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Objectives: To report 8 cases of rectourethral fistula (RUF) in patients treated with high-intensity focused ultrasound (HIFU) for either localized or locally recurrent prostate cancer (PCa)., Methods: A retrospective analysis of 363 consecutive patients with PCa who underwent HIFU from 2002 to 2010 was done. One HIFU session was performed in 341 patients with localized PCa. Two HIFU sessions were performed in 22 patients. Salvage HIFU was performed in 22 patients after radiotherapy., Results: A total of 8 patients (2.2%) developed RUF. Their mean age was 69.38 ± 6.19 years (range 61-78). The mean follow-up was 50.45 ± 25.07 months (range 25 to 84). The mean interval between HIFU and the development of RUF was 3 ± 0.93 weeks (range 1-4). RUF occurred within 4 weeks after 1 HIFU session (n = 4; 1.17%), 4 weeks after a repeated HIFU session (n = 3; 13.63%), and 3 weeks after salvage HIFU (n = 1; 4.54%). The mean fistula size was 9 ± 7.13 mm (range 3-25). Conservative treatment failed in all patients. Of the 8 patients, 4 underwent radical prostatectomy, with an omentum flap interposition, 3 received a gracilis interposition flap, performed transanally because of a small lesion (<10Ch) or perineally, and 1 underwent radical prostatectomy, rectal resection, and creation of a colonic J-pouch., Conclusions: The results of our study have shown that RUF is a rare, but severe, complication after 1 HIFU session (1.17%) for localized PCa. The occurrence of RUF after salvage HIFU (4.5%) and repeated HIFU sessions (13.63%) was markedly elevated. Spontaneous closure of RUF will not occur, requiring major abdominal surgery for definitive repair., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: To assess effectiveness of flexible ureteroscopy (fURS) in patients not with simple but with multiple unilateral renal stones., Patients and Methods: A database analysis was performed to identify patients with multiple unilateral intrarenal stones. Patients were treated using an 8.8F flexible ureteroscope. Patients were considered stone free if no residual stones were seen endoscopically and radiographically after the procedure. The efficiency and the safety of the procedures were analyzed., Results: Between 2006 and 2008, 1054 ureteroscopic procedures were performed in our department; 125 patients met the inclusion criteria. Holmium:yttrium-aluminum-garnet laser lithotripsy was necessary in 41 (32.8%) patients. The mean stone size was 11.93 ± 8.2 mm, with a mean stone burden of 83.7 ± 67.66 mm(2). The mean number of stones was 3.59 ± 3.57. Twenty-six (20.8%) patients had a stone burden ≥ 100 mm(2), and 99 (79.2%) a stone burden <100 mm(2). The overall stone-free rate after a single procedure of fURS was 74.4%. In the remaining 32 patients with residual stones, the mean stone burden dropped from 123.24 ± 84.36 mm(2) to 56.28 ± 52.53 mm(2). The stone-free rate in patients with a stone burden ≥ 100 mm(2) was 65.4% and 79.5% in patients with a stone burden < 100 mm(2), respectively. Complications have been recorded in seven (5.6%) patients, including urinary tract infection in four, ureteral perforation in one, and hematuria in two patients. No major complications occurred. All patients were treated conservatively., Conclusions: fURS is an effective treatment option in patients with multiple unilateral renal stones. Single procedure stone-free rates are high with a low rate of only minor complications.

A presacral, degenerative schwannoma ("ancient schwannoma") is a rare entity. The clinical signs are nonspecific, and a reliable preoperative diagnosis is difficult. Tumor heterogeneity with calcifications may be seen in degenerated schwannomas on MRI or CT but not necessarily. First-line treatment is complete surgical excision. We present the case of a 44-year-old male who required surgery for a presacral mass. Histopathological examination revealed the diagnosis of a schwannoma with degenerated areas.

Purpose: To investigate the occurrence of bladder outlet obstruction (BOO) after high-intensity focused ultrasound (HIFU) therapy of prostate cancer, the need for secondary transurethral interventions for BOO, and the benefit of transurethral resection of the prostate (TURP) before HIFU., Patients and Methods: After a single HIFU treatment between 2002 and 2007, 226 consecutive patients were examined and followed at least 2 years. The Ablatherm Maxis and the Integrated Imaging devices were used. The sites of BOO were recorded., Results: Median follow-up after HIFU was 52 months (range 24-80 mos). BOO developed in 58 (25.66%) patients. Repeated BOO episodes were observed in 27 (11.94%), three to seven episodes in 13 (5.75%) patients. Patients with repeated BOO were older than patients with singular BOO (71.75 ± 4.97 vs 68.18 ± 5.03; P = 0.024). In primary BOO, multiple sites of obstruction were more often involved than in repeated BOO (25/58 vs 8/27). Conversely, isolated bladder neck stenosis was predominantly found in patients with ≥two episodes of BOO. The rate of primary BOO was significantly different between patients who had undergone TURP the same day as HIFU or within 2 days of HIFU (33/96; 34.38%) and patients with TURP more than 1 month (16/89; 17.98%) before HIFU (P = 0.032). BOO occurred in 21.95% (9/41) of the patients who were treated with HIFU only., Conclusions: BOO after HIFU is common, particularly affecting the bladder neck. The risk of repeated BOO is associated with age. A longer interval between TURP and HIFU (>1 month) might reduce the risk for the development of BOO.

Purpose: Nephron sparing surgery has been established as a standard treatment for renal masses smaller than 4 cm in diameter. The benefit of nephron sparing surgery may be hampered by new types of complications. In particular, postoperative gross hematuria due to the formation of renal artery pseudoaneurysm (RAP) can lead to clinical significant hemorrhage. We retrospectively investigated the occurrence of postoperative RAP in our own consecutive series of open/laparoscopic partial nephrectomies requiring transarterial angioembolization., Methods: Open partial nephrectomy (OPN) was performed in 289 patients, and laparoscopic partial nephrectomy (LPN) in 40 patients. Six patients (1.82%) developed postoperative clinical symptomatic, persistent gross hematuria from RAP. Patient files were evaluated for preoperative, operative and postoperative data., Results: First symptom presentation was observed at a median of 12.5 days (range 6-36) after surgery. Symptoms were flank pain, gross hematuria, dizziness/syncope and/or fever. Median postoperative blood transfusion rate was 3 units (range 0-8). RAP was proven with angiography in all patients. RAP was sufficiently occluded in all patients by using microcoils in a supraselective approach. Median follow-up was 23 months (range 10-37) without any episodes of hemorrhage/flank pain in each patient., Conclusions: RAP is a rare, but typical complication after partial nephrectomy. The clinical symptoms present with delay. Angiography identifies the origin of the bleeding and provides successful minimally invasive treatment.

Purpose: Thulium:YAG (Tm:YAG) VapoEnucleation has been introduced and relief of obstruction was demonstrated. The aim of this study was to proof durability of the outcomes in patients with an postoperative follow-up >12 month., Methods: VapoEnucleation was performed using a 70 Watt continuous-wave-laser. After enucleation tissue was morcellated within the bladder. Patients were followed in terms of improvement of uroflow, intra- and postoperative course and for occurring complications., Results: 88 consecutive patients with prostatic enlargement underwent our initial series of VapoEnucleation. Prostatic volume was 61.3 +/- 24.0 cc (30-160). OR-time was 72 min +/-26.6 (35-144) and laser-time 32.4 +/- 10.1 min (16.3-59.3). Applied laser energy was 123.7 +/- 40.6 kJ (67.8-240.9). Foley catheter-time was 2.1 +/- 1.06 days on average. In 79/88 patients the postoperative period extended 12 month (mean: 16.5 month). 2 patients deceased during the follow-up, 15 patients did not respond. Therefore, 62/77 patients were available for follow-up. Flow-rate and post-voiding residual urine improved significantly [3.5 vs. 23.3 ml/s (p < 0.001); 121.3 vs. 33.4 ml (p < 0.05)]. IPSS decreased from 18.4 to 6.8, QoL dropped from 4.6 to 1.4. Early complications were urinary tract infection (n: 6/6.8%), bleeding (n: 5/5.6%) and immediate re-treatment (n: 2/2.2%), as well as urethral stricture (n: 1/1.6%) during follow-up. Postoperative short-term dysuria was recorded in 27% of the patients., Conclusion: VapoEnucleation is a safe and effective minimal invasive treatment modality for BPO. The improvement in voiding and bother is durable in patients with a postoperative period extending 12 month.