Issues n.4 - 2011


n.4 - 2011

Comparison of open and laparoscopic pyeloplasty in ureteropelvic junction obstruction surgery: Report of 49 cases

Paolo Umari, Andrea Lissiani, Carlo Trombetta, Emanuele Belgrano


Objective: This study aimed to evaluate laparoscopic dismembered pyeloplasty compared with open surgery and to determine whether the morbidity and outcome rates are different in each of these techniques. We report our 10-year experience with open and laparoscopic pyeloplasty at one istitution.

Methods: From February 1999 to October 2010, 49 patients with ureteropelvic junction obstruction were assigned into two groups. 25 patients underwent open surgical pyeloplasty (period 1999-2010) and 24 underwent laparoscopic pyeloplasty (period 2004-2010). 25 patients undergoing open pyeloplasty had a retroperitoneal flank approach. Of the 24 laparoscopic cases 18 had a transperitoneal retrocolic access, 1 had a transperitoneal transmesocolic access and 5 had a retroperitoneal access. In all 49 cases an Anderson-Hynes dismembered pyeloplasty was used. We retrospectively compared the operative time, hospital stay, perioperative complications and follow-up of the two groups. Clinical symptoms were assessed before and after surgery, subjectively.

Results: Patients dermographic data were similar between the two groups with mean age of 42 years (range 6-78) and with a male/female ratio of 1:1.45. A crossing vessel could be identified in 37.5% (9/24) with laparoscopy vs. 32% (8/25) in open surgery. Compared with open procedures, laparoscopic procedures were associated with a longer mean operating time (274 vs 143 min), a shorter mean hospital stay (9.9 vs 15.8 day) and the perioperative complication rates were 16.7% for laparoscopic pyeloplasties and 20% for open pyeloplasties. The success rates were 90.5% for laparoscopy and 90.9% for open surgery. Average follow-up was 40.9 month for the laparoscopic group and 72.3 month for the open group. Failed procedures showed no improvement in loin pain or obstruction.

Conclusions: The efficacy (in term of success rate and perioperative complications) of laparoscopic pyeloplasty is comparable to that of open pyeloplasty, with shorter mean hospital stay and better cosmetic results. These findings may suggest, that the laparoscopic dismembered pyeloplasty has the potential to replace open surgery and may be considered the first option for the treatment of ureteropelvic junction obstruction in expert hands.

Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: Initial experience

Volkan Tugcu, Alper Bitkin, Erkan Sonmezay, Hakan Polat, Yusuf Özlem Ilbey, Ali Ihsan Tasçı


Objective: We present the transperitoneal and retroperitoneal approaches to laparoscopic partial nephrectomy and compare the outcomes of each technique.

Methods: Between December 2006 and March 2010, retroperitoneal laparoscopic partial nephrectomy (RLPN) was performed in 23 patients and transperitoneal laparoscopic partial nephrectomy (TLPN) in 26 patients. They were compared regarding surgical technique, operative parameters, postoperative recovery and follow-up data. The 2 approaches used similar operative techniques to control parenchymal bleeding.

Results: The patient demographics were similar in both groups. The mean tumour size was 3.1 cm in the retroperitoneal group and 3.4 cm in the transperitoneal group. The difference was not statistically significant (p: 0.095). The mean operative time was significantly longer in the transperitoneal group (215 vs 185 minutes, p: 0.031). The mean warm ischemia time difference was not statistically significant (25 vs 28 minutes, p: 0.102). The mean estimated blood loss (EBL) was greater in the transperitoneal group (254 vs 204 cc, p: 0.003). Moreover, the mean hospital stay was 4.1 days in the RLPN and 4.3 days in the TLPN group (p: 0.303) The difference was not statistically significant. The median follow-up was 11 months (range: 2 to 35) in the retroperitoneal group and 13 months (range 1 to 36) in the transperitoneal group.

Conclusions: Our experience has shown that laparoscopic partial nephrectomy is a safe, feasible technique for patients with small exophytic renal tumours. We believe that the decision regarding the approach should be based on the tumor location on the kidney surface.

Comparison of p38MAPK (mitogene activated protein kinase), p65 NFkB (nuclear factor kappa b) and EMMPRIN (extracellular matrix metalloproteinase inducer) expressions with tumor grade and stage of superficial and invasive bladder tumors

Emin Ozbek, Alper Otunctemur, Gokhan Calik, Tamer Aliskan, Suleyman Cakir, Murat Dursun, Adnan Somay


To identify the molecular mechanisms of bladder cancer invasion pathophysiology. To assess EMMPRIN, p65NFkB and p38MAPK expressions which play a role in signal transmission system of muscle and non muscle invasive bladder tumors. Fifty-seven patients with non muscle invasive tumors (mean age 65.2 ± 16.1) and 34 patients with muscle invasive tumors (mean age 62.2 ± 20.7) were included in this study. Normal tissue from the same patients' bladders were used as control group. Patients had either TUR or radical cystectomy and paraffin sections were prepared for immunohistochemistry. Expression density was evaluated semiquantitively according to tumor grade and invasion depth. Results were compared with Mann Whitney U, Wilcoxon W, Chi Square and variation analysis tests. MAPK and EMMPRIN expression was increased according to tumor grade (p < 0.05). These expressions were also significantly higher in muscle invasive tumors than in non muscle invasive ones (p < 0.05). In normal tissue samples of both TUR and radical cystectomy materials, EMMPRIN, NFkB and MAPK expressions were lower than in tumor samples (p < 0.05). NFkB wasn’t related to tumor grade/stage (p > 0.05). It can be stated that MAPK and EMMPRIN expression is related to the grade of bladder tumor and that NFkB positivity is not related to the grade/stage of the disease. In future positivity of lymph nodes and visceral metastasis and survival must be assessed to define the relationship with the expressions in long term follow up studies involving a larger number of patients.

Analysis of survival in radical and postoperative radiotherapy for prostate cancer

Francesco Tramacere, Emilio Antonio Luca Gianicolo, Antonietta Pignatelli, Maurizio Portaluri


Purpose: To analyze survival and complications in high dose 3D conformal radiotherapy (3DCRT) patients treated with curative and post-operative intent and compare radical surgery + radiotherapy (RT) patients vs. RT only patients.

Material and method: 103 patients were treated curatively (RAD), 94 postoperatively (POST-OP). The mean age was higher in RAD group (72.6 years, range 56.4-85.1) than in POST-OP group (65.4 years, 43.9-77) (p < 0.0001). According to NCCN prognostic classification 13 (12%) patients was low risk, 48 (47%) intermediate risk and 42 (41%) high risk in RAD group. In POST-OP group 13 (14%) patients were low risk, 37 (40%) intermediate risk and 44 (46%) high risk. Hormone Therapy (HT) was administered in 98 patients (95%) in RAD and in 45 patients (47.8%) in POST-OP. Patients were treated with a three-dimensional conformal radiotherapy (3D-CRT). In RAD 15 (15%) were alive with disease (AWD), 5 (5%) dead of disease (DOD) and 10 (10%) dead of other cause (DOC); in POST-OP 14 (14.8%) were AWD, 2 (2%) DOD and 3 (3%) DOC. The prescription dose was 80 Gy in 2-Gy fractions in the RAD group, and 70 Gy in 2-Gy fractions in the POST-OP, respectively.

Results: No biochemical or clinical relapse was found in low risk patients in RAD group and 1 relapse in POST-OP group. The largest number of relapses occurred and in intermediate-high risk in RAD (39%) and POST-OP group (33%). In the cause-specific survival analysis no significant differences were found in high risk group between RAD and POST-OP (p = 0.9). In the biochemical relapse-free survival (bRFS) at 5 years analysis no significant differences were found in the high risk group between RAD and POST-OP (p = 0.1020).

Conclusion: RT in RAD low- risk is very effectiva. RAD and POST-OP RT were well tolerated with a very low toxicity. The cause-specific survival at 5 years was 95% and 97% for the two groups of treatment, RAD and POST-OP respectively (Log-rank test p = 0.2908).

Regular ultrasound examination of transplanted kidneys allows early diagnosis of renal cell carcinoma and conservative nephron sparing surgery

Paolo Lentini, Antonio Granata, Antonino Ciancio, Maurizio Gallieni


Introduction: The development of malignancies is a relevant long-term complication of organ transplantation. Carcinoma of native kidney accounts for up to 5% of all malignancies found in transplant recipients. Primary clear cell type renal cell carcinoma (RCC) usually arises in the native kidneys. Its occurrence in the renal allograft has been reported infrequently.

Case presentation: We report a rare case of de novo RCC in a kidney allograft in a 41 yearsold woman. Routine ultrasonography denoted a poorly marginated hypoechoic mass at the inferior pole of transplanted organ, confirmed by computed tomography which showed a lesion of 32 mm in diameter with characteristic radiological signs of RCC. The patient underwent nephron sparing surgery (NSS). At histological examination the tumor was T1-T2, N0, M0 with negative margins. At five years after NSS no significant impairment of renal function or recurrence was observed.

Conclusion: Primary carcinomas of the kidney can be detected after transplantation in the native or transplanted kidney. According to the European Guidelines on the long-term management of kidney transplantation, all recipients should have regular ultrasonography of native and allograft kidneys to screen for cancer, which occurs at a much higher incidence in transplanted patients. NSS is a safe and efficient procedure for the treatment of RCC in renal graft, resulting in the preservation of renal function and in long-term cancer control.

Solitary giant sarcomatoid carcinoma of the bladder. A case report

Pietro Pepe, Filippo Fraggetta, Antonio Galia, Giuseppe Candiano, Michele Pennisi, Francesco Aragona


A case of sarcomatoid carcinoma of the bladder (SCB) presenting as a giant intravesical mass in a 75-year-old man complaining of lower urinary tract swmptoms (LUTS), abdominal pain and fever is reported. SCB is a rare (0.1% of all primary bladder tumors), aggressive cancer with a complex histology (a biphasic tumor with malignant     epithelial and mesenchymal elements) and poor prognosis.

Renal cell carcinoma and synchronous thyroid metastasis with neoplastic thrombosis of the internal jugular vein: Report of a case

Deliu-Victor Matei, Antonio Brescia, Andrea Nordio, Matteo Giulio Spinelli, Sara Melegari, Gabriele Cozzi, Massimiliano Andrioli, Pietro Salvatori  


A case of thyroid metastasis of a renal clear cell carcinoma is presented. The fine-needle aspiration cytology pointed out the primary tumor origin. The patient underwent robot-assisted radical nephrectomy and contextual thyroidectomy. During the operative procedure, a neoplastic thrombus extending from the thyroid metastasis and protruding into the internal jugular vein was found. As a result, thrombectomy and ligation of the internal jugular vein were required. In cases of single synchronous thyroid metastases form RCC, radical surgery should be advisable. Robotic approach allows to associate major surgery procedures, as nephrectomy, with radical metastasectomy.

Transvestibular urethrolysis

Giorgio Carmignani, Virginia Varca, Alchiede Simonato


Objectives: Bladder outlet obstruction with obstructive and irritative urinary symptoms may be a complication of surgery for female urinary incontinence. In presence of persistent symptoms the therapy is surgical and usually consists in an accurate urethrolysis. The way of approach is generally transvaginal. In this paper we propose and describe our experience with a transvestibular approach.

Methods: From 1995 to 2009 18 women who had undergone anti-incontinence surgery (TVT 12 pts, TOT 3 pts, Burch retropubic colposuspension 3 pts) with obstruction and/or irritative symptoms underwent to a transvestibular urethrolysys. Five patients had urinary retention the other patients had post voiding residual urine > 100 ml. With a scalpel blade a circum-meatal incision was performed and the urethra was progressively freed, dissecting just below the os pubis upwards and on the vaginal wall downwards untethering it under direct vision obtaining a complete circular freeing of the urethra; at the end the urethral meatus is repositioned with circular stiches.

Results: The operation lasts between 20 and 40 minutes. Urethral catheter was left in place for 24-48 hours and no complications were observed. The post-voiding residual urine decreased in all the cases and the irritative symptoms were reduced.

Conclusions: The transvestibular approach represents a safe and effective approach to urethrolysis undependently of the type of anti-incontinence surgey carried out. Urethrolysis has the advantage of working in a relatively unscarred tissue, can allow a complete untethering of the urethra even in the retropubic space and leaves the vaginal wall intact.

Blue nevus of the prostate: Incidental finding in radical prostatectomy specimen with a pre-operative echographic image of peripheral hypoechogenic nodule

Maria Rosaria Raspollini, Lorenzo Masieri, Nicola Tosi, Marco Santucci


Blue nevus is a stromal melanin deposition, which is microscopically characterized by deeply pigmented melanin-filled spindle cells within the fibromuscular stroma. Cases with prominent melanosis such as those with grossly visible pigment are uncommon. Melanocytic lesions of the prostate are incidental findings with no evidence of malignant transformation. There have only been very few reports of a malignant melanoma of primary prostatic origin. We report an incidental finding of a blue nevus of the prostate, in a radical prostatectomy specimen, in a 64-years-old man with a pre-operative ecographic image of peripheral hypoechogenic nodule. The are very few reports of blue nevi associated to prostatic adenocarcinoma, but none has been evidentiated before surgery as a distinct ultrasound lesion interpreted as adenocarcinoma, therefore inducing the clinician to perform biopsies and consequently a radical prostatectomy.

Urinary incontinence in adults: Nurses’ beliefs, education and role in continence promotion. A narrative review

Stefano Terzoni, Emanuele Montanari, Cristina Mora, Anne Destrebecq


Introduction: Urinary incontinence (UI) has a high prevalence worldwide, in both genders; the available data suggest that the number of incontinent people will dramatically increase in the next few years. The costs generated by UI are similar to those induced by HIV and breast cancer. We aimed to investigate nurses’ beliefs, knowledge and educational situation in the field of urinary continence.

Methods: We performed a narrative review of literature, by searching qualitative and qualitative studies (2006-11) in PubMed, CINAHL and the Cochrane Library. Papers investigating pharmacological and/or surgical intervention were excluded. Only studies referred to adults have been taken into consideration.

Results: Prevalence ranges from 25 to 45% in women; in men, post-prostatectomy UI occurs in a median of 10-15% of the total cases. Benign prostatic hyperplasia, which affects 50% of men aged 50 to 60, is often associated with urge incontinence. The yearly individual expense for pads in Italy has been estimated to be as high as € 913 in 2004. People often do not know about the possible solutions to UI; nurses seem to lack education in continence promotion, notwithstanding the proven effectiveness of the conservative interventions they could perform in autonomy. In Italy, few academic programs offer nursing education in this field.

Conclusions: Urinary incontinence seems to be an underestimated problem; nurses often lack proper education in continence promotion. Academic, structured courses would be a solution; however, since education itself is not sufficient to really improve clinical practice, organizational support would be required to effectively promote continence in the broadest possible population. This would be a long-term investment for both quality of care and costs. Further studies are needed, regarding conservative management of UI; research could lead to a strong integration between clinical and academic branches of nursing, resulting in good quality evidence for clinical practice.