Giovanni Saredi

Transurethral resection and sequential chemo-immunoprophylaxis in primary T1G3 bladder cancer.

Objectives: T1G3 superficial bladder cancer is considered to be at high risk for progression, and in some institutions early cystectomy is advocated. Other authors and personal experience suggest that conservative treatment, such as TURBT followed by intravesical prophylaxis, may be adequate in the majority of cases. The purpose of the present phase II study was to assess the tolerability and efficacy of sequential intravesical administration of a chemotherapeutic agent, epirubicin, followed by BCG, after TURBT.Materials and Methods: 81 patients with primary T1G3 superficial bladder cancer, without evidence of Tis or upper tract tumor, underwent TURBT and intravesical prophylaxis with weekly epirubicin 50 mg for 8 weeks followed by weekly BCG Connaught 120 mg for 6 weeks. A control cystoscopy with bladder mapping and/or TUR of suspicious areas was performed at 15–17 weeks. Then patients were followed–up with 3–month urinary cytology and cystoscopy.Results: The sequential chemo–immunoprophylaxis was generally well tolerated. After a mean follow–up of 48 months recurrent tumors were found in 19 patients (23.4%) and progressive disease in 6 cases (7.4%). Of 6 progressions, 4 patients died (5%) of the disease.Conclusion: Sequential chemo–immunoprophylaxis with epirubicin followed by BCG is well tolerated and seems to be efficacious in primary T1G3 bladder cancer. The recurrence progression and disease–specific mortality rates were acceptable so that this study seems to confirm previous data which show that TURBT and intravesical prophylaxis are appropriate treatment for the majority T1G3 tumors.

Evaluation of the learning curve for thulium laser enucleation of the prostate with the aid of a simulator tool but without tutoring: comparison of two surgeons with different levels of endoscopic experience

BackgroundThe aim of this study was to determine the learning curve for thulium laser enucleation of the prostate (ThuLEP) for two surgeons with different levels of urological endoscopic experience.MethodsFrom June 2012 to August 2013, ThuLEP was performed on 100 patients in our institution. We present the results of a prospective evaluation during which we analyzed data related to the learning curves for two surgeons of different levels of experience.ResultsThe prostatic adenoma volumes ranged from 30 to 130xa0mL (average 61.2xa0mL). Surgeons A and B performed 48 and 52 operations, respectively. Six months after surgery, all patients were evaluated with the International Prostate Symptom Score questionnaire, uroflowmetry, and prostate-specific antigen test. Introduced in 2010, ThuLEP consists of blunt enucleation of the prostatic apex and lobes using the sheath of the resectoscope. This maneuver allows clearer visualization of the enucleation plane and precise identification of the prostatic capsule. These conditions permit total resection of the prostatic adenoma and coagulation of small penetrating vessels, thereby reducing the laser emission time. Most of the complications in this series were encountered during morcellation, which in some cases was performed under poor vision because of venous bleeding due to surgical perforation of the capsule during enucleation.ConclusionsBased on this analysis, we concluded that it is feasible for laser-naive urologists with endoscopic experience to learn to perform ThuLEP without tutoring. Those statements still require further validation in larger multicentric study cohort by several surgeon. The main novelty during the learning process was the use of a simulator that faithfully reproduced all of the surgical steps in prostates of various shapes and volumes.

Impact of Thulium Laser Enucleation of the Prostate on Erectile, Ejaculatory and Urinary Functions.

Objective: To test the impact of Thulium laser enucleation of the prostate (ThuLEP) on erectile and ejaculatory functions, on lower urinary tract symptoms and on quality of life (QoL). Methods: From July 2013 to May 2015, we prospectively evaluated 177 patients with LUTS related to benign prostatic hyperplasia. All patients were assessed with the International Index of Erectile Function (IIEF-5), Male Sexual Health Questionnaire-Ejaculatory Disease (MSHQ-EjD), International Prostate Symptom Score (IPSS), QoL, PSA and uroflowmetry before and at 4 and 8 months after surgery. Results: Erectile function did not show variation with IIEF-5 preoperative score 22.49 ± 1.8 and postoperative score 22.14 ± 3.1 (p = 0.195) and 22.18 ± 3.2 (p = 0.26) at 4 and 8 months after treatment. The ejaculatory function on the MSHQ-EjD test indicated the reduction of ejaculation, changing from 14.90 ± 6.88 to 5.51 ± 4.17 (p < 0.0001) and 5.38 ± 3.93 (p < 0.0001) at 4 and 8 months follow-up. IPSS score decreased from preoperative 21.12 ± 5.81 to 3.14 ± 3.16 (p < 0.0001) and 3.08 ± 3.12 (p < 0.0001) 4 and 8 months after surgery. PSA decreased from 4.50 ± 3.72 to 1.39 ± 1.04 (p < 0.0001) and 1.47 ± 1.14 ng/ml (p < 0.0001) at 4 and 8 months follow-up, while QoL score improved from 5.41 ± 0.69 to 0.57 ± 0.84 (p < 0.0001) and 0.51 ± 0.80 (p < 0.0001) at 4 and 8 months follow-up. Conclusions: ThuLEP does not affect erectile function and determines the resolution of LUTS with improvement of QoL. Loss of ejaculation did not impair the sexual intercourse activities of the patients.

En Bloc Thulium Laser Enucleation of the Prostate: Surgical Technique and Advantages Compared With the Classical Technique

OBJECTIVEnTo report a new technique for thulium laser enucleation of the prostate, which we called en bloc ThuLEP.nnnMETHODSnA full anatomic description of the technique is provided. We assessed operative variables of a 50-patient series, treated with the new en bloc ThuLEP, and compared them with another series of 50 patients (who had the same preoperative parameters) operated with the classical 3-lobe technique, to assess the feasibility of the new one. All procedures were carried out by the same surgeon.nnnRESULTSnIn our experience, en bloc ThuLEP permits an easier enucleation of the adenoma, reduces operating time, and reduces the amount of energy delivered per adenoma gram compared with the classical technique. Further studies are needed to validate this technical evolution of prostatic enucleation and verify the reduction of postoperative irritative symptoms.nnnCONCLUSIONnEn bloc ThuLEP may represent a valid alternative for prostatic adenoma enucleation, mostly in medium-sized prostates.

Renal Cell Carcinoma with venous neoplastic thrombosis: A ten years review

PURPOSEnTo review the 10-year experience of our urological unit in the surgical management of renal cell carcinoma (RCC) with neoplastic tumor thrombosis focusing on postoperative survival.nnnMATERIALS AND METHODSnWe underwent a retrospective analysis of the patients treated for this pathology during the last decade 2002-2012, stratifying them by tumor thrombus level and histological subtype. Kaplan-Meyer curves were used to assess survival.nnnRESULTSnOverall, 67 patients underwent surgery for RCC with neoplastic tumoral thrombosis in the period under review. 60 were clear cell RCC, 4 were urothelial papillary tumors of the renal pelvis and 3 were rare histotypes, as a nefroblastoma, a spinocellular tumor of the renal pelvis and an unclassifiable renal carcinoma. Thrombus level was I in 40 cases, II in 17, III in 2 and IV in 8 patients. We report the main postoperative complications and our survival data, with mean follow up of 36 months. Tumor stage is the most important variable in predicting survival. Patients with N0M0 disease had 70% survival at 36 months, instead of 20% for those with primitive metastatic tumor.nnnCONCLUSIONnOur survival results fit with the main reports in literature and our surgical management was completely in keeping with international guidelines. We did not observe relevany post-operative complications, except of hemorrhagic ones that occurred in 6 patients (9% of total) and were always successfully managed. Eighteen patients (26.87% of total) underwent caval filter positioning, without evidence of complications during its positioning or removal. Life expectancy was particularly low for the cases of RCC without clear cell histotype (7 cases in our series, 10.4% of total) that always was less than one year from surgery.

Comparison Between Two Different En Bloc Thulium Laser Enucleation of the Prostate: Does Technique Influence Complications and Outcomes?

OBJECTIVEnTo evaluate whether 2 similar en bloc thulium laser enucleation of the prostate (ThuLEP) techniques can influence surgical complications and outcomes.nnnMATERIALnWithin 2 institutional databases 164 men who underwent 2 different en bloc ThuLEP techniques were compared using propensity scores. With the first technique prostatic lobes were all enucleated en bloc, whereas, with the second the median lobe was enucleated first and the lateral lobes were enucleated en bloc thereafter. All patients were evaluated at baseline and 6 months after surgery with PSA, Qmax, and self-administrated IPSS. Operative data and 30-day postoperative complications were gathered.nnnRESULTSnSurgical time and 24-hour blood loss were similar between 2 groups (55 vs 55 minutes, P .97288; -0.9 vs -1.3 g/dL, P .112 respectively). Median hospital stay after surgery was 3 days in both groups (P .3251). IPSS and Qmax improved equally in both groups (median 3 vs 3, P .941; 19.17 vs 20.63 mL/s, P .8232 respectively). Early complications were mild to moderate (Clavien I 12.2% vs 12.2%; Clavien II 3.6% vs 4.84%; Clavien IIIb 1.2% vs 2.4%).nnnCONCLUSIONnOur results show that en bloc ThuLEP approaches appear feasible, have similar complications and outcomes and can be considered surgeon-independent techniques. En bloc ThuLEP may be proposed even for laser-naïve urologists as an alternative to the original 3-lobe technique.

Intraoperative Retrograde Intrarenal Surgery (RIRS) as a Good Management Option for Large Ureteropelvic Impacted Stone of Transplanted Kidney

Introduction Urolithiasis is a rare complication following kidney transplantation. Many of the clinical features of urinary stones after transplantation differ from those of non- transplant patients, but the course is essentially similar to that in non-transplant patients with lithiasis. The management of kidney stones has evolved radically over the years and involved extracorporeal shock wave lithotripsy (ESWL), flexible ureteroscopy and in situ lithotripsy, percutaneous nephrolithotomy (PCNL), open pyelolithotomy and open cystolitholapaxy. Retrograde URS with laser lithotripsy and/or basket extraction is a reasonable option for treating small and large stones also in transplanted kidney. In order to overcome the difficulty of complex anatomy typical of non-native ureter, ureteroscope can be introduced through a small surgical ureterotomy allowing quite complete stones clear. Matherials and Methods We present surgical treatment and outcome in a 69-year-old male patient with a large ureteropelvic impacted stone of transplanted kidney one year and three months after transplantation. The transplated ureter and the ureteroneocystotomy was identified at the right anterior bladder wall. Ureterotomy was performend on the third part of transplated urether, the double J stent was removed and the ureter was eventually cannulated. Retrograde pyelography revealed an angulation of the mid-ureter toward the renal pelvis seen medially. Access was established with both a standard teflon wire and a superstiff teflon guidewire. A flexible ureteroscope was advanced beyond the midureter through ureterotomy into the transplanted kidney. Laser lithotripsy was then effectively performed in the standard manner by means of 200/273&mgr;m Holmium laser fibers. A tipless nitinol basket was used to extract the fragments. Discussion Native anatomy makes ureteroscopy simple. The orthotopic location of the ureteral orifices allow the urologist to take advantage of the bladder trigone as a backbone to advance wires and ureteroscopes. This is lost in cases as in that one described previously, where the non-native ureter is in a more anterior location. The last attempt to remove pelvic stones in trasplanted kidneys is to introduce the ureteroscope through surgical ureterotomy. In this way is possible to avoid surgical incision of renal pelvis itself which is very difficult to isolate considering its proximity to vascular structures. Conclusion Upper urinary tract endoscopy has long been established as a safe and efficient means of managing urolithiasis with great success. With technological advances, ureteroscopy has evolved into a powerful tool in the armamentarium of the urologist. Management of patients with complex anatomy is now possible while avoiding more invasive interventions such as percutaneous nephrostolithotomy or surgical pyelotomie. Figure. No caption available.

Holmium laser versus thulium laser enucleation of the prostate: a matched-pair analysis from two centers

Background: The aim of our study was to compare perioperative and functional outcomes of two different prostatic laser enucleation techniques performed in two high-volume centers: 100 W holmium laser enucleation of the prostate (HoLEP) (Lyon, France) and 110 W thulium laser enucleation of the prostate (ThuLEP) (Varese, Italy). Materials and Methods: A nonrandomized, observational, retrospective and matched-pair analysis was performed on two homogeneous groups of 117 patients that underwent prostate laser enucleation in the HoLEP or ThuLEP centers between January 2015 and April 2017, following the classical ‘three lobes’ enucleation technique. The American Society of Anesthesiologists (ASA) score and prostate volume were the main parameters considered for matching the patients between the two groups. Patients on anticoagulant therapy, with documented detrusor hypoactivity or hyperactivity or with the finding of concurrent prostate cancer were excluded from the study. Follow up was assessed at 3, 6 and 12 months after surgery. Results: Median enucleation and morcellation time was 75.5 and 11.5 min, respectively, in the HoLEP group versus 70.5 and 12 min, respectively, in the ThuLEP group (p = 0.001 and 0.49, respectively). Enucleated adenoma weight was comparable (44 g versus 45.6 g, p = 0.60). Energy index (3884.63 versus 4137.35 J/g, p = 0.30) and enucleation index (0.57 versus 0.6 g/min, p = 0.81) were similar in the two groups. Catheterization time was comparable (1 versus 1 day; p = 0.14). The International Prostate Symptom Score and Quality of Life score significantly decreased, as well as maximal urinary flow rate. Median prostate-specific antigen (PSA) drop 1 year after surgery was 2.1 ng/ml in the HoLEP group (−52.83%) versus 1.75 ng/ml in the ThuLEP group (−47.85%) (p = 0.013). Conclusion: Both HoLEP (100 W) and ThuLEP (110 W) relieve lower urinary tract symptoms in a comparable way with high efficacy and safety, with negligible clinical differences.

Real-time Intraoperative Fluorescent Lymphography: A New Technique for Lymphatic Sparing Surgery

BACKGROUNDnMany surgical procedures can produce persistent lymphorrhea, lymphoceles, and lymphedema after lymph node and lymph vessel damage. Appropriate visualization of the lymphatic system is challenging. Indocyanine green (ICG) is a well-known nontoxic dye for lymphatic flow evaluation. ICG fluorescence-guided lymphography has emerged as a promising technique for intraoperative lymphatic mapping.nnnOBJECTIVEnOur goal was to develop a high spatial resolution, real-time intraoperative imaging technique to avoid or recognize early deep lymphatic vessel damage.nnnMETHODSnWe intraoperatively performed ICG fluorescence-guided lymphography during a kidney transplant. ICG was injected in the subcutaneous tissue of the patients groin in the Scarpas triangle. A dedicated laparoscopic high-definition camera system was used.nnnRESULTSnSoon after ICG injection, the lymphatic vessels were identified in the abdominal retroperitoneal compartment as fluorescent linear structures running side by side to the iliac vessels. Surgical dissection was therefore performed, avoiding iatrogenic damage to major lymphatic structures. Another ICG injection at the end of the procedure confirmed that the lymphatic vessels were intact without lymph spread.nnnCONCLUSIONSnIntraoperative lymphatic mapping with an ICG fluorescence-sensitive camera system is a safe and feasible procedure. ICG real-time fluorescence lymphography can be used to avoid or recognize early deep lymphatic vessel damage and reduce postoperative complications related to the lymphatic system.