Ivano Morra

Randomised Controlled Trial Comparing Laparoscopic and Robot-assisted Radical Prostatectomy

BACKGROUND The advantages of robot-assisted radical prostatectomy (RARP) over laparoscopic radical prostatectomy (LRP) have rarely been investigated in randomised controlled trials. OBJECTIVE To compare RARP and LRP in terms of the functional, perioperative, and oncologic outcomes. The main end point of the study was changes in continence 3 mo after surgery. DESIGN, SETTING, AND PARTICIPANTS From January 2010 to January 2011, 120 patients with organ-confined prostate cancer were enrolled and randomly assigned (using a randomisation plan) to one of two groups based on surgical approach: the RARP group and the LRP group. INTERVENTION All RARP and LRP interventions were performed with the same technique by the same single surgeon. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The demographic, perioperative, and pathologic results, such as the complications and prostate-specific antigen (PSA) measurements, were recorded and compared. Continence was evaluated at the time of catheter removal and 48 h later, and continence and potency were evaluated after 1, 3, 6, and 12 mo. The student t test, Mann-Whitney test, χ(2) test, Pearson χ(2) test, and multiple regression analysis were used for statistics. RESULTS AND LIMITATIONS The two groups (RARP: n=60; LRP: n=60) were comparable in terms of demographic data. No differences were recorded in terms of perioperative and pathologic results, complication rate, or PSA measurements. The continence rate was higher in the RARP group at every time point: Continence after 3 mo was 80% in the RARP group and 61.6% in the LRP group (p=0.044), and after 1 yr, the continence rate was 95.0% and 83.3%, respectively (p=0.042). Among preoperative potent patients treated with nerve-sparing techniques, the rate of erection recovery was 80.0% and 54.2%, respectively (p=0.020). The limitations included the small number of patients. CONCLUSIONS RARP provided better functional results in terms of the recovery of continence and potency. Further studies are needed to confirm our results.

Long-Term Functional Evaluation of the Treated Kidney in a Prospective Series of Patients Who Underwent Laparoscopic Partial Nephrectomy for Small Renal Tumors

BACKGROUND Renal scintigraphy may allow long-term monitoring of ischemic damage after partial nephrectomy (PN). OBJECTIVE Evaluate use of renal scintigraphy for evaluating long-term effects of warm ischemia on renal function in patients with a normal contralateral kidney. DESIGN, SETTING, AND PARTICIPANTS We prospectively examined kidney function of 54 patients who underwent laparoscopic PN (LPN). Minimum follow-up time was 4 yr. INTERVENTION LPN was performed with warm ischemia by transperitoneal or retroperitoneal approach. MEASUREMENTS Demographic, perioperative, and pathologic data and postoperative complications were registered. Split renal function (SRF) and effective renal plasma flow (ERPF) were evaluated by renal scintigraphy preoperatively, at 3 and 12 mo postoperatively, then yearly. Baseline weighted differentials (b-WDs) of both SRF and ERPF in the affected kidney were calculated between baseline condition and every time point. Multivariate linear regression was used to find independent variables for increased b-WDs at 3 and 48 mo. P values<0.05 were considered significant. RESULTS AND LIMITATIONS The SRF and ERPF of kidneys treated by LPN decreased significantly at month 3 and subsequently remained stable through the duration of follow-up. Conversely, neither serum creatinine nor estimated glomerular filtration rate changed significantly during follow-up. The regression model showed statistical significance at month 3 for warm ischemia time (WIT) and age, whereas at 48 mo, statistical significance was reached by WIT alone. No new onset of cardiovascular disease was registered. No evidence of local recurrence was recorded with computed tomography scan. Our study may be underpowered due to small sample size; however, this is one of the largest long-term prospective series using renal scintigraphy to evaluate the renal function after LPN. CONCLUSIONS WIT contributes to irreversible kidney damage observed at month 3 that does not appear to worsen.

Treatment of simple renal cysts by percutaneous drainage with three repeated alcohol injections

OBJECTIVES This study sought to show the effectiveness and safety of three repeated alcohol injections for the treatment of simple large renal cysts. METHODS From September 1991 to December 1997 we treated 72 renal cysts. The cyst was drained with an 8F mono J stent. Ninety-five percent sterile ethanol was injected into the cyst and left in place for 20 minutes. Two repeat alcohol injections were performed every 24 hours. After the third alcohol injection, the catheter was removed. To avoid pain in the last 39 patients, 20 mL of 2% lidocaine hydrochloride was injected into the cyst for 15 minutes before the alcohol injections. RESULTS The follow-up period ranged from 8 to 83 months (mean 48). One patient underwent surgical intervention because of considerable bleeding in the cystic cavity that occurred after percutaneous drainage. In 1 patient in whom the cystic cavity communicated with the urinary tract, no alcohol injections were performed. After the repeated alcohol injections, the cystic cavity completely disappeared in 68 of the 70 treated cysts at first ultrasound examination. This result, observed at the first ultrasound control observation, remained unchanged during follow-up. CONCLUSIONS In our experience, percutaneous drainage with three repeated alcohol injections offers a high rate of success without the cost and morbidity associated with other procedures, such as operation or laparoscopy.

Selective versus Standard Ligature of the Deep Venous Complex during Laparoscopic Radical Prostatectomy: Effects on Continence, Blood Loss, and Margin Status

BACKGROUND Continence after laparoscopic radical prostatectomy is critical to patients and to surgeons. In this setting, the management of deep venous complex (DVC) without involvement of the sphincter fibres could be an important step of the procedure. OBJECTIVE To evaluate the effects of a personal selective suture of the plexus (selective ligature of the deep venous complex [SLDVC]) on continence, blood loss, and surgical margin status during laparoscopic radical prostatectomy (LRP). DESIGN, SETTING, AND PARTICIPANTS We planned a prospective randomised study. Sixty consecutive patients with clinically localised prostate cancer were involved in the study and were divided into two groups: group A (30 patients) underwent LRP with extraperitoneoscopic approach with standard management of DVC; group B (30 patients) underwent LRP with SLDVC. INTERVENTION In group A, a standard ligature of DVC was performed (ligature and subsequent section); in group B, a selective ligature of DVC after its section was performed. MEASUREMENTS Continence was evaluated during follow-up visits at catheter removal, and after 1, 3, 6, and 12 mo, perioperative variables and pathologic features of specimens were recorded. RESULTS AND LIMITATIONS The two groups were comparable in terms of age, body mass index (BMI), prostate-specific antigen (PSA) values, and Gleason score at biopsy. No differences were found between the two groups in terms of operative times, blood loss, catheterisation time, and postoperative stay or histologic status. As far as continence rate is concerned, a significant difference was recorded between the groups (53% in group A vs 80% in group B) after 3 mo. CONCLUSIONS This selective ligature of the DVC after its section can contribute to early recovery of continence. Our data suggest that SLDVC compromises neither the safety of the procedure nor its oncologic effectiveness.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery–Assisted Minilaparoscopic Nephrectomy: A Step Towards Scarless Surgery

The feasibility of a transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy has already been demonstrated using standard laparoscopic ports through the abdominal wall. We evaluated the feasibility of a transvaginal NOTES-assisted minilaparoscopic nephrectomy (mLN). The patient is positioned in a semilumbotomy position with legs separated to allow for vaginal access. A 3.5-mm port is placed at the umbilicus for a 30° laparoscope; two 3.5-mm ports are placed in the flank in the same location as for a standard transperitoneal nephrectomy; and a 12-mm port is placed through the vagina, perforating the vaginal wall. Kidney dissection is performed following the steps of a traditional nephrectomy. The renal pedicle is dissected and secured with Hem-o-Lok clips through the vaginal access port. The specimen is then extracted through an extended incision in the posterior wall of the vagina. We treated five patients. The average operative time was 120 min, blood loss was 160 ml, and no complications were recorded. Our initial experience suggests that transvaginal NOTES-assisted mLN is feasible and appears to be safe. It is simpler than a pure NOTES procedure and ensures excellent cosmetic results.

Standard vs mini-laparoscopic pyeloplasty: perioperative outcomes and cosmetic results

Study Type – Therapy (case series)

A second cycle of tamsulosin in patients with distal ureteric stones: a prospective randomized trial.

To evaluate, in a prospective randomized pilot study, the effectiveness and safety of tamsulosin, administered in patients with distal ureteric stones and who have already undergone an unsuccessful first cycle of medical expulsive therapy (MET).

Extraperitoneoscopic Transcapsular Adenomectomy: Complications and Functional Results After at Least 1 Year of Followup

PURPOSE Laparoscopic simple prostatectomy has been proposed to treat large glands. To date groups have investigated the feasibility and perioperative results of laparoscopic simple prostatectomy but to our knowledge no study has focused on its complications and functional results at longer followup. We investigated complications and functional results in patients with a large prostate who were treated with laparoscopic simple prostatectomy and had at least 1 year of followup. MATERIAL AND METHODS From our prospectively maintained database we extracted data on 78 patients treated with laparoscopic simple prostatectomy at our institution who had at least 1 year of reported followup. Demographics, perioperative results, early and late complications, and functional results were evaluated. Followup was planned at 1, 3, 6 and 12 months, and every 6 months thereafter. RESULTS Mean followup was 30 months. Grade III complications were recorded in 2 cases and late complications were reported in 4 (5%). Statistically significant differences were observed in the International Prostate Symptom Score, the International Prostate Symptom Score quality of life index and maximum urine flow when comparing preoperative and postoperative results. No significant differences were recorded in maximum urine flow or the International Prostate Symptom Score quality of life index during followup. CONCLUSIONS Results suggest that laparoscopic simple prostatectomy is safe and effective even after a significant period, as indicated by the low complication rate and positive, stable functional results found during followup. In our opinion laparoscopic simple prostatectomy can be offered to patients as a valid treatment option for a large prostate at advanced laparoscopic centers.

Transvaginal ultrasonography in the assessment of organic diseases of female urethra

The current investigation aimed to check the effectiveness of transvaginal ultrasonography in the diagnosis of organic urethral diseases, comparing its results with those of conventional examinations (physical examination, voiding cystourethrography, pelvic ultrasonography, cystourethroscopy). Transvaginal ultrasonography was performed in 560 female patients with recurrent cystitis, dysuria, or palpable masses and diagnosed the following urethral diseases: 25 diverticula, seven stenoses, three carcinomas, two leiomyomas of periurethral tissue, and one incomplete duplex urethra. In our study transvaginal ultrasonography proved to be the most reliable diagnostic tool among imaging methods used.

Transperitoneal left laparoscopic pyeloplasty with transmesocolic access to the pelvi‐ureteric junction: technique description and results with a minimum follow‐up of 1 year

To describe and evaluate the safety and outcome of transperitoneal left laparoscopic pyeloplasty (TLLP) with a direct approach to the pelvi‐ureteric junction (PUJ) through the mesentero‐colic space, which avoids mobilization of the descending colon.