Urinary fistulas are a known complication that can occur after partial nephrectomy, potentially causing considerable morbidity if not properly treated. The present study examines the case of a 71-year-old male patient who developed a urinary fistula six months following a robot-assisted partial nephrectomy. Initial efforts to address the fistula through the placement of a double pigtail ureteral stent proved ineffective. Subsequent interventional radiology procedures successfully achieved fistula closure by administering adhesive fibrin directly within the fistulous tract. This case highlights the importance of a multidisciplinary approach in handling post-surgical complications like urinary fistulas.

AIMThe upgrading or staging in men with prostate cancer (PCA) undergoing active surveillance (AS), defined as Gleason score (GS) ≥ 3+4 or more than 2 area with cancer, was investigated in our experience using the software-based fusion biopsy (FB).METHODSWe selected from our database, composed of 620 biopsies, only men on AS according to criteria of John Hopkins Protocol (T1c, < 3 positive cores, GS = 3+3 = 6). Monitoring consisted of PSA measurement every 3 months, a clinical examination every 6 months, confirmatory FB within 6 months and then annual FB in all men. The suspicious MRI lesions were scored according to the Prostate Imaging Reporting and Data System (PI-RADS) classification version 2. FB were performed with a transrectal elastic free-hand fusion platform. The overall and clinically significant cancer detection rate was reported. Secondary, the diagnostic role of systematic biopsies was evaluated.RESULTSWe selected 56 patients on AS with mean age 67.4 years, mean PSA 6.7 ng/ml and at least one follow-up MRI-US fusion biopsy (10 had 2 or 3 follow-up biopsies). Lesions detected by MRI were: PIRADS-2 in 5, PIRADS-3 in 28, PIRADS-4 in 18 pts and PIRADS-5 in 5 patients. In each MRI lesion, FB with 2.1 ± 1.1 cores were taken with a mean total cores of 13 ± 2.4 including the systematic cores. The overall cancer detection rate was 71% (40/56): 62% (25/40) in target core and 28% (15/40) in systematic core. The overall significant cancer detection rate was 46% (26/56): 69% (18/26) in target vs 31% (8/26) in random cores.CONCLUSIONSThe incidence of clinical significant cancer was 46% in men starting active surveillance, but it was more than doubled using MRI/US Target Biopsy 69% (18/26) rather than random cores (31%, 8/26). However, 1/3 of disease upgrades would have been missed if only the targeted biopsies were performed. Based on our experience, MRI/US fusion target biopsy must be associated to systematic biopsies to improve detection of significant cancer, reducing the risks of misclassification.

BACKGROUND The aim of the work is to describe an original technique of posterior musculofascial reconstruction (PMFR) during robot-assisted radical prostatectomy (RARP). METHODS From January 2015 to June 2016, 121 consecutives patients underwent RARP and were submitted to a novel technique of PMFR, using a single 3/0 barbed bidirectional (Filblock®, Assut Europe) suture. The first step of this new technique of PMFR, is to approximate the posterior layer of Denonvilliers fascia (DF) to the posterior part of the sphincteric apparatus. Then, the second step consists in the anastomosis of the posterior blabber neck edge with the posterior urethra edge. We realize the completion of anastomosis clockwise from 7 to 12 o'clock and anticlockwise from 5 to 12 o'clock. RESULTS No leakage of anastomosis was observed and the catheter was removed in the 5th day after surgery. After catheter removal, the urinary recovery of early continence at 3 days was 45% and at 7 days was 75%, while the urinary continence recovery at 1 month was 88% and at 3 months was 94%. CONCLUSIONS In our experience this novel approach results feasible in all patient, without extending the operation time and gives a good safety in terms of reduction of bleeding and leakage with shorter urinary continence recovery's time. The aim of the combination of the PMFR and the vesicourethral anastomosis with one bidirectional barbed suture is to have all the advantages of both techniques plus the stability of a single running suture.

BACKGROUND:To report the perioperative and early functional outcomes of patients undergoing Robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion performed by a single surgeon after a modified modular training.METHODS:The surgeon (A.P.) attained a 30-days modified modular training at a referring Center mentored by a worldwide-recognized robotic surgeon (P.W.). The training program consisted of: 1) e-learning based on 10 hours of theoretical lessons made by the mentor; 2) video-session concerning the different steps of the procedure, 3) step-by-step in vivo modular training. Demographics, intraoperative data and post-operative complications were recorded for each patient.RESULTS:Twenty-four consecutive patients were prospectively evaluated. Median age was 68.5 years (IQR 59-75). Thirteen (54.2%) and 11 (45.8%) patients received RARC with orthotopic neobladder (ONB) and ileal conduit (IC), respectively. Overall mean (±SD) operative time was 392 (± 34.8) minutes. The median number of lymph node retrieved was 30 (IQR 24-42), the mean intraoperative estimated blood loss (EBL) was 403 mL (±60) with average hospitalization of 7.8 days (±2.2). All procedures were completed successfully without open conversion. A statistically significant difference in terms of overall operative time (OT) and urinary diversion operative time (UDOT) was found in favor of IC group compared to ONB group (P=0.002). Overall complication rate was 33%, 7 out of 9 (88%) were graded as minor (Clavien 1-2). Two (22%) major complications (Clavien 3-5) occurred solely on ONB group.CONCLUSIONS:Robot-assisted radical cystectomy with totally intracorporeal urinary diversion is a challenging procedure with a steep learning curve. An adequate modular training with an experienced mentor and a skilled robotic team could be essential to reach these optimal results. Further studies investigating the impact of modular learning curve and a dedicated menthorship on operative and functional outcomes after RARC are needed.

OBJECTIVES:The aim of this study is to analyze the principal advantages of posterior muscolo-fascial reconstruction using knotless barbed sutures (BS) during robot-assisted radical prostatectomy (RARP).MATERIALS AND METHODS:We analyzed the available evidence regarding the efficacy and safety of principal BS (Quill™ SRS Angiotech Pharmaceuticals Inc., Vancouver, Canada; V-Loc™ Medtronic, Dublin, Ireland; STRATAFIX™ Ethicon Inc., Somerville, New Jersey; Filbloc® Assut Europe S.p.A., Rome, Italy).RESULTS:We analysed the principal outcomes (operative time and suturing time of urethra-vesical anastomosis, length of catheterization, hospital stay, and postoperative complications rate) reported in literature.CONCLUSIONS:In light of our experience, we believe that the utilization of BS during RARP is safe as the development of a new surgical technique of urethrovesical anastomosis offers advantages in terms of continence rate, length of catheterization, and other surgical outcomes. Other studies (prospective trials) are necessary to investigate the real benefits of BS in comparison to conventional sutures (CS).

Objectives A pencil in the urinary bladder is an unusual problem for urologists. We present a case in a 44-year-old female with an eyeliner pencil self-introduced into the urethra. Materials and Methods The patient was referred to us with a recent history of “ingestion of foreign body”. The clinical presentation, radiologic data, and treatment were reported. Results The patient had a pencil placed sideways in the urinary bladder, with focal perforation of the left wall. A cystoscopy was performed and the pencil was removed at the same time by using grasping forceps and hydraulic overdistention of the urinary bladder. Conclusions Bladder is the most common location of foreign bodies of the urogenital tract, almost always due to self-insertion into the urethra for the purpose of masturbation or as a result of non-inhibited or altered behavior due to psychiatric diseases, or to the influence of drugs. Most patients were too ashamed to admit they had inserted or applied any object and usually presented when a complication had occurred such as difficulty in voiding, hematuria, pain or swelling, extravasations or abscess formation. The treatment can be endoscopic, and it depends on the type of the foreign object and the operator's skills.

A retroperitoneal metastasis from malignant melanoma is an uncommon event and mostly secondary to a primary lesion of the posterior trunk. We report on a 38-year-old patient with malignant melanoma of the anterior trunk who presented a symptomatic metastatic mass of the left renal hilum not originating from the retroperitoneal lymph nodes of the renal hilum, surrounding and infiltrating the renal pelvis, treated with left nephrectomy, complete mass excision and regional lymph node dissection. The patient later developed also brain metastases and is now undergoing immunotherapy.

Objective: The aim of this work was to verify the tolerability and the preliminary clinical results of intensive intravesical instillations of a mitomycin C (MMC) regimen. Patients and Methods: From September 2007 to November 2009, 40 consecutive evaluable patients with pathologically confirmed intermediate-risk non-muscle-invasive bladder cancer (NMIBC) were enrolled after complete transurethral resection of all visible tumors. The mean age of the patients was 64.5 years. 40 mg MMC diluted in 50 ml of saline was instilled in the bladder three times a week for 2 weeks. The median follow-up was 9 months. Results: All patients fulfilled the scheduled treatment. The local adverse events seen were negligible, while no significant deviation from normal values was observed in blood counts for each patient. Twenty-three of 40 patients (57.5%) showed negative at the cystoscopic control which was performed every 3 months with normal spontaneous and washing cytological exams. Conclusion: MMC is a well-known chemotherapeutic agent for the intravesical therapy of NMIBC. With a view to improving its results, we changed the frequency and intensity of the instillations. No significant local or systemic toxicity was reported. Intensive intravesical instilllations of MMC might become a tool in the management of NMIBC.

Advances in imaging have an increasingly significant role in the diagnosis, staging and restaging of patients with bladder cancer. This paper reviews the current use of imaging in bladder neoplasms, comparing the different radiologic investigations, and discusses the potential applications of novel imaging techniques in the management of patients with bladder cancer.