Rosa Pappalardo

Different patterns of pelvic ureteral endometriosis. What is the best treatment? Results of a retrospective analysis

OBJECTIVE Endometriosis is an estrogendependent disease. The incidence of urinary tract endometriosis (UE) increased during the last few years and, nowadays, it ranges from 0.3 to 12% of all women affected by the disease. The ureter is the second most common site affected. The ureteral endometriosis is classified in extrinsic and intrinsic. The aim of this study is to individuate the best treatments for each subset of ureteral endometriosis. MATERIALS AND METHODS 32 patients diagnosed with surgically treated UE were retrospectively reviewed. The patients were divided into 3 subsets (intrinsic UE, extrinsic UE with and without obstruction). The patients with intrinsic UE (n = 10) were treated with laser endoureterotomy. The patients with extrinsic UE (n = 22) were divided in two subsets with (n = 16) and without (n = 6) hydronephrosis. All the patients underwent ureteral stenting, and resection and reimplantation was performed in the first group, and when the mass was > 2.5 cm (n = 3) Boari flap was performed. Laparoscopic ureterolysis (shaving) was performed in the second group. RESULTS In the extrinsic subset of UE, we obtained an high therapeutic success (84%). Conversely, in the intrinsic subset there was a recurrence rate of the disease in 6/10 of the patients (60%). CONCLUSIONS Ureterolysis seems to be a good treatment in extrinsic UE without obstruction. Resection and reimplantation allows excellent results in the extrinsic UE with obstruction. In the intrinsic subset, the endoureterotomy approach is inadequate.

Hybrid Transvaginal NOTES Nephrectomy: Postoperative Sexual Outcomes. A Three-center Matched Study

OBJECTIVE To evaluate our experience in patients undergoing hybrid transvaginal natural orifices transluminal endoscopic surgery (NOTES) nephrectomy and evaluate the sexual functions in the postoperative period. MATERIALS AND METHODS Prospective data of 71 patients with renal tumors who underwent hybrid NOTES radical nephrectomy in three different centers were collected from March 2010 to October 2015. Patient and surgical characteristics were recorded. Sexual function was evaluated using the Female Sexual Function Index questionnaire the day prior to the operation and 3 months after. RESULTS The mean age, tumor size, and operation duration were 66.16 ± 11.21, 8.51 ± 3.31 cm, and 119.94 ± 21.38 minutes, respectively. Five patients were immediately reoperated due to bleeding from uterine veins. The complication risk increases significantly with increasing tumor size. Among the whole cohort, even the Female Sexual Function Index score differences are small; there is a statistically significant decrease in the postoperative period in all domains except sexual satisfaction. In fact, the patients reported unaltered sexual function after surgery and satisfaction with the result when asked directly. In subgroup analyses, in nulliparous patients (n = 60), arousal, sexual desire, orgasm, and satisfaction domains have no significant differences in pre- and postoperative periods. CONCLUSIONS Hybrid NOTES nephrectomy is a feasible, safe operation that can be performed for large renal tumors. Due to incisions in the vaginal wall for specimen retrieval, sexual function can be altered in the postoperative period. So patient selection, preoperative evaluation, and close follow-up are mandatory. With this in mind, we strongly support the use of hybrid transvaginal NOTES nephrectomy for large renal tumors especially in nulliparous patients.

LithoVue™: A new single-use digital flexible ureteroscope.

Over the last 20 years new technologies have emerged in urology, while there has been an increase in the incidence of kidney stone disease with growing use of flexible ureteroscopy [1]. In 2004 Gyrus ACMI introduced the first totally digital flexible ureteroscopic system, the DUR-D Invisio platform [2]. This was a watershed moment as all the major companies began producing digital flexible ureteroscopes from that moment forward with an improved armamentarium available for the urologist [3]. In October 2015 Boston Scientific introduced the LithoVue™. This is the first single-use flexible ureteroscope developed to access the upper urinary tract. The LithoVue™ The LithoVue™ (Boston Scientific, Marlborough, MA) is a new single-use digital flexible ureteroscope (Figure 1). Figure 1 The new single use flexible ureteroscope: LithoVue™. A. The LithoVue™ external aspect in the hands of the surgeon and the LithoVue™ monitor can be seen at the back. B. Maximum deflection of the ureteroscope tip; 270° in ... The handle is extremely ergonomic, permitting the user to easily perfom the 6 principal movements in a natural way (deflection: up/down, supination/pronation, forward/backward). The deflection system has both options of standart and the reverse modes with a maximum deflection of 270˚ in both directions (Figures 1 & 2). The outer diameter is 9.5 Fr (≤3.23 mm) and the tip diameter is 7.7 Fr (Figures 1 & 2). These diameters allow endourologists to work with all of the ureteral access sheaths currently on the market. Figure 2 External view of the LithoVue™. A. The tip at maximum deflection. B. External view of the device with the tip straight. C. External view of the device with the tip at maximum deflection. The working channel width measures 3.6 Fr and allows the introduction of various endoscopic instruments such as laser fibers, baskets and different kinds of graspers (Figure 3). Figure 3 Endoscopic view from the LithoVue™ demonstrating the digital image quality during upper urinary tract endoscopy. A. Kidney stone inside the caliceal system. B. Kidney stone and a green coated 272 μm laser fiber. In order to maximize the vision it has a complementary metal-oxide-semiconductor (CMOS) imager system with a working distance of 2–50 mm (Figures 3 & 4). Figure 4 Endoscopic view from the LithoVue™ demonstrating the digital image quality during upper urinary tract endoscopy. A stenotic infundibulum and a small stone fragment can be seen. The LithoVue™ possesses chip-on-the-tip technology as the camera and light source are fully integrated in the scope, and it has a workstation monitor with the integrated image processing software mounted on a compact, rolling mobile cart. It is possible to use the LithoVue™ system alone or to connect it to the operating room’s existing DVI monitors and recording systems (Figure 5). Figure 5 Monitor station of the LithoVue™ at Tenon University Hospital. DISCUSSION Different flexible ureteroscopes are on the market, including fiberoptic and digital versions. The latter offer better vision quality, though in their study comparing digital versus fiber-optic scopes, Somani et al. found the only advantage of the digital scope in cases of stone treatment was the decrease in operative time by 20% [4]. It is important to note that the European Association of Urology (EAU) guidelines state the importance of using the technological advancements in the treatment of upper urinary tract tumors [5]. However, the increasing improvement of ureteroscopes has led to several problems. The principal issue is durability and depends on many factors such as a surgeon’s experience and skills, time of use, and the use of other devices or instruments. Another important, open question is the sterilisation factor when considering scope damage. Abraham et al. demonstrated that two identical fiberoptic scopes underwent two different sterilisation processes (Steris 1™ and Cidex OPA) after 100 cycles. The first one, which was sterilised in the Steris system, had a 12-mm tear on its shaft, 297 damaged fibers, and a 37% drop in resolution. The second, sterilised with Cidex, had only 10 damaged fibers and no visible external damage [6]. The durability of flexible ureteroscopes has been a concern for many years. Refurbished flexible ureteroscopes have been reported to be very fragile after undergoing comprehensive repair, especially if they are used by multiple surgeons and this situation leads to significant maintenance, repair, and administrative costs [7]. Actually, there are studies showing some advancements of ureteroscope durability with repeated uses of up to 107.7 hours with a single ureteroscope, but still the latest data is telling us that the durability of flexible ureteroscopes needs to be improved [8]. Additionally it should be kept in mind that, with LithoVue™, the performance of a brand-new endoscope is experienced in each procedure, bypassing the loss of deflection with repeated use. When cost-effectiveness is evaluated, the reusable flexible ureteroscopes are burdened with purchase, repair, and service costs in addition to cleaning, disinfection and sterilization costs as well as costs related to health care and time consumption. However, single-use flexible ureteroscopes bring with them purchase and storage costs of the scopes themselves and their corresponding work stations as well as costs related to waste handling. Ureteroscopes represent semicritical devices due to their contact with patients’ mucous membranes and must be sterilized with high-level disinfectants. Failure to properly disinfect the scopes can lead to transmission of infection [9]. The working channel of the ureteroscopes must be actively perfused with high-level disinfectants otherwise disinfection does not occur [9]. These steps are also acknowledged by the American Urological Association and failure to comply can result in urinary tract infections [10]. This process constitutes one of the major steps that accounts for the high expenditure of re-usable scopes. It should also be emphasized that the price of the LithoVue™ should be discussed with the local company in each country because the costs may change according to different purchasing options as well as different countries. All of these problems can be avoided by using the LithoVue™, which guarantees performance equal to that of new reusable ureteroscopes but without the risk of possible contamination. The optical characteristics of the LithoVue™, the Flex-Xc (Karl Storz, Germany) and the Cobra (Richard Wolf, Germany) were compared by Kaplan et al. who concluded that the LithoVue™ has superb optical capabilities, deflection and flow, thus making it a viable alternative to standard non-disposable 4th generation flexible digital and fiberoptic ureteroscopes [11]. Furthermore, in their study on fresh cadavers, Proietti et al. compared the LithoVue™ with other ureteroscopes and demonstrated that the vision and handling are comparable to other ureteroscopes. LithoVue™ was preferred in all of the renal units used in these experiments due to its maneuverability [12].

Re: Mark W. Ball, Nathaniel Readal, Phillip M. Pierorazio, Mohamad E. Allaf. Splitting One Kidney into Two: Robotic Partial Kidney Transplant in a Porcine Model. Eur Urol 2016;69:968–9

We read with great interest the research letter by Ball et al [1]. We think that new techniques are needed to meet the needs related to an upward trend in kidney transplants and an aging population. The authors described a innovative transplantation technique, splitting one kidney in two in a porcine model [1]. However, some steps and choices of the surgical technique are not explained in the article. The calicovesicostomy created a direct anastomosis between the calyceal cavities and bladder. Not many articles in the literature describe this technique. Hsu et al described a laparoscopic approach with satisfactory clinical outcomes in a patient with horseshoe kidney and large-capacity bladder (>1000 ml) secondary to benign prostatic hyperplasia [2]. We think that, in this case, the authors had a good result because of a large bladder and that without normal reflux, the kidney could be damaged. For us, it would be ideal to transplant the pole directly onto the receiver’s ureter or rather, in addition to performing nephrectomy with subsequent division of the two poles, to run a ureterectomy so the transplant pole and ureter take advantage of the natural antireflux ureter mechanism. Regarding the vascular anastomosis of the renal graft, it is not very clear from the article how this was performed. Usually in these cases, some authors use vascular grafting to obtain optimal vascular anastomosis. We believe that this technique could be a starting point for a new field of research, particularly in obese patients,

Spontaneous Subcapsular Renal Hematoma: Strange Case in an Anticoagulated Patient with HWMH after Aortic and Iliac Endovascular Stenting Procedure

Spontaneous subcapsular renal hematoma is a rare condition in clinical practice. It is caused by renal cysts, benign and malignant renal tumors, vascular lesions, and antiplatelet or anticoagulant therapy. In this paper we report an unusual case of rupture of a renal cyst of a 66-year-old male patient during an aortic and iliac endovascular procedure for a massive calcified atheroma above the iliac bifurcation. We suspected that the bolus of high weight molecular heparin given during the procedure caused the rupture of the cyst. According to the literature, this is the first case of renal cyst rupture during an endovascular aortic procedure after administering a high weight molecular heparin bolus.

Is whole gland salvage cryotherapy effective as palliative treatment of haematuria in patients with locally advanced prostate cancer? Results of a preliminary case series

Objectives: Locally advanced prostate cancer may cause several complications such as haematuria, bladder outlet obstruction, and renal failure due to the ureteral obstruction. Various treatments have been suggested, including radiotherapy, antifibrinolytics, bladder irrigation with alum solution, transurethral surgery and angioembolization, none of which have proven effectiveness. In the last years cryoablation has become a valid therapeutic option for prostate cancer. In our experience we used this ‘new’ technique as haemostatic therapy. Methods: We selected four patients with gross haematuria affected by locally advanced hormone refractory prostate cancer, who had already been treated with primary radiotherapy. We used third-generation cryotherapy: under ultrasonographic guidance, we inserted six cryoprobes, two in each of the vascular pedicles reaching at least −60°C, and three thermometers. We then induced two freeze–thaw cycles. Results: After the operation the haematuria stopped in all patients and at 9-month follow up we observed a mean of four red cells (range three to five) in the urinary sediment with no evidence of bacteriuria. Prostate volume, prostate-specific antigen and postmicturition residue were significantly reduced. Qmax improved significantly too. Conclusion: Our experience has given us good results with minimal intra- and postoperative complications. We think that haemostatic cryotherapy as a palliative approach for locally advanced prostate cancer could represent a valid treatment option and more consideration could be given to its use.

Calidad de vida y supervivencia global en pacientes de alto riesgo tras cistectomía radical con una derivación urinaria simple

OBJECTIVE To evaluate quality of life (QoL) and overall survival after radical cystectomy with cutaneous ureterostomies for locally advanced bladder cancer in elderly patients with high surgical risk. METHODS Fifty eight patients older than 74 years (mean age 80,6±4,3) with locally advanced bladder cancer (group A), underwent radical cystectomy and ureterocutaneous diversion. Patients completed the EORTC QLQC30 before and six months after surgery to assess functional, clinical and QoL outcomes. The same evaluation was carried out in a control group (group B) of 29 patients (mean age 82,3±3,8 years), who had refused cystectomy. Questionnaires were also administered to patients of both groups who survived at least 20 months and 5 years. RESULTS All patients presented with an ASA score ≥3. Mean hospital stay was 15.1 days (±4.8) in group A and 23.5 days (±4.1) in Group B. No intraoperative complications occurred in group A. Postoperative overall survival evaluated within 6 months in group A was 97% versus 79% in group B (p<0.001). CONCLUSION Radical cystectomy with cutaneous ureterostomy represents a valid alternative in elderly patients with invasive bladder cancer and high operative risk. Comparison between two groups showed a statistically significant difference for almost all the Qol related parameters and for short and medium term overall survival.

PD30-01 URETEROSCOPY IN PREGNANT WOMEN WITH COMPLICATED COLIC PAIN: A TWO CENTER-MATCHED RETROSPECTIVE STUDY

.Additionally, 4 urologists were shown images from each phase of the study and their visual score was recorded e very satisfactory (4), satisfactory (3), disappointed (2) and extremely disappointed (1). RESULTS: Table 1 Figure 1 CONCLUSIONS: The described novel technique of MR assessment of urethral gap in pelvic fracture urethral injuries shows promising results and is a true reflection of the actual urethral gap which helps in planning surgical approach. The simple modification of having a full bladder, use of Tamsulosin and straining (dynamic images) helps to mimic a conventional VCUG and RGU along with advantages of MRI.

Thulium laser vaporesection of the prostate: Can we operate without interrupting oral antiplatelet/anticoagulant therapy?

Purpose Thulium vaporesection of the prostate (ThuVARP) is a new and safe approach for patients receiving anticoagulant therapy in whom transurethral resection of the prostate (TURP) may possess a high bleeding risk. We aimed to demonstrate the efficacy and safety of ThuVARP in patients receiving oral antiplatelet/anticoagulant (OAP/OAC) therapy. Materials and Methods A total of 103 patients who underwent ThuVARP between 2011 and 2013 were enrolled in the study. Patients were divided into 2 groups. Group A consisted of 47 patients who underwent low molecular weight heparin (LMWH) bridging and group B consisted of 56 patients who were operated on while receiving OAP/OAC therapy. Results The drop in hemoglobin levels in the pre- and postoperative periods was significantly higher in group A than in group B. When subgroups were analyzed, the mean drop in hemoglobin was significantly lower in the warfarin and ticlopidine subgroups of group B than in group A. International Prostate Symptom Scores were significantly lower 3, 12, 18, and 24 months after surgery in group A than in group B. Quality of life scores, maximal flow rate values, and postmicturition residual urine volumes (mL) were similar between the 2 groups. A total of 38 and 41 patients in groups A and B, respectively, had no complications. Conclusions Our study showed the safety profile of continuing different OAP/OAC therapies in terms of bleeding problems in patients undergoing ThuVARP. We strongly recommend abandoning LMWH bridging and maintaining the OAP/OAC regimen patients are already receiving.

Ureteroscopy in pregnant women with complicated colic pain: Is there any risk of premature labor?

OBJECTIVE Clinical presentation of ureteral stones during pregnancy is generally with renal colic pain. The aim of this study is to present our experience in the management of renal colic during pregnancy in emergency settings. MATERIALS AND METHODS 208 pregnant patients who presented to emergency department with renal colic pain and underwent ureteroscopy (URS) due to failed conservative therapy were enrolled in the study. Urinary tract stones were diagnosed either with ultrasound (US) examination or during URS. Laser lithotripsy and double J (DJ) stent placement were routinely done in all patients with ureteral stones. The incidence of infective complications and premature uterine contractions (PUC) due to URS were compared. RESULTS No stone was identified in 36.1% (n = 75) of patients with using US and diagnostic URS. Of the remaining 133 patients, 30 (22.6%) had no stone at US but stones were diagnosed during diagnostic URS. The type of anesthesia had no significant effect on PUC. An increased risk of sepsis and PUC was found in patients with fever at the initial presentation. Interestingly, PUC was more frequent in patients with lower serum magnesium levels. There was a significant correlation with time delay until the intervention and the risk of urosepsis and PUC, individually. CONCLUSIONS Ureteroscopy is a safe option for evaluation of pregnant patients with unresolved renal colic. According to the current findings, timing of the operation is the most important factor affecting the septic risks and abortion threat. Surgical intervention with URS must be planned as soon as possible.