F.M. Turri

Delayed-onset ureteral lesions due to thermal energy: An emerging condition

OBJECTIVESnTo describe the risks of ureteral damage occurring during urological and gynecological procedures utilizing energybased surgical devices (ESD) during both laparoscopic and open procedures.nnnMATERIALS AND METHODSnDuring the last 20 months we observed five cases of iatrogenic ureteral lesions caused by ESD which required open surgery. There were 3 lesions of the lower ureter occurring during gynecological laparoscopic or robotic procedures, and 2 lesions of the upper ureter occurring during open enucleation of low-stage renal cell carcinomas.nnnRESULTSnIn the laparoscopic gynecological lesions the cause was attributable to monopolar cutting and bipolar coagulation: they presented with urine extravasation after 20, 15 and 15 days respectively and required ureteral reimplantation in 2 out of 3 cases. In the upper ureteral lesions the causes were bipolar coagulation and LigaSure Impact TM used for perirenal fat dissection: they presented after 2 and 4 months respectively and required uretero-ureterostomy and inferior nephropexy in one case and nephrectomy in the other. In 3 out of 5 cases there was an unsuccessful attempt at placing an ureteral double J stent, and in the 2 cases where it was placed it did not prevent the formation of subsequent stricture in one.nnnCONCLUSIONSnThe widespread diffusion of ESD has the potential drawback of inadvertent thermal energy transmission to the ureter. Delayed presentation of ureteral lesions and difficulties in ureteral stent placement were the common features of the cases observed. Inadvertent ureteral damage by different thermal energy sources is an emerging condition, requiring awareness, prompt recognition and adequate treatment with the reconstructive urology principles.

Minimally invasive treatment of urinary fistulas using N-butyl-2-cyanoacrylate: a valid first line option

BackgroundA few single case reports and only one clinical series have been published so far about the use of N-butyl-2-cyanoacrylate in the treatment of urinary fistulas persisting after conventional urinary drainage.Case presentationWe treated five patients with a mean age of 59.2 years presenting iatrogenic urinary fistulas which persisted following conventional drainage manouvres. There were 3 calyceal fistulas following open, laparoscopic and robotic removal of renal lesions respectively, one pelvic fistula after orthotopic ileal neobladder and a bilateral dehiscence of uretero-sigmoidostomy. We used open-end catheters of different sizes adopting a retrograde endoscopic approach for cyanoacrylate injection in the renal calyces, while a descending percutaneous approach via the pelvic drain tract and bilateral nephrostomies respectively was used for the pelvic fistulas. Fluoroscopic control was always used during the occlusion procedures. The amount of adhesive injected ranged between 2 and 5 cc and in one case the procedure was repeated. With a median follow-up of 11 months we observed clinical and radiological resolution in 4 cases (80%), while a recurrent and infected calyceal fistula after laparoscopic thermal renal damage during tumor enucleoresection required nephrectomy. No significant complications were documented.ConclusionsIn an attempt to spare further challenging surgery in patients that had been already operated on recently, minimally invasive occlusion of persistent urinary fistulas with N-butyl-2-cyanoacrylate represents a valid first line treatment, justified in cases when the urinary output is not excessive and there is a favorable ratio between the length and diameter of the fistulous tract.

Complete intraperitoneal displacement of a double J stent: a first case

OBJECTIVESnUreteral double-J stents are known to migrate proximally and distally within the urinary tract, while perforation and stent displacement are uncommon. Possible mechanisms of displacement are either original malpositioning with ureteral perforation or subsequent fistula and erosion of the excretory system, due to infection or long permanence of the device. We present the unique case of complete intraperitoneal stent migration in a 59-year-old caucasian male without evidence of urinary fistula at the moment of diagnosis, so far an unreported complication.nnnMATERIALS AND METHODSnEight months after the placement of a double-J stent for lower right ureteral stricture at a district hospital, the patient came at our observation for urosepsis and hydro-uretero-nephrosis. A CT scan demonstrated intraperitoneal migration of the stent outside the urinary tract. Cystoscopy failed to visualize the lower extremity of the stent, a percutaneous nephrostomy was placed to drain the urinary system and the stent was removed through a small abdominal incision on the right lower quadrant.nnnRESULTSnIn our case we presume that during the positioning manoeuvre the guide wire perforated simultaneously the lower ureteral wall and the pelvic peritoneum, and that once the upper end of the stent was coiled, the lower extremity was also attracted intraperitoneally. The lack of pain due to the spinal lesion concurred to this unusual complication.nnnCONCLUSIONSnWe must be aware that ureteral double J stents may be found displaced even inside the peritoneal cavity, and that the use of retrograde pyelography during placement is of paramount importance to exclude misplacement of an apparently normally coiled upper extremity of the stent.

A Novel Approach for Apical Dissection During Robot-assisted Radical Prostatectomy: The “Collar” Technique

BACKGROUNDnApical dissection in robot-assisted radical prostatectomy (RARP) affects not only cancer control, but also continence recovery.nnnOBJECTIVEnTo describe a novel approach for apical dissection, the collar technique, to reduce apical positive surgical margins (PSMs).nnnDESIGN, SETTING, AND PARTICIPANTSnA total of 189 consecutive patients (81 in the control group, 108 in the collar technique group) underwent RARP at a single center.nnnPRIMARY OUTCOMEnrates of apical PSMs; secondary outcome: urinary continence.nnnINTERVENTIONnThe urethral sphincter complex is incised 2-3mm distally to the apex, to stay farther from it and reduce PSMs; the underlying smooth muscle is exposed and incised closer to the apex to preserve the maximal length of the lissosphincter.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnMann-Whitney U and chi-square tests compared median and proportions between the two groups, respectively. Univariate logistic regression tested the association between technique employed and risk of apical PSMs.nnnRESULTS AND LIMITATIONSnFourteen patients (7.4%) revealed apical PSMs (9.9% in the control group, 5.6% in the collar group; p=0.7). When the collar technique was used, significantly lower rates of apical PSMs occurred in pT2 disease (0% vs 7.1%; p=0.03). In case of apical tumor at preoperative magnetic resonance imaging (MRI; n=43), the collar technique determined significantly lower overall (9.7% vs 42%) and apical (3.2% vs 42%) PSMs (all p≤0.02). Continence recovery in the collar and control groups was similar. When preoperative MRI showed an apical tumor, the collar technique had a significantly lower risk of apical PSMs (odds ratio: 0.05, p=0.009).nnnCONCLUSIONSnThe collar technique reduces the rates of apical PSMs in case of apical tumor, preserving the length of the lissosphincter.nnnPATIENT SUMMARYnWe describe a novel approach for apical dissection during robot-assisted radical prostatectomy. Our technique reduces the rates of apical surgical margins in case of apical tumor at preoperative magnetic resonance imaging and leads to optimal continence recovery.

Robot-assisted nephro-ureterectomy for upper tract urothelial carcinoma: Results from two high-volume robotic surgery institutions

Robot-Assisted NephroUreterectomy (RANU) represents a minimally invasive alternative to open NephroUreterectomy (NU) for management of Upper Tract Urothelial Carcinoma (UTUC) but its oncologic safety is still controversial. The objective of this study was to investigate the peri-operative, pathologic and oncologic outcomes of RANU for UTUC. From 2008 to 2017, 78 patients diagnosed with UTUC and elected for RANU at 3 high-volume robotic surgery centres were retrospectively assessed. Surgery was performed using da Vinci Si® and Xi® systems. RANU was done adhering to oncological principles as in open surgery. The outcomes of the study were: (1) peri-operative morbidity, namely intra- and post-operative complications, blood loss, length of hospital stay and operative time; (2) oncologic outcomes, namely overall survival (OS) and recurrence-free survival (RFS). Peri-operative overall complication rate was 24.4% and high-grade complication rate was 2.6%. Median blood loss, length of hospital stay and operative time were 124 ml, 4 days and 167 min. Lymphadenectomy was performed in 31 (41%) patients. Lymph-node involvement was present in 9 (29%) patients. At median follow-up of 15 months, 2- and 4-year OS were 79% and 66%, respectively, and RFS was 63% and 53%. Peritoneal dissemination was recorded in 1 (1.3%) patient with pT4N2R1 UTUC. Our study is limited by the relatively small cohort of patients and its retrospective character. RANU as minimally invasive treatment for patients with UTUC is safe and feasible. Post-operative morbidity is low and major complications are rare. Oncologic outcomes are acceptable and no evidence of increased risk of peritoneal dissemination is recorded. Long-term data are needed. RANU should be regarded as an alternative to open surgery for UTUC that can offer good peri-operative and oncologic results.

The management of small renal masses: what is likely to change?

The diffusion of imaging has determined an increased discovery of small renal masses (SRMs). Recent publications have been reviewed to present the state of the art in the management of SRMs and to try to foresee the next steps in this challenging condition. The role of percutaneous biopsies is expanding, since management algorithms include also active surveillance and ablative therapies. However up to 30% of biopsies fail to provide histological diagnosis and there is the risk of under-evaluating high-grade tumors. Active surveillance has been proposed in patients with reduced life expectancy and numerous comorbidities. The average growth of SRMs is slow, and metastatic progression has been observed in about 1%. Ablative therapies (cryotherapy and radiofrequency ablation) are used in patients with relevant comorbidities or advanced age and unfit for surgery, but who desire active treatment. Compared to conservative surgical treatment both techniques have increased local progression rates, while metastatic progression is relatively low. Partial nephrectomy (PN) is the recommended curative treatment for SRMs and can be performed open, laparoscopically or robotically. Open PN represents the benchmark, with similar cancer specific survival and better preservation of renal function compared to nephrectomy. Laparoscopy is comparable to open surgery in terms of oncologic results, but a long learning curve is necessary. Perioperative outcomes of robot-assisted PN appear superior to laparoscopy and the learning curve is shorter, but data for oncological results are still immature. With the increasing diffusion of robotic technology it is likely more SRMs will be managed with this approach.

Follow-Up of Patients After Male-to-Female (Mtf) Sex Reassignment Surgery (SRS)

Following surgery and legalization of the gender reassignment, long-term physical, sexual, hormonal, and psychological follow-up is necessary to establish and maintain the success of the procedure. Since persistent regret after sex reassignment surgery must be considered, along with suicide, as the worst conceivable outcome of SRS [1], it is crucial to know the opinion of patients when evaluating the cosmetic and functional results of the surgery [2].