A. Celia

Analysis of radical cystectomy and urinary diversion complications with the Clavien classification system in an Italian real life cohort

INTRODUCTION Standardized methods of reporting complications after radical cystectomy (RC) and urinary diversions (UD) are necessary to evaluate the morbidity associated with this operation to evaluate the modified Clavien classification system (CCS) in grading perioperative complications of RC and UD in a real life cohort of patients with bladder cancer. MATERIALS AND METHODS A consecutive series of patients treated with RC and UD from April 2011 to March 2012 at 19 centers in Italy was evaluated. Complications were recorded according to the modified CCS. Results were presented as complication rates per grade. Univariate and binary logistic regression analysis were used for statistical analysis. RESULTS RESULTS AND LIMITATIONS 467 patients were enrolled. Median age was 70 years (range 35-89). UD consisted in orthotopic neobladder in 112 patients, ileal conduit in 217 patients and cutaneous ureterostomy in 138 patients. 415 complications were observed in 302 patients and were classified as Clavien type I (109 patients) or II (220 patients); Clavien type IIIa (45 patients), IIIb (22 patients); IV (11 patients) and V (8 patients). Patients with cutaneous ureterostomy presented a lower rate (8%) of CCS type ≥IIIa (p = 0.03). A longer operative time was an independent risk factor of CCS ≥III (OR: 1.005; CI: 1.002-1.007 per minute; p = 0.0001). CONCLUSIONS In our study, RC is associated with a significant morbidity (65%) and a reduced mortality (1.7%) when compared to previous experiences. The modified CCS represents an easily applicable tool to classify the complications of RC and UD in a more objective and detailed way.

Mortality and flexible ureteroscopy: analysis of six cases.

AbstractPurpose Advancements in the endourological equipment have made retrograde intrarenal surgery (RIRS) an attractive, widespread technique, capable of competing with traditional shock wave lithotripsy and percutaneous nephrolithotomy. Since the complication rate is generally low, even less is known about dramatic and fatal complications after RIRS. MethodsWe performed a survey asking 11 experienced endourologists to review their RIRS series and report the cases of mortality to their best knowledge. ResultsSix urologists reported on six fatal cases. In three cases, a history of urinary tract infections was present. Four patients died from urosepsis, one due to an anesthetic and one due to hemorrhagic complication. The use of ureteral access sheath was not common.ConclusionEven respecting the standards of care, it may happen that physicians are occasionally tempted to overdo for their patients, sometimes skipping safety rules with an inevitable increase in risks. Despite the fact that RIRS has become a viable option for the treatment of the majority of kidney stones, its complication rates remain low. Nevertheless, rare fatal events may occur, especially in complex cases with a history of urinary tract infections, and advanced neurological diseases.

Experimental varicocele in the rat: early evaluation of the nitric oxide levels and histological alterations in the testicular tissue

The relationship between varicocele and male infertility remains to be explained. Oxidative damage because of the testicular venous backflow may represent one of the causes of gonad injury and seems to precede the histological alteration. Therefore measuring the values of spermatic or intratesticular nitric oxide (NO) could be useful in evaluating this oxidative distress. The aim of this study is to assess the role of testicular NO in early detection of the damages induced by an experimental varicocele in the Wistar rat. A left varicocele was induced in 10 animals (group A). A control group of 10 rats was performed (group B). Animals were killed 3 months after the operation. Both testicles were harvested, weighed and sectioned in two equal parts: one for the evaluation of the NO level and the other one for histological examination. All the rats in group A showed a conspicuous dilatation of the left spermatic vein. The histopathological analysis was normal in both the groups. Biochemistry showed a meaningful statistical difference (P < 0.001) in the concentrations of NO among the specimens of the left and right gonads in group A but no difference was found in group B. The increase in NO values and the presence of other oxidant agents represent the first sign of testicular distress and it seems to anticipate histopathological changes. As it is well known that a great difference exist between human and animal sperm, NO could therefore in the future be taken into consideration together with others parameters for the evaluation of patient who is affected by varicocele.

Comparison of Contrast-Enhanced Ultrasound Scan (CEUS) and MRI in the follow-up of cryoablation for small renal tumors. Experience on 25 cases

Introduction Percutaneous ablation in the kidney is now performed as a standard therapeutic nephron-sparing option in patients who are poor candidates for resection. Its increasing use has been largely prompted by the rising incidental detection of renal cell carcinomas with cross-sectional imaging and the need to preserve renal function in patients with comorbid conditions, multiple renal cell carcinomas, and/or heritable renal cancer syndromes. To date, clinical studies indicate that cryoablation is an effective therapy with acceptable short- to intermediate-term outcomes and with a low risk in the appropriate setting. This article focuses on the efficiency of contrast enhanced ultrasound scan (CEUS) as compared to contrast enhanced magnetic resonance imaging (MRI) during the follow-up after cryoablation of small renal tumors. Material and Methods In our Department, percutaneous or laparoscopic assisted cryoablation is offered in the treatment of small renal masses. Between January 2009 and January 2013, 25 patients (pts) were treated with laparoscopic assisted cryoablation or percutaneous cryoablation for renal tumors <3.5 cm in pts unfit for surgery. All pts had severe comorbidities (ASA score 3). Transperitoneal laparoscopic approach was performed in 11 pts, extraperitoneal approach in 3 pts, percutaneous technique was performed in 11 patients. “Tru-cut biopsy” of the renal mass was always performed before cryoablation. The SeedNet system (Galil Medical, Arden Hills, MN) was used in 12/25 pts; the Precise system (Galil Medical, Arden Hills, MN) was used in 13/25 pts. In all cases, IceRod needles were used. Real-time ultrasound guidance was used to localize the tumour and to monitor the progression of “iceball”. A double “freeze-thaw cycle” was used. All pts had MRI and CEUS before cryoablation and the follow-up consisted in CEUS/MRI every 3 months during the first year and every 6 months thereafter. Results The mean age of the 25 pts was 67.7 years (range 56–79); 5 pts were females and 20 were males. The mean tumor size was 2.8 cm (range 1.5–3.5). No patient required conversion to open procedure. 19 tumors were located at the lower pole, 4 were interpolar and 2 tumors were located at the upper pole. There were no intraoperative complications. The mean hospital stay was 4 days (range 1–7). Two pts required a blood transfusion; there was no statistically significant difference between preoperative and postoperative serum creatinine levels. The biopsy showed RCC in all cases. In 24/25 patients both CEUS and MRI showed no enhancement. In 1/25 pts, during the follow-up, CEUS and MRI showed a well visible recurrence at the perfusion study. It was histologically confirmed. The final results of CEUS and MRI were concordant in all pts. Conclusions CEUS is effective during the follow-up of renal tumor cryoablation. It could be an alternative technique to standard CT and MRI, with some advantages: low cost, short time consuming procedure, no radiation exposure, reduced amount of contrast agent (1–2 mL) and rare adverse reactions.

Evolving transurethral resection of the prostate: enucleation-resection of the prostate.

BACKGROUND AND PURPOSE Enucleation-transurethral resection of the prostate (e-TURP) is our evolution of the conventional TURP. The aim of this study was to report our experience with e-TURP for the endoscopic management of benign prostatic hyperplasia (BPH). PATIENTS AND METHODS The e-TURP combines the basic steps of classic TURP with the technique of holmium laser enucleation of the prostate (HoLEP) but using only the bipolar resector. The charts of 64 patients who underwent e-TURP for BPH in our department between October 2005 and October 2009 were retrospectively studied. RESULTS The mean resected tissue weight was 27.21 g, and the mean operative time was 75.7 min. The mean decreases in hemoglobin and serum sodium levels were 1.63 g/dL and 0.55 mEq/L, respectively. Mean catheter duration was 2.53 days, and the mean total hospitalization time was 3.75 days. There was a significant improvement in urinary peak flow rate (Qmax) 2 months postoperatively (P = 0.009718), as well as a significant decrease in the International Prostate Symptom Score during the same period (P < 0.0001). No major complications were observed, and the rates for early and late complications were 10% and 5%, respectively, at 14.75-month mean follow-up. CONCLUSION The e-TURP seems to be a safe and effective method for the endoscopic management of BPH. Further investigation with randomized trials is needed on this matter.

Ex vivo models for training in endourology: construction of the model and simulation of training procedures.

Background Training in endourology by ex vivo models is an effective tool for unskilled urologists to get qualification. Urologists have different kinds of training models at urological conferences, but, in order to get skilled, they need models available at their own department. Methods The article describes how to build an ex vivo porcine model to train on the main endourological procedures. Results Questionnaires filled by the trainers attending the courses at our department, over the last three years, have proved the high degree of satisfaction about this kind of training system. Conclusions Validation studies about these models still lack. The growing interest about them re-quires randomized controlled validation studies in the future, including large numbers of participants.

Changes in peak systolic velocity induced by chronic therapy with phosphodiesterase type‐5 inhibitor

The aim of this study was to assess the influence of chronic therapy with phosphodiesterase type‐5 inhibitor on penile haemodynamics at colour Doppler ultrasound. Thirty patients affected by erectile dysfunction (ED) of different aetiology tested with the International Index of Erectile Function (IIEF‐5) were evaluated with penile colour Doppler ultrasound during basic and dynamic phases (10 μg PGE1) before and after chronic self‐administration of sildenafil citrate (dosage: 100 mg as required, two to three times a week) for a period of 5–20 months (mean: 12.3). Treatment was interrupted 14–21 days before the second ultrasound evaluation. Peak systolic velocity (PSV) and end‐diastolic velocity (EDV) were recorded by means of colour Doppler; cut off values were 25 and 5 cm s−1 respectively. Data were compared by nonparametric tests. Twenty‐two of the 30 patients showed normal pre‐treatment PSV, while eight of 30 had an insufficient arterial flow. Mean pre‐treatment EDV was 4.7 ± 0.5. After chronic therapy with sildenafil, a global improvement of 10.5% on PSV was seen (P < 0.001), without any statistical difference between patients with normal pre‐treatment peak and those with a borderline one. No statistically significant changes were found for EDV (P = 0.98). It is concluded that chronic therapy with phosphodiesterase‐5 inhibitor results in a significant improvement in PSV values, probably due to a penile chronic vasoactive enhancement.

Cryotherapy of Renal Lesions: Enhancement on Contrast-Enhanced Sonography on Postoperative Day 1 Does Not Imply Viable Tissue Persistence

To investigate whether persistent enhancement detected on contrast‐enhanced sonography at postoperative day 1 (early contrast‐enhanced sonography) after cryoablation of renal tumors implies the presence of residual viable tumor tissue, defined as residual enhancing tissue on reference imaging (computed tomography or magnetic resonance imaging) performed 6 months after the procedure.

Evaluation of laparoscopic vs robotic partial nephrectomy using the margin, ischemia and complications score system: a retrospective single center analysis

OBJECTIVE To evaluate differences between Laparoscopic Partial Nephrectomy (LPN) and Robot-Assisted Partial Nephrectomy (RAPN) using the Margin, Ischemia and Complications (MIC) score system and to evaluate factors related with MIC success. MATERIALS AND METHODS Single centre retrospective study on 258 LPN and 58 RAPN performed between January 2012 and January 2014. Success was defined when surgical margins was negative, Warm Ischemia Time (WIT) was ≤ 20 minutes and no major complications occurred. Mann-Whitney-U and Pearson χ2 correlation were used to compare LPN and RAPN. A matched pair comparison was also performed. Spearman correlation (Rho) was used to evaluate the relationship between clinical, intra and post-operative and pathological patients characteristics with MIC score. A binary regression analysis was also performed to evaluate independent factors associated with MIC success. RESULTS The MIC rate in LPN and RAPN was 55% and 65.5% respectively. No differences in clinical, intra and post-operative outcomes between groups were found. Clinical tumor size (p-value: < 0.001; OR: 0.829; 95% CI: 0.697-0.987), PADUA score (p-value: < 0.001; OR: 0.843; 95% CI: 0.740-0.960), PADUA risk groups (intermediate; p-value: < 0.001; OR: 0.416; 95% CI: 0.238- 0.792; high: p-value: < 0.001; OR: 0.356; 95% CI: 0.199- 0.636), WIT (p-value: < 0.001; OR: 0.598; 95% CI: 0.530- 0.675) were independently associated with MIC. eGFR (< 60 vs ≥ 60 ml/min per 1.73 m2: p-value: < 0.001; OR: 3.356; 95% CI: 1.701-6.621) and Fuhrman nuclear grade (p-value: 0.014; OR: 1.798; 95% CI:1.129-2.865) were also independently associated with MIC. CONCLUSIONS MIC score system is a simple and useful tool to report and to compare different surgical approach.

MP49-02 PERIOPERATIVE MORBIDITY OF CLAMP VS OFF-CLAMP ROBOTIC PARTIAL NEPHRECTOMY: PRELIMINARY RESULTS FROM A MULTICENTRE RANDOMIZED CLINICAL TRIAL (THE CLOCK STUDY)

INTRODUCTION AND OBJECTIVES: To assess the significance of mannitol used as renal protective agent during nephronsparing surgery (NSS) on renal functional outcomes after NSS. METHODS: A prospective, randomized, placebo-controlled, double-blind, phase 3 trial (ClinicalTrials.gov identifier NCT01606787) designed to detect a 5% difference between treatment arms with a power of 90%. Patients were randomized 1:1 to receive mannitol (12.5 g) or normal saline solution placebo intravenously within 30 min prior to renal vascular clamping. Eligibility criteria included age >18 yr, renal artery clamping during NSS, and preoperative estimated glomerular filtration rate (eGFR) >45 mL/min/1.73m. Intraoperatively, a standardized fluid management algorithm was used to maintain hemodynamic stability and urine output 0.5 mL/kg/h. Postoperatively, eGFR was obtained at 6 wk and 6 mo. A renal scan was obtained pre operatively and at the 6-mo endpoint. An ANCOVA model was used to assess the differences in eGFR at 6 wk and 6 mo, and in renal scan at 6 mo after NSS. Differences in grade 3-5 complications were assessed using Fisher0s exact test. At the interim analysis on the first 88 patients, the O0Brien-Fleming stopping boundaries requiring a significance level of 0.0031 were not met (p 1⁄4 0.6). RESULTS: A total of 105 patients per treatment arm were enrolled. After excluding 11 patients (7 in the placebo and 4 in the mannitol arm) who did not undergo NSS; 2 patients (1 in each arm) converted to radical nephrectomy, and 1 patient from the mannitol arm who never received the study drug, 98 and 101 patients in the placebo and mannitol arms, respectively, were evaluated. Median age was 56 yr (interquartile range [IQR] 48, 63) and 60 yr (IQR 50, 66) in the placebo and mannitol arm, respectively. Comparing placebo to the mannitol arm, the adjusted difference of 0.2 eGFR units at 6 mo after NSS was not significant (95% confidence interval [CI] -3.1, 3.5; p1⁄4 0.9). The adjusted difference of -2.6 eGFR units at 6 wk after NSS was not significant (95% CI -5.8, 0.7; p 1⁄4 0.12). No significant differences were detected between treatment arms in median split function on 6-mo renal scan (difference -1.7; 95% CI -3.8, 0.4; p 1⁄4 0.11), or in grade 3-5 complication rates within 90 days of NSS (difference 3.2%; 95% CI -4.1%, 11%; p 1⁄4 0.4). CONCLUSIONS: This randomized prospective trial provides evidence against the use of mannitol as renal protective agent during NSS since no clinical or statistically significant advantage to the use of intravenous mannitol in patients undergoing NSS was found.