Elisa De Lorenzis

Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta‐analysis

To evaluate the influence of posterior musculofascial plate reconstruction (PR) on early return of continence after radical prostatectomy (RP); an updated systematic review of the literature. A systematic review of the literature was performed in June 2015, following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement and searching Medline, Embase, Scopus and Web of Science databases. We searched the terms posterior reconstruction prostatectomy, double layer anastomosis prostatectomy across the ‘Title’ and ‘Abstract’ fields of the records, with the following limits: humans, gender (male), and language (English). The authors reviewed the records to identify studies comparing cohorts of patients who underwent RP with or without restoration of the posterior aspect of the rhabdosphincter. A meta‐analysis of the risk ratios estimated using data from the selected studies was performed. In all, 21 studies were identified, including three randomised controlled trials. The overall analysis of comparative studies showed that PR improved early continence recovery at 3–7, 30, and 90 days after catheter removal, while the continence rate at 180 days was statistically but not clinically affected. Statistically significantly lower anastomotic leakage rates were described after PR. There were no significant differences for positive surgical margins rates or for complications such as acute urinary retention and bladder neck stricture. The analysis confirms the benefits at 30 days after catheter removal already discussed in the review published in 2012, but also shows a significant advantage in terms of urinary continence recovery in the first 90 days. A multicentre prospective randomised controlled trial is currently being conducted in several institutions around the world to better assess the effectiveness of PR in facilitating an earlier recovery of postoperative urinary continence.

Robotics in uro-oncologic surgery.

In urology, the main use for the robotic technique has been in radical prostatectomy for prostate cancer. Robotic surgery for other organs, such as the kidneys and bladder, has been less explored. However, partial nephrectomy or radical nephroureterectomy can be difficult for inexperienced laparoscopic surgeons. The advent of the da Vinci robot, with multijointed endowristed instruments and stereoscopic vision, decreases the technical difficulty of intracorporeal suturing and improves the reconstructive steps. The objective of this article is to offer an overview of all robotic procedures recently developed in the field of urology. We evaluate the feasibility of these procedures and their potential advantages and disadvantages. We also describe perioperative, postoperative, and oncologic outcomes of robot-assisted surgery as well as perform a comparison with open and laparoscopic techniques. Comparative data and an adequate follow-up are needed to demonstrate equivalent oncologic outcomes in comparison with traditional open or laparoscopic procedures.

Robotic prostatectomy: an update on functional and oncologic outcomes

Since the first procedure performed in 2000, robotic-assisted radical prostatectomy (RARP) has been rapidly gaining increasing acceptance from both urologists and patients. Today, RARP is the dominant treatment option for localised prostate cancer (PCa) in the United States, despite the absence of any prospective randomised trial comparing RARP with other procedures. Robotic systems have been introduced in an attempt to reduce the difficulty involved in performing complex laparoscopic procedures and the related steep learning curve. The recognised advantages of this kind of minimally invasive surgery are three-dimensional (3D) vision, ten-fold magnification, Endowrist technology with seven degrees of freedom, and tremor filtration. In this article, we examine this technique and report its functional (in terms of urinary continence and potency) and oncologic results. We also evaluate the potential advantages of RARP in comparison with open and laparoscopic procedures.

Primary large cell neuroendocrine carcinoma of the renal pelvis: a case report.

We report a case of primary large cell neuroendocrine carcinoma of the renal pelvis, diagnosed in a 79-year-old man. The abdominal computed tomography showed a solid, vegetant lesion in the left renal pelvis, conditioning marked hydronephrosis. The patient underwent radical nephroureterectomy. The histological examination showed a large cell neuroendocrine carcinoma associated with a high-grade urothelial carcinoma, with local invasion (pT3). Large cell renal neuroendocrine carcinomas are rare tumors with an aggressive course and a bad prognosis. At present, only five cases were reported in literature.

A novel tool for predicting extracapsular extension during graded partial nerve sparing in radical prostatectomy

To create a statistical tool for the estimation of extracapsular extension (ECE) level of prostate cancer and determine the nerve‐sparing (NS) approach that can be safely performed during radical prostatectomy (RP).

Transmesenteric approach for left transperitoneal renal surgery: technique and experience.

INTRODUCTION In the last few years laparoscopic surgery has become the gold standard for the treatment of several urological diseases such as renal cancer and ureteropelvic junction obstruction (UPJO). A transmesenteric approach for left laparoscopic pyeloplasty has been recently described in order to avoid bowel manipulation and the potentially related complications. The aim of the present study is to describe the surgical technique and the advantages of the transmesenteric approach for laparoscopic pyeloplasty, pyelolithotomy, and simple nephrectomy in our experience. SUBJECTS AND METHODS From December 2007 to May 2010, 12 laparoscopic procedures for left renal diseases were performed using a transmesenteric approach. The indications were left UPJO in 9 cases, left pelvic-ureteral stones in 2 cases, and left end-stage kidney disease in one case. RESULTS No conversions or intraoperative complications were observed. No blood transfusions were required. Resumption of oral intake and canalization occurred in all cases within 48 hours of the procedure. All patients had an uneventful postoperative course. CONCLUSIONS The laparoscopic transmesenteric approach represents an interesting and advantageous technical improvement of minimally invasive surgery for the treatment of left renal diseases.

Medical Expulsive Therapy for Symptomatic Distal Ureter Stones: Is the Combination of Bromelain and Tamsulosin More Effective than Tamsulosin Alone? Preliminary Results of a Single-Center Study

Objectives: To assess the safety and efficacy of bromelain plus tamsulosin versus tamsulosin alone as medical expulsive therapy (MET) for promoting spontaneous stone passage (SSP) of symptomatic distal ureter stones. Patients and Methods: One-hundred-fourteen patients with a 4–10 mm distal ureteral stone were enrolled (Group A). Patients self-administered daily bromelain with tamsulosin for 30 days or until SSP or intervention was mandatory. Patients were compared to those from a control group taking tamsulosin as MET (Group B) and matched for the following factors: sex, age ±10%, stone diameter. A logistic regression model evaluated bromelain and the ureteral stone diameter as explanatory variables. Results: SSP rates were 87.7 vs. 75.4% for group A vs. group B respectively (p = 0.016); with no difference observed for the time to self-reported stone expulsion (11.68 vs. 11.57 days; p = 0.91). Considering larger stones (> 5 mm), the SSP rate was 83.3% in group A and 61% in group B (p < 0.01). With each millimeter increment of stone diameter, the probability of SSP decreased by 59.1% (p < 0.0001), while it increased of 3.3 when bromelain was present. Only 3 cases of tamsulosin-related adverse events were recorded. Conclusion: The association of bromelain and tamsulosin as MET increases the probability of SSP of symptomatic distal ureteral stones, with no bromelain-related side effects recorded.

Prevalence and predictors of being lost to follow-up after transurethral resection of the prostate

Patient follow-up after transurethral resection of the prostate (TURP) is crucial to evaluate treatment-related outcomes and potential adverse events. We sought to determine the rate of, and factors associated with, patient nonadherence to follow-up after TURP. Data from 180 patients who underwent TURP were analysed. Patient counselling and follow-up were standardized among the cohort. Patients were considered lost to follow-up (LTF) if they were at least 30 days from their first scheduled follow-up appointment. Descriptive statistics and logistic regression analyses were performed to determine the impact of predictors on the rate of compliance with prescribed follow-up. Of 180 patients, 55 (30.5%) were LTF. LTF patients were younger (p < 0.001), had lower educational status (p = 0.007) and were more frequently single (p = 0.03) than those who were not LTF. Importantly, patients who experienced a postoperative-related event (PRE) were more likely to follow-up (p = 0.04). Multivariable analysis revealed that younger age (p < 0.001) and low educational status (p < 0.001) were independent predictors of being LTF. One out of three men submitted to TURP is lost to follow-up in the real-life setting. Noncompliance to follow-up was more frequent among young, single patients with low educational status. On the contrary, patients who experienced a PRE were more likely to follow-up.

Incidence and predictors of readmission within 30 days of transurethral resection of the prostate: A single center European experience

Hospital readmission rates have been analyzed due to their contribution to increasing medical costs. Little is known about readmission rates after urological procedures. We aimed to assess the incidence and predictors of 30-day readmission after discharge in patients treated with transurethral resection of the prostate (TURP). Data from 160 consecutive patients who underwent TURP from January 2015 to December 2016 were analysed. Intra hospitalization characteristics included length of stay (LOS), catheterization time (CT) and complications. Comorbidities were scored with the Charlson Comorbidity Index (CCI). Mean (SD) age was 70.1 (8.1) yrs and mean prostate volume was 80 (20.1) ml. Mean LOS and CT were 4.9 (2.5) days and 3.3 (1.6) days, respectively. The overall 30-day readmission rate was 14.4%, but only 7 (4.4%) patients required hospitalization. The most frequent reasons for readmission were haematuria (6.8%), fever/urinary tract infections (4.3%) and acute urinary retention (3.1%). Multivariable logistic regression analysis revealed age, CCI and CT to be independent predictors of readmission. However, when analysed according to age at the time of surgery, a beneficial effect from longer CT was observed only for patients older than 75 years. These parameters should be taken in account at the time of discharge after TURP.

Role of Bed Assistant During Robot-assisted Radical Prostatectomy: The Effect of Learning Curve on Perioperative Variables

BACKGROUND A remote interaction between a console surgeon (CS) and a bedside surgeon (BS) makes the role of the latter critical. No conclusive data are reported about the length of the learning curve of a BS. OBJECTIVE To highlight the role of a BS during robot-assisted radical prostatectomy (RARP) and to analyze the effect of the learning curve of a BS on intra- and postoperative outcomes. DESIGN, SETTING, AND PARTICIPANTS From June 2013 to September 2016, 129 RARPs were performed by one expert CS (>1000 RARPs) and two BSs (residents). According to the learning curve of the BS, the patients were divided into three groups: group 1 (first 20 procedures), group 2 (21-40 procedures), and group 3 (>40 procedures). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Preoperative variables, pathological data, operating time (OT), blood loss (BL), number of lymph nodes excised (LE), length of hospital stay (LHS), and time to catheter removal (CR) were analyzed. Linear/logistic regression analyses tested the impact of BS experience on surgical outcomes. T test and chi-square test compared the outcomes of the two BSs. RESULTS AND LIMITATIONS Perfect interaction between CSs and BSs are requested to obtain the optimal exposure and avoid any conflict. On the linear regression model, BS learning curve was not related to OT, BL, LHS, and CR, but was related to LE (r2=0.09; p=0.03). On multivariate analyses, no correlation between BS experience and OT, BL, LHS, CR, LE, margin status, and complications (all p>0.05) was found. Comparing the two BSs, no difference was found for the abovementioned outcomes in the first 40 surgeries (all p>0.05). Study limitations include the limited cohort of patients and its retrospective nature. CONCLUSIONS In this study, BS learning curve does not appear to influence the surgical outcomes; good experience of the CS was probably the explanation. PATIENT SUMMARY In our experience, it is the primary surgeon who dictates the perioperative outcomes during robot-assisted radical prostatectomy.