Claudio Valotto

Renal Cysts: Can Percutaneous Ethanol Injections Be Considered an Alternative to Surgery?

Aim: To evaluate the efficacy of a new sclerotization technique with pure ethanol in the treatment of symptomatic renal cysts. Patients and Methods: Fourteen patients having renal cysts with a meant diameter of 10 (range 5–15) cm were treated. Our technique includes: ultrasound-guided percutaneous puncture with an 18-gauge needle, positioning of a 5-Fr catheter, complete cyst fluid aspiration, injection of pure alcohol equal to 15% of the initial cyst volume, and alcohol aspiration after 90 min. The procedure was repeated eight times within 5 days. The patients were followed up by ultrasound and/or CT scan for 1 year. Results: All patients became symptom free. Follow-up showed a progressive reduction of the cyst diameter in all cases. Three cysts only (in 2 patients; cyst diameter <2 cm) persisted after 12 months. No significant complications were observed. Conclusions: In our experience, injections of pure ethanol in renal cysts, repeated after some days, were effective in eliminating recurrences and related symptoms. The procedure was not associated with significant complications. Our findings suggest that it be considered the first-choice procedure in the treatment of renal cysts, due to the good results and the low cost of ethanol.

Spermatic Cord Sarcoma: Our Experience and Review of the Literature

Introduction: Spermatic cord tumors represent 4% of scrotal tumors. The most common neoplasms are lipomas. Spermatic cord sarcomas (SCS) of the genitourinary tract account for 2% of all urological tumors. Herein we presented our experience in the treatment of these tumors and a review of the literature. Patients and Methods: A review of the literature was performed using the Medline database with no restriction on language and date of published papers. The literature search used the following terms: epidemiology, surgery, chemotherapy, radiotherapy and spermatic cord sarcomas. Four cases treated from December 2009 to May 2010 are described. Results: All patients were treated with radical orchiectomy. The final pathological report showed different types of sarcomas. Two of the patients were treated with adjuvant chemotherapy. 12 months after surgery, 2/4 patients were alive without signs of relapse. Conclusion: SCS are very rare tumors with a poor prognosis. SCS’s prognostic factors have been identified in grading, size, depth of invasion and surgical margin status. Age and performance status of the patient are however very important. Lymphatic and hematogenous dissemination is uncommon. Surgery is the most important treatment both in the first approach and in local relapse. The role of adjuvant chemotherapy and radiation therapy is still debated.

Utility of racemase and other immunomarkers in the detection of adenocarcinoma in prostatic tissue damaged by high intensity focused ultrasound therapy

Aims: High intensity focused ultrasound (HIFU) is an emerging alternative for the treatment of prostate adenocarcinoma. Alpha‐methylacyl‐CoA racemase (AMACR) has been shown to be a sensitive immunomarker for prostate cancer, however, there is no information available concerning its utility and that of other immunomarkers for the detection of malignancy after HIFU therapy. Methods: AMACR expression was examined in 11 cases of prostatic carcinoma treated by HIFU, with histological evidence of residual carcinoma. In seven cases tumour was examined from thin core biopsies and in four cases from tissue fragments obtained by transurethral resection of prostate (TURP). In addition to AMACR, immunostaining was also undertaken for p63, cytokeratin 34βE12, cytokeratin 5, cytokeratin 8‐18, prostate specific alkaline phosphatase (PSAP), prostate specific antigen (PSA), chromogranin and CD56. Results: In two of the cases foci of tumour were cut out in serial sections. AMACR was expressed in eight of nine evaluable cases (4/5 biopsies and 4/4 TURP specimens). Cytokeratin 8‐18 and PSAP were positive in all cases, whereas PSA was positive in five of nine cases. Cytokeratin 34βE12, cytokeratin 5, and p63 marked the basal layer in normal prostatic glands, but were negative in neoplastic glands. In four cases we found tumour cells with positive staining for CD56 and chromogranin. Conclusions: A panel with positive markers for AMACR, and negative markers for p63/cytokeratin 5/cytokeratin 34βE12 confirms the neoplastic nature of the residual glands on biopsies or TURP fragments sampled after HIFU therapy.

The Value of Open Conversion Simulations During Robot-Assisted Radical Prostatectomy: Implications for Robotic Training Curricula

INTRODUCTIONnThere is a lack of protocols, formal guidance, and procedural training regarding open conversions from robot-assisted radical prostatectomy (RARP) to open radical prostatectomy (ORP). An open conversion places complex demands on the healthcare team and has recently been shown to be associated with adverse perioperative outcomes.nnnAIMSnTo perform a root cause analysis of open conversion simulations from RARP to ORP to identify errors that may contribute to adverse events.nnnMETHODSnFrom May 2013 to December 2013, with a team of two surgeons, an anesthesiologist, and three nurses, we simulated 20 emergencies during RARP that require open conversion. A human simulation model was intubated and prepared in the Trendelenburg position; a robot da Vinci SI was locked to it. All simulations were timed, transcribed, and filmed to identify errors and areas for improvement. An institutional conversion protocol was developed at the end of the conversion training.nnnRESULTSnThe average conversion time was 130.9 (interquartile range [IQR] 90-201) seconds. Frequencies of the observed errors were as follows: lack of task sequence (70%), errors in robot movements (50%), loss of sterility (50%), space conflict (40%), communication errors (25%), lack of leadership (25%), and accidental fall of surgical devices (25%). Four main strategies were implemented to reduce errors: improving leadership, clearly defining roles, improving knowledge base, and surgical room reorganization. By the last simulation, conversions were performed without errors and using 55.2% less time compared with initial simulations.nnnCONCLUSIONSnIn this preliminary study, repeated simulations, increased leadership, improved role delineation, and surgical room reorganization enabled faster and less flawed conversions. Further studies are needed to identify if such protocols may translate to actual safety improvement during open conversions.

Endovascular snare kit in the combined antegrade and retrograde management of ureteral avulsion: report of two cases

We report the feasible and safe use of the Amplatz Goose Neck® Snare kit for avulsed ureter retrieval during ureteroscopy. A 49-year-old lady and a 61-year-old man complaining of urolithiasis underwent ureteroscopy; following stone fragmentation, and basketing avulsion of the ureter occurred. Using the Amplatz Goose Neck® Snare kit it was possible to place an indwelling ureteral catheter in both cases aiming at restoring the urinary upper tract continuity. The snare-assisted endovascular technique may be an interesting tool even in endourology for the management of ureteral avulsion. This endoscopic mini-invasive procedure makes it possible to avoid an immediate invasive surgical approach often resulting in nephrectomy, having time for planning a possible durable conservative treatment.

A prospective accuracy study of Prostate Imaging Reporting and Data System version 2 on multiparametric magnetic resonance imaging in detecting clinically significant prostate cancer with whole-mount pathology

OBJECTIVEnTo assess the accuracy of Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) in detecting clinically significant prostate cancer (csPCa) on multiparametric magnetic resonance imaging (mpMRI) using whole-mount sections after radical prostatectomy (RP) as reference standard.nnnMETHODSnForty-eight patients undergoing mpMRI before RP were prospectively enrolled. Two experienced radiologists independently scored and mapped imaging findings according to PI-RADS v2. One experienced uropathologist mapped cancers detected on whole-mount sections using the PI-RADS v2 sector scheme. Per-lesion and per-patient analyses were run. Primary outcomes were sensitivity and false discovery rate (FDR) in detecting csPCa using PI-RADS v2 score ≥3 and ≥4 as thresholds. Secondary outcome was inter-reader agreement.nnnRESULTSnOn the per-lesion analysis, sensitivity and FDR at the PI-RADS v2 threshold score ≥3 were 0.75 and 0.17 for Reader 1, and 0.67 and 0.13 for Reader 2, respectively. At the PI-RADS v2 threshold score ≥4, sensitivity was slightly lower, and FDR nearly halved for both readers. On the per-patient analysis, sensitivity for csPCa at the PI-RADS v2 threshold score ≥3 was 0.85 for Reader 1, and 0.78 for Reader 2. At the PI-RADS v2 threshold score ≥4, sensitivity was slightly lower for both readers. Inter-reader agreement was substantial (k 0.72 and 0.65 for PI-RADS v2 threshold score ≥3 and ≥4, respectively).nnnCONCLUSIONnIn our prospective study with pathology after RP as standard of reference, PI-RADS v2 showed good sensitivity in detecting csPCa on mpMRI with substantial agreement between 2 experienced readers. Threshold score ≥4 had lower FDR.

Sliding-clip technique for renorrhaphy improves perioperative outcomes of open partial nephrectomy

Abstract Introduction: the aim of this work is to assess whether renorrhaphy with the sliding-clip technique improves perioperative and early functional outcomes compared with traditional renorrhaphy in a contemporary series of patients undergoing open partial nephrectomy (PN). Material and Methods: A single-center single-surgeon cohort of 107 consecutive patients treated with open PN between July 2013 and March 2017 was analyzed. A study group of 48 patients undergoing renorrhaphy with the sliding-clip technique was compared with a control group of 59 patients receiving traditional renorrhaphy. Outcome measures were operative room (OR) time, warm ischemia time (WIT), estimated blood loss (EBL), rate of overall 90-day postoperative complications, and percentage change in estimated glomerular filtration rate (PCE)u2009>u200910% and >20% 1 month postoperatively. Results: OR time (pu2009=u20090.02), WIT (pu2009=u20090.01) and EBL (pu2009<u20090.001) were significantly lower in the study versus control group. Overall 90-day postoperative complications were observed in 8 (16.7%) versus 21 (35.7%) patients in the study versus control group (pu2009=u20090.02). PCEu2009>u200910% and >20% 1 month postoperatively were observed in approximately 40% and 20% of patients, respectively, with no significant differences between groups. On multivariable analysis, a sliding-clip technique was an independent predictor of WITu2009>20u2009min and/or EBLu2009>500u2009ml (OR 0.238, 95%CI 0.074–0.767; pu2009=u20090.01) and overall 90-day postoperative complications (OR 0.360, 95%CI 0.151-0.856; pu2009=u20090.02). Conclusions: In patients undergoing open PN, renorrhaphy with the sliding-clip technique was associated with better intraoperative and postoperative outcomes compared with traditional renorrhaphy. No significant differences were observed in terms of early renal function change.

Retrosigmoid Versus Traditional Ileal Conduit for Urinary Diversion After Radical Cystectomy

BACKGROUNDnUreteroileal anastomotic stricture (UAS) after ileal conduit diversion occurs in a non-negligible proportion of patients undergoing radical cystectomy (RC). Surgical techniques aimed at preventing this potential complication are sought.nnnOBJECTIVEnTo describe our surgical technique of retrosigmoid ileal conduit, and to assess perioperative outcomes and postoperative complications with a focus on UAS rate.nnnDESIGN, SETTING, AND PARTICIPANTSnA prospective single-centre, single-surgeon cohort of 67 consecutive patients undergoing open RC with ileal conduit urinary diversion between July 2013 and April 2017 was analysed. A study group of 30 patients receiving retrosigmoid ileal conduit was compared with a control group of 37 patients receiving standard Wallace ileal conduit.nnnSURGICAL PROCEDUREnRetrosigmoid versus Wallace ileal conduit diversion after open RC.nnnMEASUREMENTSnOperative room (OR) time, estimated blood loss (EBL), transfusion rate, and 90-d postoperative complications were recorded and compared between the two groups. In particular, rate of UAS, defined as upper collecting system dilatation requiring endourological or surgical management, was assessed and compared.nnnRESULTS AND LIMITATIONSnThe two groups were comparable with regard to all demographic, clinical, and pathological variables. No differences were observed in terms of OR time (p=0.35), EBL (p=0.12), and transfusion rate (p=0.81). Ninety-day postoperative complications were observed in 11 (36.7%) patients who underwent a retrosigmoid ileal conduit and 20 (54.1%) patients who received a traditional ileal conduit (p=0.32). Major complications (grade 3-4) were observed in three (10%) cases in the former group and in 12 (32.4%) cases in the latter group (p=0.08). Mean (standard deviation) follow-up time was 10.8±4.0 mo in the study group and 27.5±9.5 mo in the control group (p<0.001). No single case of UAS was observed in the study group, whereas six (16.2%) cases of UAS occurred in the control group (p=0.02). The main limitation is a nonrandomised comparison of a relatively small cohort with short-term follow-up.nnnCONCLUSIONSnIn our study, we observed a significantly reduced rate of UAS and no increase in postoperative complications with the retrosigmoid ileal conduit diversion compared with standard Wallace ileal conduit diversion after open RC.nnnPATIENT SUMMARYnWe describe our surgical technique of retrosigmoid ileal conduit as urinary diversion after open radical cystectomy. Compared with traditional techniques, our technique for ileal conduit was found to be safe and reduce the risk of ureteric strictures.

Close surgical margins after radical prostatectomy: how to make a complex story even more complex

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Endourologic Diagnosis and Robotic Treatment of a Giant Fibroepithelial Polyp of the Ureter

Abstract Background: Fibroepithelial polyps (FEPs) are a rare cause of ureteropelvic junction (UPJ) obstruction. Radiologists and urologists are not always confident with this disease because of its rarity, complex diagnosis, and heterogeneity of the available treatment options. Case Presentation: We present the endourologic diagnosis and the robotic management of a ureteral polyp close to the left UPJ. A 16-year-old woman with a 12 years history of left lumbar pain was referred to our Center. A computed tomography scan detected a left hydronephrosis with no signs of obstructions at MAG-3 scintigraphy. The endourologic evaluation revealed a giant FEP of the left ureter, which was removed surgically with a videolaparoscopic robot-assisted approach. Conclusion: Considering that conventional radiologic imaging techniques can hardly detect a ureteral FEP, an endourologic study of the urinary tract is mandatory to directly observe the polyp. The mini-invasive treatment of ureteral FEPs is feasible and safe, and should be considered as first option in young patients.