Fabrizio Dal Moro

Interstitial biodegradable balloon for reduced rectal dose during prostate radiotherapy: results of a virtual planning investigation based on the pre- and post-implant imaging data of an international multicenter study.

PURPOSE To evaluate dose reduction caused by the implantation of an interstitial inflatable and biodegradable balloon device aiming to achieve lower rectal doses with virtual 3D conformal external beam radiation treatment. MATERIALS AND METHODS An inflatable balloon device was placed, interstitially and under transrectal ultrasound guidance, into the rectal-prostate interspace prior treatment initiation of 26 patients with localized prostate cancer, who elected to be treated with radiotherapy (3D CRT or IMRT). The pre- and post-implant CT imaging data of twenty two patients were collected (44 images) for the purpose of the 3D conformal virtual planning presented herein. RESULTS The dorsal prostate-ventral rectal wall separation resulted in an average reduction of the rectal V70% by 55.3% (± 16.8%), V80% by 64.0% (± 17.7%), V90% by 72.0% (± 17.1%), and V100% by 82.3% (± 24.1%). In parallel, rectal D2 ml and D0.1 ml were reduced by 15.8% (± 11.4%) and 3.9% (± 6.4%), respectively. CONCLUSIONS Insertion of the biodegradable balloon into the prostate-rectum interspace is similar to other published invasive procedures. In this virtual dose distribution analysis, the balloon insertion resulted in a remarkable reduction of rectal volume exposed to high radiation doses. This effect has the potential to keep the rectal dose lower especially when higher than usual prostate dose escalation protocols or hypo-fractionated regimes are used. Further prospective clinical investigations on larger cohorts and more conformal radiation techniques will be necessary to define the clinical advantage of the biodegradable interstitial tissue separation device.

Successful Repair of Iatrogenic Rectourinary Fistulas Using the Posterior Sagittal Transrectal Approach (York-Mason): 15-Year Experience

IntroductionRectourinary fistulas (RUFs) represent a challenging clinical problem. Most RUFs are secondary to lower urinary or intestinal tract surgery. Several surgical approaches have been proposed. The aim of this study was to review a 15-year experience using the York-Mason posterior sagittal transrectal approach to iatrogenic RUFs.MethodsSeven patients with RUFs secondary to urologic surgery were operated on with the York-Mason technique at the Department of Urology, University of Padova, Italy between 1988 and 2003. The patients’ data have been collected and analyzed retrospectively.ResultsAll the patients were treated successfully (100%). In one patient with Crohn’s disease the fistula recurred 11 years after the first surgery. One patient died for metastasis of prostate cancer 1 year after surgical repair of the RUF. A temporary colostomy was performed in five patients; the colostomies were subsequently closed, and the patients regained complete fecal continence with no postoperative anal strictures. The colostomy remained in place in one patient with Crohn’s disease and in another with ulcerative rectocolitis.ConclusionsThe posterior sagittal transrectal approach provided easy access and identification of RUFs and good surgical exposure, with no subsequent strictures or fecal incontinence. Our data show that the York-Mason technique alone is a highly effective option for treating an iatrogenic postoperative RUF.

Do Weather Conditions Influence the Onset of Renal Colic? A Novel Approach to Analysis

Background/Aim: To investigate the seasonal variations of the incidence of renal colic by a computerized analysis of cyclic climatic features. Methods: 1,163 consecutive patients with acute renal colic were studied. Eigendecomposition and signal reconstruction of district temperature and humidity were performed to establish any cyclic variation. Average temperatures and humidity values were calculated at time periods of 15, 30, 45 and 60 days preceding each renal colic. Results: Patients were allocated to groups every 30 days, since eigendeanalysis suggested that intervals of this duration have homogeneous climatic features. With an average time period of 15 days preceding each renal colic, a positive correlation coefficient of temperature (r = +0.75 with CI 0.31–0.93, p < 0.005) and a cubic relationship at the regression analysis (R = 82.4%, p = 0.015) were found with the onset of colics. We observed a negative correlation between humidity and renal colic (rho = –0.70 with CI –0.92 to –0.21, p < 0.01), with an inverse relation as regression model (R = 57.9%, p < 0.05). Conclusions: We demonstrated an association between the onset of renal colics and exposure to hot and dry weather, particularly when temperatures rose above 27°C and relative humidity fell below 45%.

Cellular and molecular gateways to urolithiasis: a new insight.

Urolithiasis is a relevant clinical problem in everyday practice with a subsequent burden for the health system. Urolithiasis is classically explained as the derangement in the process of biomineralization involving the equilibrium between promoters and inhibitors of crystallization: a deficit of one or several inhibitors or an excess of one or several promoters plays a pivotal role in the stone formation. The revolutionary introduction of the molecular biology in medicine has given a new insight in urolithiasis too. Genetic factors have also been postulated to play an important role. A review of the current knowledge on urolithiasis based upon a molecular and genetic approach is reported.

Twenty-year experience with surgical management of recto-urinary fistulas by posterior sagittal transrectal approach (York-Mason).

BACKGROUND We describe our 20-year experience with a posterior transrectal approach (York-Mason procedure) to treat recto-urinary fistula (RUF). Most RUFs are secondary to lower urinary or intestinal tract surgery. Spontaneous closure is infrequent, and operative treatment is often mandatory. Several surgical approaches have been proposed. METHODS We reviewed retrospectively the medical records of 14 patients presenting with RUF in our Department between 1988 and 2010. In 10 patients, RUFs developed after radical retropubic prostatectomy (RRP); in the other 4 patients, RUFs resulted after other surgical interventions. All patients were treated with the York-Mason approach. A temporary colostomy and suprapubic cystostomy were performed in all patients except one. RESULTS All patients were treated successfully. After fistulectomy, colostomies were closed after 4 mo, and patients reported fecal continence and no postoperative anal strictures. The colostomy was left in place permanently in 1 patient due to the simultaneous presence of Crohns disease, in another with ulcerative rectocolitis, and in a third scheduled for adjuvant radiotherapy for relapse after RRP. In 1 patient, daily medications were essential because of wound infection. In the patient with Crohns disease, the fistula recurred 11 years after first repair. Two patients died of metastatic prostate cancer 1 year after repair of the RUF. CONCLUSION The posterior sagittal transrectal approach allows easy access and good surgical exposure, facilitating identification of the fistulous tract. In our opinion, the York-Mason approach guarantees the greatest success rate with the least morbidity.

Urinary Markers in the Everyday Diagnosis of Bladder Cancer

Bladder cancer (BC) represents the fourth most common neoplasia in men and the ninth most common cancer in women, with a significant morbidity and mortality. Cystoscopy and voided urine cytology (involving the examination of cells in voided urine to detect the presence of cancerous cells) are currently the routine initial investigations in patients with hematuria or other symptoms suggestive of BC. Around 75-85% of the patients are diagnosed as having non-muscle-invasive bladder cancer (NMIBC). Despite the treatment, these patients have a probability of recurrence at 5 years ranging from 50 to 70% and of progression to muscle invasive disease of 10-15%. Patients with NMIBC must undergo life-long surveillance, consisting of serial cystoscopies, possibly urine cytology and ultraso-nography. Cystoscopy is unsuitable for screening because of its invasiveness and costs; serial cystoscopies may cause discomfort and distress to patients. Furthermore, cystoscopy may be inconclusive, falsely positive or negative. Although urine cytology has a reasonable sensitivity for the detection of high-grade BC, it lacks sensitivity to detect low-grade tumors (sensitivity ranging from 4 to 31%). The overall sensitivity and specificity of urine cytology range from 7 to 100 and from 30 to 70%, respectively. There is a need for new urine biomarkers that may help in BC diagnosis and surveillance. A lot of urinary biomarkers with high sensitivity and/or specificity have been investigated. Although none of these markers have proven to be powerful enough to replace standard cystoscopy, some of them may represent accurate predictors of BC. A review of recent studies is presented.

Combined Robotic-Assisted Retroperitoneoscopic Partial Nephrectomy and Extraperitoneal Prostatectomy. First Case Reported:

A 54-year-old man with a history of prostate cancer and clear cell renal cell carcinoma of the left kidney underwent concomitant robot-assisted laparoscopic partial nephrectomy and radical prostatectomy. We report, to our knowledge, the first case of a concomitant retroperitoneal robotic-assisted partial nephrectomy and extraperitoneal radical prostatectomy.

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

INTRODUCTION There 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. AIMS To perform a root cause analysis of open conversion simulations from RARP to ORP to identify errors that may contribute to adverse events. METHODS From 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. RESULTS The 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. CONCLUSIONS In 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.

Anesthesiologic Effects of Transperitoneal Versus Extraperitoneal Approach During Robot-Assisted Radical Prostatectomy: Results of a Prospective Randomized Study

ABSTRACT Objectives: To compare the effects of CO2 insufflation on hemodynamics and oxygen levels and on acid-base level during Robot-Assisted Radical Prostatectomy (RARP) with transperitoneal (TP) versus extra-peritoneal (EP) accesses. Materials and Methods: Sixty-two patients were randomly assigned to TP (32) and EP (30) to RARP. Pre-operation data were collected for all patients. Hemodynamic, respiratory and blood acid-base parameters were measured at the moment of induction of anesthesia (T0), after starting CO2 insuffation (T1), and at 60 (T2) and 120 minutes (T3) after insufflation. In all cases, the abdominal pressure was set at 15 mmHg. Complications were reported according to the Clavien-Dindo classification. Students two–t-test, with a significance level set at p<0.05, was used to compare categorical values between groups. The Mann-Whitney U-test was used to compare the median values of two nonparametric continuous variables. Results: The demographic characteristics of the patients in both groups were statistically comparable. Analysis of intra-operative anesthesiologic parameters showed that partial CO2 pressure during EP was significantly higher than during TP, with a consequent decrease in arterial pH. Other parameters analysed were similar in the two groups. Postoperative complications were comparable between groups. The most important limitations of this study were the small size of the patient groups and the impossibility of maintaining standard abdominal pressure throughout the operational phases, despite attempts to regulate it. Conclusions: This prospective randomized study demonstrates that, from the anesthesiologic viewpoint, during RARP the TP approach is preferable to EP, because of lower CO2 reabsorption and risk of acidosis.

Lighting from the urethral cystoscope side: A novel technique to safely manage bowel division during intracorporeal robotic urinary diversion

DOI: 10.1111/iju.13035 RC and UD represent the “gold standard” treatment for muscle-invasive BC. Laparoscopic RC and RARC are emerging techniques; in comparison with open RC, these approaches are characterized by reduced blood loss and postoperative pain, and improvement in recovery of intestinal function. The robotic creation of an intracorporeal neobladder has gradually been adopted as part of complete RARC procedures, but it does remain subject to controversy. Technological advances could further improve the ease and efficiency of robotic intracorporeal diversion. One of the most critical points in intracorporeal reconfiguration is the manipulation of the bowel. As the recent Pasadena Consensus Panel noted, there are various ways of facilitating safe manipulation of the ileum, one of which is the Marionette technique. However, no mention was made in the final Pasadena document about the problem of incising the mesentery to avoid major injury to ileal vascularization. In our opinion, this maneuver represents one of the most dangerous steps in intracorporeal UD. An anastomotic leakage, especially that resulting from ileal–ileal anastomosis, is a dangerous and sometimes life-threating complication. Meticulous preservation of the bowel mesenteric vascularization could help avoid bowel ischemia and might decrease the risk of such complications. The literature describes a technique to isolate the bowel segment, using fluorescence imaging to confirm vascular anatomy: indocyanine green solution, given intravenously for mesenteric angiography, can successfully identify the mesenteric arcades. Identification of bowel vascularization was one of the earliest and most frequently studied applications of indocyanine green, and this efficacious and well-known method has already been tested during nephron-sparing surgery. However, it is expensive and requires expert use of a special robotic camera. Nevertheless, the majority of intracorporeal reconstructions are carried out without strict visualization of the arcades, and some robotic surgeons use a stapler and apply this parallel with the direction of the vessels with no problem. Starting from personal experience, we would like to suggest a novel method, which is inexpensive and easy to carry out (Fig. 1a, Video S1). During a case of robotic radical prostatectomy, because of extensive lysis of tenacious intestinal adhesions (as a result of prior complex abdominal surgery), we needed to evaluate the proper preservation of intestinal vascularization. The idea was (after removal of the prostate) to insert a flexible cystoscope into the urethra (Fig. 1b); Johan and fenestrated grasping forceps were used for bowel manipulation. When the robotic arms had been used to subject the ileal segment to gentle traction, we turned off the camera light and, using only the light from the cystoscope, transilluminated the mesenteric tract, which allowed clear-cut visualization of the vessels. The vascular arcades turned out to be easy to identify, the perfusion status of the intestine could be checked and normal vascularization was confirmed . . . all very quickly and easily. As shown in Figure 1, mesenteric vascularization is more clearly visualized with this technique (Fig. 1d,e) than with only the conventional robotic camera (Fig. 1c). This simple, fast, inexpensive and easy-to-perform technique can be used during the steps of bowel isolation for UD. We know that the common backlight technique used during open RC is apparently superior in terms of the visibility of the mesenteric vasculature compared with this technique, but considering that near-infrared fluorescence imaging is not always available during RARC, transillumination via a urethral cystoscope can be used to pinpoint the site of bowel mesenteric division, and appropriate perfusion of the proximal and distal margins of the resection can be achieved. Although various surgical departments use certain differences in techniques when carrying out routine RARC (or laparoscopic RC), in our opinion the above in-house technique should form part of the armamentarium of robotic surgeons. Further technical improvement of the