiological problems. Conclusions ECIRS performed in GMSV position seems to be a safe, effective, and versatile procedure with a high one-step stone-free rate, unquestionable anaesthesiological advantages, and no additional procedure-related complications.

AIM To investigate if targeted prostate biopsy (TBx) has superior performance to standard untargeted biopsy (SBx) in determining the optimal agreement between biopsy and surgical Gleason Score (GS). PATIENTS AND METHODS An analysis of our institutional longitudinal database identified 683 consecutive patients who underwent either SBx (18-20 standardized transrectal ultrasound peripheral/transitional zone cores) or TBx alone (4-6 cores for each multiparametric magnetic resonance suspicious lesion, Prostate Imaging Reporting and Data System [(PI-RADS)≥3] after a previous negative first SBx. A total of 246 consecutive patients with diagnosis of prostate cancer (117 SBx and 129 TBx diagnoses) who underwent robot-assisted radical prostatectomy between January 2014 and December 2015, were enrolled. The concordance of biopsy GS to pathological GS, as well as the association between categorical variables [age, digital rectal exam (DRE), TNM, PI-RADS], were analyzed by Fisher's exact test. RESULTS Prostate cancer was diagnosed in 32.0% of the SBx group and in 49.3% of TBx. The rate of correctly classified, up-graded and down-graded GS was 53.8% vs. 91.5%, 39.3% vs. 7.8% and 6.8% vs. 0.8% for SBx and TBx, respectively (p

Objective The most commonly used staging system for renal cell carcinoma (RCC) is the tumor-node-metastasis (TNM) system. In the most recent TNM edition, lymph node (LN) involvement is defined as pN0, pN1, or pN2, depending on the number of metastatic LNs (none, 1, or >1). This study evaluated the prognostic value of this classification and tried to improve its clinical impact by considering an additional parameter, that is, LN density (ratio between number of positive LNs and total number of LNs retrieved). Methods All pathologic reports of radical nephrectomies performed for RCC in two urologic centers between November 1983 and December 1999 were reviewed. For each patient, complete clinical and pathologic data, number of LNs removed, location and number of positive LNs, and LN density were recorded. The Kaplan-Meyer method and the log-rank test were used to calculate cause-specific survival rates and to compare survival curves, respectively. Results A total of 735 patients underwent radical nephrectomy. Lymphadenectomy was performed in 618 cases, and the rate of positive LNs was 14.2%. The 5-yr cause-specific survival rate of pN+ patients was 18%, with no statistically significant difference between pN1 and pN2. The average number of LNs removed was 13 (range, 1–35). The median number of LNs involved was 3 (range, 1–18). LN density ranged between 3.7% and 100% (median, 22.9%). The number of LNs removed had no impact on survival in pN+ patients. The only significant unfavorable prognostic factors were >4 LNs involved ( p =0.02) and LN density >60% ( p =0.01). Conclusion The results show that in RCC the current TNM stratification of positive LNs is not significantly correlated with prognosis. From our data it appears that classification as ≤4 or >4 LNs involved, supported by LN density, better reflects the impact of the disease on survival.

Objective To demonstrate the safety of the Millin extraperitoneal laparoscopic adenomectomy by comparing the laparoscopic and open approaches. Methods From January 2003 to April 2005, patients, with indication of prostatic adenomectomy, were offered the chance to choose between 2 types of procedure: Millin adenomectomy with open or extraperitoneal laparoscopic approach. Forty patients were included in this prospective non-randomised study. The patients were divided into 2 Groups. Group A (20 patients) underwent extraperitoneal laparoscopic adenomectomy, while Group B (20 patients) was treated by open surgery. Pre-operative, peri-operative and post-operative parameters were evaluated. Group A was subdivided in two sub-groups (first ten and last ten) and peri-operative parameters were considered in order to determine the learning curve. Results In terms of pre-operative parameters considered, the 2 study groups are comparable ( p >0.3). As far as peri and post-operative parameters are concerned: mean blood loss for Group A was 411.6±419ml, for Group B 687.5±298.6ml ( p =0.004). For all the other parameters no significant statistical differences were recorded ( p >0.4). Mean operative time was 107.2±34.9min in Group A, and 95.5±22.5min in Group B. Mean adenoma weight in Group A was: 69,5±21.5g, in Group B: 88.1±43.8g. Mean haemoglobin levels in Group A was: 11.2±1.8g/dl, Group B: 11.6±1.2 (10–13.4) g/dl. Mean Analgesic consuming (Tramadol) during the post-operative stay was 385±36mg in Group A, versus 430±108mg in Group B. Mean catheterization time was 6.3±3.7 days in Group A, 5.6±1.1 days in Group B. The mean hospital stay was 7.8±4.1 days in Group A, and 7±1.6 days in Group B. One patient (5%) from Group A was re-operated for bleeding and clot retention, whilst in Group B patients did not present complications which required any further intervention. As far as peri-operative and post-operative parameters of the two sub-Groups A (first ten patients and last ten patients) are concerned, the statistical evaluation shows a significant difference only on operative time ( p =0.01). The p-value for the other parameters was not significant ( p >0.1). Conclusions The extraperitoneal laparoscopic adenomectomy is a safe technique presenting results comparable to open surgery with the advantage of significantly lower peri-operative blood loss.

Urachal carcinoma is a rare neoplasm treated with surgical resection. We report a case of adenocarcinoma of the urachus treated with a new surgical technique. In a 44-year-old man affected by urachal carcinoma we performed a combined endoscopic-laparoscopic surgical en bloc resection of the urachus and bladder dome. The procedure lasted 240 min, and no postoperative complications were recorded. The patient was discharged on fourth day and the catheter was removed on eighth day. Bladder capability resulted normal with no evident physical change. Multiple bladder biopsy and computed tomography scans at 6, 12 and 18 months proved negative.

Over the last 40 years the treatment of urolithiasis passed from open surgical therapies to minimally invasive approaches. From the introduction of the first ureteroscopes in ‘80s many technological improvements allowed to reduce endourological instruments’ size, ensuring in the meanwhile an increasingly high success rate in the resolution of the urolithiasis. The purpose of the study is to review the current role of the ureteroscopy(URS) in the treatment of urinary stones. A non-systematic review was performed considering the most recent Guidelines and results from Literature. The results confirm that, considering ureteral calculi, the stone-free rate (SFR) for URS is significantly higher than for ESWL in the treatment of distal ureteral stones 10 mm. Endoscopy has a first-line role also in the treatment of proximal ureteral stones >10 mm, together with ESWL. Retreatment rate and ancillary procedures are also lower in patients treated with URS, despite it is more invasive if compared with ESWL. Recent data are available in Literature about the treatment of nephrolithiasis with Retrograde Intra-Renal Surgery (RIRS). RIRS is the first-line treatment, together with ESWL, for stones 20 mm. However, for large renal stones the role of RIRS is still being discussed. In conclusion, the majority of urinary stones can be treated by rigid or flexible URS. Further studies are required to clarify the role of endoscopy in the treatment of large stones, especially if compared to percutaneous approaches.

We describe our technique of laparoscopic diverticulectomy under ultrasound (US) guidance after a transurethral resection of prostate (TURP) in the treatment of patients with benign prostatic hyperplasia and bladder diverticulum. A standard TURP is performed with an Iglesias resectoscope. A 12-Fr Foley catheter is positioned in the diverticulum and the catheter balloon is then inflated with 30 mL of water; then a Tiemann catheter is placed through the urethra into the bladder. A US probe is inserted through the 12 mm port placed in the right side by the surgeon, then laparoscopic transperitoneal bladder diverticulectomy is performed under US guidance. In our experience, the use of endolaparoscopic US makes identification and dissection of the diverticulum easy, safe and effective, even when the procedure has to be performed in disadvantageous anatomic conditions such as lateral-posterior diverticulum or post-TURP imbibition of pelvic tissue.

OBJETIVOS El carcinoma de celulas transicionales del tracto urinario superior es relativamente raro, supone entre el 2-5% de todos los tumores uroteliales. Su incidencia parece estar aumentando como resultado de los progresos en tecnicas de imagen, endoscopia y la mejoria de la supervivencia del carcinoma vesical. Los tumores de la pelvis renal representan el 10% de todos los canceres renales. Las neoplasias pielicas tienen una incidencia de dos a cuatro veces superior a la de los tumores de ureter, de los que el sitio mas comun es el tracto distal (sobre el 70%). Un tercio de los carcinomas uroteliales del tracto urinario superior son multifocales, y el 1% simultaneos y bilaterales. Los dos abordajes endoscopicos alternativos para las lesiones localizadas en el sistema colector del rinon son la ureteroscopia retrograda y la via percutanea anterograda. El tratamiento de eleccion depende de varios criterios: tamano de la lesion, localizacion y multifocalidad. Las lesiones pequenas < 1 cm accesibles se tratan preferentemente por ureteroscopia, manteniendo la integridad del tracto urinario. La introduccion de los laseres represento un gran paso del diagnostico y tratamiento endoscopico de los tumores del tracto urinario superior. El exito de un tratamiento laser en pacientes afectos de lesiones del tracto urinario viene definido por una seleccion cuidadosa. Generalmente, solo los pacientes con lesiones de bajo grado y papilares deberian tratarse endoscopica mente con laser. Los pacientes con lesiones de alto grado o invasivas deberian mejor ser sometidos a intervencion quirurgica clasica. En realidad, el urologo dispone de una amplia gama de tecnologia laser para elegir (laser de Holmio, de Tulio). Para un tratamiento correcto y seguro de las lesiones ureterales y pielicas con el laser es absolutamente necesario respetar algunos consejos tecnicos. Antes de nada, es imperativo un acceso adecuado para obtener una buena vision de ureter y de la pelvis renal. De hecho, el urologo siempre deberia trabajar con seguridad, con un control optimo de sus instrumentos. Por lo tanto, es importante definir el tipo de laser y el nivel de energia; el desarrollo de la tecnologia laser (por ejemplo fibras de laser flexibles y pequenas) permite tambien un tratamiento radical, seguro y minimamente invasivo de los tumores uroteliales utilizando ureteroscopios flexibles. Por supuesto es obligatorio evaluar el grado y estadio de los tumores despues de la biopsia por ureteroscopia: los tumores invasivos deben ser tratados inmediatamente mediante nefroureterectomia, mientras que el tratamiento endoscopico deberia reservarse para aquellos pacientes con rinon unico, insuficiencia renal, tumores bilaterales, comorbilidad severa o afectos de tumores solitarios con menos de 15 mm de diametro y bajo grado/estadio.

Objective This article describes both the open and laparoscopic operative techniques of supra-ampullar cystectomy (SAC). Methods Both open (photographs and drawings) and laparoscopic (attached DVD) SAC are explained step by step. Results Between May 1984 and December 2005, 31 patients with bladder tumour underwent SAC with ileal orthotopic neobladder (2 Camey I, 26 Camey II, and 3 Y). Three patients underwent laparoscopy. Preoperatively, 26 patients had superficial high-risk transitional cell carcinoma (TCC). Median follow-up was 95.0 mo (range: 5–260 mo). The 10-yr cause-specific survival rate was 76.7%. Two patients had local recurrence. Potency was preserved in 28 patients (90.3%); 15 patients (48.3%) also maintained antegrade ejaculation, allowing procreation in 3 cases. In one patient the Camey I neobladder was converted into an ileal conduit (high postvoid residual, recurrent pyelonephritis). None of the remaining patients had daytime incontinence, eight had nightime urinary incontinence, and six performed intermittent self-catheterisation. Conclusion SAC with detubularised ileal orthotopic neobladder allows preservation of sexual function and maintenance of urinary continence in most patients, without compromising oncologic outcome. The key element is the very strict and careful preoperative selection of the patients.

Purpose: To present a simple alternative technique to close the membranous urethra during laparoscopic radical cystectomy. Patients and Methods: A series of 18 laparoscopy-assisted cystectomies were performed in our institute from November 2002 to May 2005. In order to prevent neoplastic-cell spillage, in 14 of these patients, the membranous urethra was closed with Hem-o-lok® clips after careful dissection of the urethra and withdrawal of the bladder catheter. Results: In all cases, one or two Hem-o-lok® clips were easily, safely, and quickly positioned. The remaining length of the membranous urethra was sufficient for anastomosis with the neobladder if appropriate. In follow-up (mean 14 months), no local recurrence has been recorded. Conclusion: The closing of the membranous urethra with Hem-o-lok clips during laparoscopy-assisted cystectomy is in our experience a simple, fast, safe, and effective alternative that should be considered when laparoscopic radical cystectomy is performed.

We compared two techniques of early ligature of the renal artery during transperitoneal laparoscopic radical nephrectomy: a standard technique and a direct approach to the artery.Of 100 patients undergoing transperitoneal laparoscopic radical nephrectomy at our institution, in the last 70, we used early renal-artery ligature. Of these, the standard technique after exposure of the vascular pedicle was used in 45 patients (group A), and ligature with a direct access to the renal artery was attempted in 25 patients (group B).No statistical differences were noted between the two groups in terms of age, lesion size, operative time, estimated blood loss, or intraoperative and postoperative complications. There were no recurrences of disease by CT evaluation in either group during follow-up (range 1-46 months).Transperitoneal laparoscopic radical nephrectomy with direct access to renal artery for early ligature is technically difficult but feasible and safe.

physical therapy. He received adjuvant chemotherapy and is alive without evidence of disease recurrence at 1 year. CONCLUSIONS: There is a risk of obturator nerve injury during pelvic lymph node dissection. Hem-o-lock clips may be removed with the use of a clip remover or harmonic instrument. If transected and recognized, immediate apposition of the nerve is necessary to yield recovery. Robotic suturing of the transected nerve was technically feasible in this case.