A. Gregori

The Tongue as an Alternative Donor Site for Graft Urethroplasty: A Pilot Study

PURPOSE Urethroplasty with a buccal mucosal graft provides excellent clinical results but it may also cause oral complications in some cases. The mucosa covering the lateral and under surface of the tongue is identical in structure with that lining the rest of the oral cavity. We evaluated LMGs for urethroplasty. MATERIALS AND METHODS From January 2001 to September 2004, 8 men 34 to 65 years old (mean age 46.1) with urethral strictures 1.5 to 4.5 cm long were selected for 1-stage dorsal onlay urethroplasty. The site of the harvest graft was the lateral mucosal lining of the tongue. Postoperatively all patients were followed with urethrography, uroflowmetry, cystourethrography and flexible urethroscopy after 3 and 12 months. Successful reconstruction criteria were peak flow rate greater than 15 ml per second and no need for postoperative urethral dilation. RESULTS Median followup was 18 months (mean 22.1, range 3 to 47). Seven cases were successful. One patient had a partial urethral stricture. In successful cases cystourethrography revealed no significant graft contractures or sacculations and at flexible urethroscopy LMG was almost indistinguishable from native urethra. There were no pain, esthetic or functional complications at the donor site. CONCLUSIONS Harvesting the LMG is feasible and easy to perform. Compared with the buccal mucosal graft the LMG seems to be associated with less postoperative pain and a minor risk of donor site complications. These preliminary functional and esthetic data are satisfactory.

Minimally Invasive Laparoscopic Neobladder

PURPOSE To our knowledge orthotopic reconstruction after laparoscopic radical cystectomy has not been described in the human. After anatomical and surgical studies on cadavers we developed an original technique and performed the first laparoscopic radical cystectomy with pelvic lymphadenectomy and ileal orthotopic neobladder reconstruction in a patient. MATERIALS AND METHODS Our technique has 3 steps, namely laparoscopic pelvic clearance, external reconstruction and laparoscopic reconstruction. After cystoprostatectomy and lymphadenectomy were completed via laparoscopy we removed the surgical specimens through a 5 cm. supraumbilical incision. Through the same incision an ileal loop was extracted from the abdominal cavity, isolated, detubularized and partially reconfigured. Intestinal continuity was restored extracorporeally. All intestinal loops were inserted back into the abdomen and pneumoperitoneum was started again. The ureteroileal (nipple valve) and urethroileal anastomoses were formed via laparoscopy and the neobladder was then completed with an intracorporeal running suture. RESULTS Operative time was 450 minutes and blood loss was 350 ml. Postoperatively pain was minimal. The patient was ambulatory, regained bowel activity on postoperative day 2 and began food intake 2 days later. He was discharged home on postoperative day 7 with an indwelling catheter, which was removed after 7 days. Histopathological examination showed organ confined bladder cancer without margin invasion. CONCLUSIONS To our knowledge we report the first case of laparoscopic radical cystectomy with ileal orthotopic reconstruction. This original technique combines the advantages of minimally invasive laparoscopy with the speed and safety of open surgery.

Laparoscopic radical cystoprostatectomy: a technique illustrated step by step.

OBJECTIVES Laparoscopic surgery is expanding among urologists as a minimally invasive treatment and may now be applied to treat neoplasms of the pelvic organs. Laparoscopic cystoprostatectomy has still not been well codified and illustrated. We describe a technique of laparoscopic radical cystoprostatectomy that we have developed in 10 patients after practicing in laparoscopic radical prostatectomy. METHODS Between June 2001 and July 2002, 10 men with bladder cancer underwent laparoscopic cystoprostatectomy with urinary diversion. This report details step by step our 5-port transperitoneal technique with primary access to the seminal vesicles and Denonvilliers fascia, ureters detection after umbilical arteries incision, endopelvic fascia incision and dorsal vein complex control before division of the vesical and prostatic fibrovascular pedicles with a harmonic scalpel. RESULTS We performed 6 orthotopic ileal neobladders, 2 sigmoid ureterostomies and 2 cutaneous ureterostomies. In all cases no conversion to open surgery was necessary. The mean time to perform the laparoscopic radical cystoprostatectomy, including the lymph node dissection, was 166 minutes (range 150-180). Mean estimated blood loss was 310 ml (range 220-440). Mean hospital stay was 8.1 days (range 7-9) for ileal orthotopic neobladder, 8 days (range 7-9) for sigmoid ureterostomy and 5 days for cutaneous ureterostomy. The mean follow up is 12.3 months (range 5-18). Two patients respectively with stage T2bN0 G2-3 and stage pT1N0 (plus carcinoma in situ) G3 transitional cell carcinoma and surgical margins tumor free had diffusive metastatic disease after 6 months. The other 8 patients are free from disease. CONCLUSIONS Laparoscopic radical cystectomy is still an operation for pioneers but this procedure may be not strictly relegated to a few academic centers. In our opinion laparoscopic cystoprostatectomy is a feasible, fast, safe and easy procedure and urinary diversion may be performed with a laparoscopic, open or combined approach without reducing the advantages of laparoscopy.

Lingual Mucosal Graft Urethroplasty for Anterior Urethral Reconstruction

OBJECTIVE Evaluate the use of lingual mucosal graft (LMG) in anterior urethral strictures. METHODS From January 2001 to December 2006, 29 men (mean age, 48.5 yr) with anterior urethral strictures underwent graft urethroplasty with LMG. The mean length of stricture was 3.6cm. Patients with bulbar, penile, or bulbopenile strictures received one-stage dorsal free graft urethroplasties. In patients with failed hypospadias repair we performed a two-stage urethroplasty. Criteria for successful reconstruction were spontaneous voiding with no postvoid residual urine and no postoperative instrumentation of any kind. Clinical assessment included the donor site morbidity. RESULTS Mean follow-up was 17.7 mo. One-stage bulbar and penile urethroplasties without meatal involvement had an 81.8-100% success rate. Bulbopenile urethroplasties were successful in 60% of the cases, whereas one-stage urethral reconstructions in patients with meatal involvement were successful in 66.6%. The two cases of two-stage urethral reconstruction with LMG and buccal mucosal graft after failed multiple hypospadias repairs were unsuccessful. The overall early recurrence rate was 20.7%. Patients with the graft harvested from the tongue reported only slight oral discomfort at the donor site and difficulty in talking for 1 or 2 d. CONCLUSIONS The mucosa of the tongue, which is identical to the mucosa of the rest of the oral cavity, is a safe and effective graft material in the armamentarium for urethral reconstruction with potential minor risks of donor site complications. LMG may be used alone for short strictures (<5cm) or in combination with buccal mucosa when longer grafts are needed.

LINGUAL MUCOSAL GRAFT URETHROPLASTY FOR ANTERIOR URETHRAL RECONSTRUCTION

Article infoArticle history:Accepted January 7, 2008Published online ahead ofprint on January 16, 2008Keywords:Buccal mucosaFree graftsHypospadiasOral mucosaTongueTransplantsUrethraUrethral strictureUrethroplastyAbstractObjective: Evaluate the use of lingual mucosal graft (LMG) in anteriorurethral strictures.Methods: FromJanuary2001toDecember2006,29men(meanage,48.5yr)withanteriorurethralstricturesunderwentgrafturethroplastywithLMG.The mean length of stricture was 3.6 cm. Patients with bulbar, penile, orbulbopenilestricturesreceivedone-stagedorsalfreegrafturethroplasties.In patients with failed hypospadias repair we performed a two-stageurethroplasty. Criteria for successful reconstruction were spontaneousvoiding with no postvoid residual urine and no postoperative instrumen-tation ofany kind.Clinical assessment includedthe donor sitemorbidity.Results: Mean follow-up was 17.7 mo. One-stage bulbar and penile ure-throplasties without meatal involvement had an 81.8–100% success rate.Bulbopenile urethroplasties were successful in 60% of the cases, whereasone-stage urethral reconstructions in patients with meatal involvementweresuccessfulin66.6%.Thetwocasesoftwo-stageurethralreconstruc-tionwithLMGand buccalmucosalgraftafterfailedmultiplehypospadiasrepairs were unsuccessful. The overall early recurrence rate was 20.7%.Patientswiththegraftharvestedfromthetonguereportedonlyslightoraldiscomfort at the donor site and difficulty in talking for 1 or 2 d.Conclusions: The mucosa of the tongue, which is identical to the mucosaof the rest of the oral cavity, is a safe and effective graft material in thearmamentarium for urethral reconstruction with potential minor risksof donor site complications. LMG may be used alone for short strictures(<5 cm) or in combination with buccal mucosa when longer grafts areneeded.

Laparoscopic Radical Prostatectomy: Perioperative Complications in an Initial and Consecutive Series of 80 Cases

OBJECTIVES We retrospectively evaluated the intraoperative and early postoperative complications of the initial experience with the first 80 laparoscopic radical prostatectomies performed at our institution. METHODS Between January 17, 2001 and July 24, 2002, 80 patients between 53 and 78 years old (mean age 63.8) with clinically localized prostate cancer underwent laparoscopic radical prostatectomy with the Montsouris technique. A total of 24 (30%) staging pelvic lymphadenectomy were performed. The inpatient and outpatient medical records as well as all complications were reviewed. RESULTS The pathological tumor stage revealed 18 pT2a (22.5%), 29 pT2b (36.25%), 21 pT3a (26.25%), 10 pT3b (12.5%), 1 pT4 (1.25%), 1 pT4 N1 (1.25%). No conversion was necessary in all cases. Mean operative time was 218 minutes (range 150-420) overall, mean blood loss was 376 ml (range 50-1000) and the mean postoperative hospital stay was 4.5 days (range 3-9). The mean and the median duration of bladder catheterization were respectively 11 and 10 days (range 7-23). Injury to the epigastric vessels was detected intraoperatively in 5 cases (6.25%) with immediate hemostasis achieved. There was 1 death (1.25%) 35 days after a cerebrovascular accident occurred on postoperative day 3. We observed 1 (1.25%) postoperative ileus, hemoperitoneum in 5 cases (6.25%), 2 (2.5%) acute urinary retentions, 6 (7.5%) anastomotic leakages, 1 (1.25%) anastomotic stricture, 1 (1.25%) hydrocele and 2 (2.5%) urinary tract infections. CONCLUSIONS In our initial experience laparoscopic radical prostatectomy was performed with no complications in 77.5% of patients. We observed major and minor complications respectively in 16.25% and 6.25% of the patients. Our series provides evidence that the laparoscopic approach is feasible and associated with acceptable perioperative morbidity.

Transrectal Ultrasound–Guided Implantation of Adjustable Continence Therapy (ProACT): Surgical Technique and Clinical Results After a Mean Follow-Up of 2 Years

BACKGROUND Treatment for stress urinary incontinence (SUI) after radical prostatectomy (RP) with the male Adjustable Continence Therapy (ProACT) system, implanted using fluoroscopy for guidance, has been described with promising clinical results. OBJECTIVE This retrospective study aims to describe the surgical technique in detail and to evaluate the continence recovery and complication rate of a cohort of male patients with SUI after RP. All patients were treated with a modified technique that uses transrectal ultrasound (TRUS) for guidance and that may be performed under local anaesthesia. DESIGN, SETTING, AND PARTICIPANTS Between June 2005 and March 2009, we operated on 79 consecutive patients with post-RP urodynamic intrinsic sphincter deficiency. SURGICAL PROCEDURE ProACT system implantation was performed with TRUS guidance under general or local anaesthesia. MEASUREMENTS Perioperative data and adverse events were recorded in all patients. Outcome data (24-h pad test, number of pads per day (PPD) used by patients, a validated incontinence quality of life questionnaire) were analysed in the 62 of 79 patients who completed the postoperative system adjustments. In this group of patients, the mean follow-up is 25 mo. RESULTS AND LIMITATIONS According to the 24-h pad test and the mean number of PPD used, 41 patients were dry (66.1%), 16 patients improved (25.8%), and 5 patients failed treatment (8%). The dry rate in previously irradiated patients was 35.7%. Complications included intraoperative bladder perforations (2 of 79; 2.5%), transient urinary retention (1 of 79; 1.2%), migrations (3 of 79; 3.8%), and erosions (2 of 79; 2.5%). According to the degree of incontinence, the dry rate in patients with mild, moderate, and severe incontinence was, respectively, 85%, 63.6%, and 33.3%. CONCLUSIONS TRUS guidance for ProACT implantation results in success and complication rates that compare favourably with published data using fluoroscopy for guidance. Previous radiotherapy and severe incontinence seem to be a relative contraindication. Larger series and longer follow-up are progressing to establish long-term efficacy.

Penile dermal flap in patients with Peyronie's disease: long-term results.

PURPOSE In 1995 a penile dermal flap was described as an ideal operation for penile curvature due to Peyronies disease. We report our experience with penile dermal flaps in patients with penile curvature due to Peyronies disease. MATERIALS AND METHODS Between January 2001 and May 2004, 26 potent white men with Peyronies disease underwent corporoplasty with a penile dermal flap. They were evaluated at 3, 6 and 12 months, and yearly thereafter by determination of penile length changes and residual curvature, and the International Index of Erectile Function-5. RESULTS At the maximum followup (mean 95 months, range 81 to 108) 22 of 26 patients (85%) were available for examination, of whom 14 (63.6%) had no residual curvature, and 2 (9.1%) and 7 (31.8%) had improved and worse erectile function, respectively. Nine patients (40.9%) had inclusion cysts at the surgical site, including 5 who underwent surgical cyst removal with no cyst recurrence. Only 9 of 22 patients (40.9%) were satisfied with the cosmetic and functional outcome. CONCLUSIONS Despite the attractiveness of the operation to our knowledge no other experience with this technique has been reported. Our results differ from those reported, although we tried to exactly follow the original technique of dermabrading the flap with sandpaper. Based on these results we abandoned the penile dermal flap in patients with Peyronies disease.

Elective segmental ureterectomy for transitional cell carcinoma of the ureter: long-term follow-up in a series of 73 patients

Study Type – Therapy (outcome)

Implantation of an adjustable continence therapy system using local anesthesia in patients with post-radical prostatectomy stress urinary incontinence: a pilot study

PURPOSE We evaluated whether transrectal ultrasound guided ProACT system implantation in patients under local anesthesia and with stress urinary incontinence after radical prostatectomy is feasible in a day hospital setting, and is safe and well tolerated. MATERIALS AND METHODS The procedure was used in 11 consecutive patients (mean age 69.9 years) with stress urinary incontinence after undergoing radical prostatectomy between November 2006 and July 2007. The ProACT system was implanted with a transrectal ultrasound guided procedure after administration of local anesthesia (40 ml ropivacaine 7.5 mg/ml) in perineal skin, subcutaneous tissue, pelvic diaphragm and laterally to the anastomosis. During surgery any reason for discomfort was collected. Pain was evaluated with the visual analogue scale, Numeric Pain Intensity Scale and Simple Descriptive Pain Intensity Scale. Transrectal ultrasound was performed 7 days after surgery to exclude device migrations due to early patient mobilization. RESULTS The ProACT systems were successfully implanted in all patients under local anesthesia without any need for general anesthesia, and without perioperative surgical or anesthesia related complications. Subjective discomfort was minimal. Mean visual analogue scale was 13 mm (range 0 to 28). Mean Numeric Pain Intensity Scale was 1.4 points (range 0 to 4). On the Simple Descriptive Pain Intensity Scale 4 patients (36.3%) reported no pain, 5 (45.5%) reported mild pain and 2 (18.2%) reported moderate pain. Discharge from the hospital was possible for all patients after 6 hours. All transrectal ultrasound performed after 7 days excluded balloon migrations. CONCLUSIONS Transrectal ultrasound guided ProACT system implantation with the patient under local anesthesia only is feasible, safe, well tolerated and may be performed as a day surgery procedure.