Aim: The aim of this study was to demonstrate that listening to music during flexible cystoscopy and cold cup biopsy decreases patient pain. Materials and methods: We analysed 100 patients who underwent flexible cystoscopy plus at least one cold cup biopsy (50 control patients without music and 50 patients with classical music). Before cystoscopy, these patients were tested for urinary analysis and culture, and then they received the same local anaesthesia. Hemodynamic values were also collected for each patient. After the procedure, the visual analog scale (VAS) of 0–10 and the numeric pain intensity scale (NRS) were used to report the patient’s pain during the cystoscopy. Results: Both groups were similar with regards to the reasons for undergoing cystoscopy. Group 1 patients (no music controls) reported higher values of VAS and NRS, compared to patients in Group 2 (classical music; p < 0.001). No significant differences were detected between the two groups regarding hemodynamic parameters. Conclusions: In our experience, music significantly reduced feelings of pain.

A 67-year-old patient underwent robotic-assisted laparoscopic radical prostatectomy and experienced right ureteral lesion. The laceration was recognized intraoperatively and immediately repaired over the ureteral double J stent. The wire and the stent were first advanced distally to the bladder. Then the wire was pulled with its soft end, cranially through one of the side holes of the proximal end of the stent toward the kidney allowing exact positioning of the stent. Postoperative hospitalization was similar to a classic laparoscopic robotic-assisted prostatectomy. Robotic approach and the "side hole" technique represent an accurate and safe option in case of ureteral laceration management.

Objective: To investigate the impact that surgeon and operative room team experience rule in operative time and surgical outcomes. Material and Methods: We retrospectively collected data of 150 robotic radical prostatectomy (RALPs) performed by the same surgeon in two different hospitals in different periods of his robotic experience. The first and the last 50 RALPs performed in a dedicated center of robotic surgery at University of Southern California were included respectively in group 1 and group 2. The first 50 RALPs performed at University Campus Bio-Medico of Rome were included in group 3. In this case, both first assistant and nursing team were at the beginning of their robotic experience. Monovariate analysis was performed comparing each group in terms of oncological and surgical outcomes. Multivariate logistic regression models were used to assess the risk of positive margin. Results: The mean docking time in group 2 and 3 decreases significantly compared to group 1. In group 3 the operative time is significant longer. The mean estimated blood loss is higher in group 1 and the number of transfusions decreases in group 2 and 3. The probability to have surgical positive margins increases from pT2a-b-c to pT3b tumor stage. The study is limited because of its retrospective form. Conclusion: Surgeon, assistant, and nurses have a cardinal role in operative and surgical outcomes. Tumor stage is the principle parameter that influences the oncological outcome. About 50 procedures are required to reach satisfactory operative outcomes although the learning curve continues for hundreds procedures. Cristina Falavolti1, Federico Sergi2, Tommasangelo Petitti3, Vincenzo Pagliarulo4, Maurizio Buscarini1 1Department of Urology, Campus Biomedico University, Italy 2Department of Urology and Kidney Transplant, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Italy 3Hygiene and Public Health Researcher, Campus Biomedico University, Italy 4Department of Urology, University of Bari, Italy Cristina F, et al. Clinics in Surgery Urology Surgery Remedy Publications LLC., | http://clinicsinsurgery.com/ 2016 | Volume 1 | Article 1087 2 of PSM is traditionally considered one of the strongest measures of operative outcome [11]. Surgical outcomes are however influenced by multiple variables as operative experience, fellowship training, high volume center of practice and all these parameters have been shown to play a significant role [12,13]. The aim of the present study is to investigate the impact that surgeon's experience and dedicated operative room team rule in operative time and surgical outcomes. To investigate the role of surgical experience in starting a new robotic program in different country, we have retrospectively collected data of 150 RALPs performed by the same surgeon (MB) in two different hospitals in different periods of his robotic experience. We have analyzed the most important variables like DT, OT, estimated blood loss (EBL) and PSM and individuated the ones that were affected the most. Furthermore, we have demonstrated that environmental changing as hospital, assistant, nursing team determine differences in operative RALP outcomes. Materials and Methods We retrospectively compared the first 50 cases of RALPs and the last 50 cases performed by a single surgeon (MB) at the University of Southern California (USC) from 2003 to 2007 and the first 50 RALPs performed by the same surgeon at Campus Bio-Medico University of Rome (UCBM) from 2011 to 2012. We have subdivided the first and the last 50 RALPs performed at USC in a dedicated center of robotic surgery with dedicated nursing team and senior first assistant, respectively in group 1 and group 2. This served as a measure of the single surgeon’s learning curve going from novice to competent (first 50) to expert (last 50). The total number of cases performed in the USC series was 577 and only the first and last 50 were analyzed. The first 50 RALPs performed at UCBM were included in group 3. In this case, the center was not dedicated and both first assistant and nursing team were at the beginning of their robotic experience. All patients received general endotracheal anesthesia and were placed in steep Trendelenburg position with central docking. The 4-arm da Vinci® Surgical System and a 6 porttransperitoneal approach were used. All patients underwent RALP according to Montsouris’s technique [14]. For each patient we analyzed: preoperative and postoperative Gleason score, preoperative and postoperative prostatic specific antigen (PSA) and the stage of cancer. The surgical specimens were staged according to the 2002 TNM staging system. We calculated for each procedure the DT, the OT; the EBL and the PSM rate. Statistical analysis Mean values for every numerical variable and relative frequency for every variable were calculated. Monovariate analysis was performed comparing each group of patient in terms of positive surgical margin rate, operative time and docking time, estimated blood loss and number of transfusions required. χ2 test and oneway analysis of variance were used.Patients were divided into three different classes following the pathological postoperative stage: patients affected by pT2a-2b-2c tumor; patients affected by pT3a tumor and patient affected by pT3b tumor. Multivariate logistic regression models were used to compare the effect of covariates on the risk of having positive margin in each group. Group 3 was set as baseline. Linear regression was used to estimate the OT reduction in subsequent patients, divided into the three Groups. P-value in all tests was set at 0.05. Statistical analysis was performed with Stata 10 TM.

Robot-assisted laparoscopic radical prostatectomy (RALRP) is one of the best treatment for patients with localized prostate cancer. RALRP is currently performed in patients without previous surgical treatment for benign prostatic hyperplasia. This paper presents a successfully performed RALRP after previous open transvesical adenomectomy (TVA).

Hemorrhagic cystitis (HC) occurring after allogeneic transplantation significantly affects quality of life and, in some cases, becomes intractable, increasing the risk of death. To date, its therapy is not established. We used the hemostatic agent fibrin glue (FG) to treat 35 patients with refractory post-transplantation HC. Of 322 adult patients undergoing an allogeneic transplantation for hematological malignancy, 35 developed grade ≥ 2 HC refractory to conventional therapy and were treated with FG, diffusely sprayed on bleeding mucosa by an endoscopic applicator. The cumulative incidence of pain discontinuation and complete remission, defined as regression of all symptoms and absence of hematuria, was 100% at 7 days and 83% ± 7%, respectively, at 50 days from FG application. The 6-month probability of overall survival for all 35 patients and for the 29 in complete remission was 49% ± 8% and 59% ± 9%, respectively. In the matched-pair analysis, the 5-year probability of overall survival for the 35 patients with HC and treated with FG was not statistically different from that of the comparative cohort of 35 patients who did not develop HC (32% ± 9% versus 37% ± 11%, P = not significant). FG therapy is a feasible, effective, repeatable, and affordable procedure for treating grade ≥2 HC after allogeneic transplantation.

Purpose: Published data demonstrated that zoledronic acid (ZOL) exhibits antiangiogenetic effects. A promising tool for monitoring antiangiogenic therapies is the measurement of circulating endothelial cells (CECs) and circulating endothelial precursor cells (CEPs) in the peripheral blood of patients. Our aim was to investigate the effects of ZOL on levels of CECs and CEPs in localized prostate cancer. Methods: Ten consecutive patients with a histologic diagnosis of low-risk prostate adenocarcinoma were enrolled and received an intravenous infusion of ZOL at baseline (T0), 28 days (T28) and 56 days (T56). Blood samples were collected at the following times: T0 (before the first infusion of ZOL), T3 (72 h after the first dose), T28, T56 (both just before the ZOL infusion) and T84 (28 days after the last infusion of ZOL) and CEC/CEP levels were directly quantified by flow cytometry at all these time points. Results: Our analyses highlighted a significant reduction of mean percentage of CECs and CEPs after initiation of ZOL treatment [p = 0.014 (at day 3) and p = 0.012 (at day 84), respectively]. Conclusion: These preliminary results demonstrate that ZOL could exert an antiangiogenic effect in early prostate cancer through CEP and CEC modulation.

OBJECTIVE:To report a case of severe hydronephrosis 20 years after bladder exstrophy (BE) repair, managed by bilateral ureteral tapering and secondary ureteroneocystostomy.CASE PRESENTATION:A 21-year-old woman with a history of BE and ureteral reimplantation, presented with hematuria-dysuria syndrome and recurrent febrile urinary tract infections. After counselling, she elected to undergo bilateral ureteral tapering and second ureteroneocystostomy.CONCLUSION:Hydronephrosis secondary to ureteralvesical stricture in BE patients can be successfully managed with ureteral reimplantation associated to ureteral tapering even after a prior reimplantation.

Background Rectourinary fistula (RUF) is an uncommon but devastating condition in men. It usually occurs as a complication of prostatic cancer treatment, whether this is by radiation therapy or surgery. It can also occur in patients with benign pathology of the prostate, inflammatory bowel disease, or Fournier’s gangrene, and following pelvic trauma. RUF represents a challenge for the surgeon because spontaneous closure is a rare event. Several techniques have been described for surgical repair of fistula. The goal of the present study was to demonstrate that the York Mason posterior, transrectal correction of an iatrogenic RUF is a reliable approach that offers good postoperative outcomes. Methods We retrospectively reviewed the medical records of 39 patients who underwent York Mason repair from 1998 to 2012 at the University of Southern California (USC) and Campus Bio-Medico University of Rome (UCBM). The most frequent common causes of RUF were itemized, and statistical analysis was performed to determine correlations between the fistula’s etiology and surgical outcome. Patients were then divided into two different cohorts: those who had undergone only one previous procedure (group 1) and those who had undergone two or more surgeries (group 2). We performed a statistical analysis between the two groups and calculated the percentage of fistula repair by means of the posterior trans-sphincteric approach with the York Mason technique in each groups We evaluated the presence of comorbidities (diabetes and infection) and their influence on the surgical outcome. Finally, we reported patient outcomes during follow-up. Results In the present series, the RUF was iatrogenic in every case. The onset of the fistula followed prostate cancer treatment, most commonly after laparoscopic procedures. The success rate of fistula repair was found to be independent of the fistula’s etiology. Diabetes and infections did not influence the surgical outcome. Overall, more than 50 % of patients treated with the York Mason posterior, transanal, transrectal approach remained free of fistula during follow-up. Almost 90 % of those who were previously operated only once remained free of fistula. Conclusions The posterior trans-sphincteric approach of the York Mason technique is effective in treating RUF.

To present a case of laparoscopic roboticassisted simple prostatectomy with temporary clamping of the bilateral hypogastric arteries. A 74-year-old patient with large prostatic adenoma ([80 ml) underwent roboticassisted laparoscopic transvesical adenoma enucleation according to Sotelo's technique. The hypogastric arteries were isolated just below the ureteral cross with the iliac vessels and bilaterally occluded for 12 minutes during enucleation of the adenoma. The patient's pain was mild after surgery and he required short-term analgesics and antibiotic prophylaxis. Blood loss was 80 ml. The transient occlusion of the internal iliac arteries is a proven maneuver to reduce bleeding during pelvic surgery. We propose the temporary clamping of the bilateral internal iliac arteries as a safe and rapid surgical maneuver to reduce the intraoperative risk of bleeding, especially when performing first procedures.

To report a rare congenital anomaly of the genitourinary tract, renal dysplasia is associated with ipsilateral incomplete duplicated ectopic ureter and seminal vesicle cyst in an adult, successfully treated with robotic-assisted laparoscopic approach.

External beam radiotherapy (EBRT) is frequently used in the management of prostate cancer (PCa) as definitive, postoperative, or salvage local treatment. Although EBRT plays a central role in the management of PCa, complications remain a troubling by-product. Several studies have demonstrated an association between radiotherapy and elevated risk of acute and late toxicities. A secondary malignancy induced by initial therapy represents one of the most serious complications related to definitive cancer treatment. The radiation-related secondary primary malignancy risk increases with increasing survival time. Transitional cell carcinoma of the bladder is the most frequent secondary primary malignancy occurring after radiotherapy and is described as more aggressive; it may be diagnosed later because some radiation oncologists believe that the hematuria that occurs after prostate EBRT is normal. Some patients treated for localized PCa will subsequently develop invasive bladder cancer requiring surgical intervention. Patients with PCa treated with EBRT should be monitored closely for the presence of bladder cancer.

The aim of this paper is to report a case of severe hydronephrosis and incontinence 20 years after bladder exstrophy repair, managed successfully by secondary ureteroneocystostomy and by transurethral submucosal injection of Macroplastique.

Aim. To report a unique case of retroperitoneal urinoma extending to the scrotum through the spermatic cord and successfully treated with nephrostomy, drainage, and gracilis muscle flap.

Objectives Tissue Engineering can develop scaffolds of Poly-L-Lactic Acid (PLLA) for tissue regeneration. The purpose of the present job is to test the possibility to seed human adult mesenchymal stem cells on a scaffold supplemented with specific grow factors to differentiate them into urothelium. Methods The Electrospinning technique was used to realize three scaffolds. The first one was seeded with urothelial cells, of a primary culture, and Keratinocyte serum free medium (KSFM); the second one was seeded with human mesenchymal stem cells (hMSC) and a minimum essential medium (αMEM); the third one was seeded with hMSC and conditioned medium. Results Electron microscopy showed scaffolds with cellular vitality (>90%) and their cellular proliferation. Moreover, the differentiation of hMSC, seeded in conditioned medium, into urothelial cells was demonstrated through immunofluorescence assays. Conclusions Tissue Engineering can develop PLLA scaffolds thanks to the Electrospinning technique. The scaffold is a perfect environment for cellular culture and proliferation; a protocol for the differentiation of hMSC into urothelial cells is now available. Immunofluorescence assays can demonstrate the hMSC differentiation into urothelial cells.

BACKGROUND: Patients undergoing hematopoietic stem cell transplant (HSCT) are particularly exposed to the risk of developing hemorrhagic cystitis (HC), which is characterized by symptoms ranging from macroscopic hematuria to renal failure. Although HC significantly affects the quality of life and in a few cases becomes intractable leading to patient death, its therapeutic management has not been established. Fibrin glue (FG), a hemostatic agent derived from human plasma, has been largely employed in different surgical settings including urologic procedures.STUDY DESIGN AND METHODS: In this pilot study we used FG to treat refractory HC. During cystoscopy, bladder distension was maintained at a constant pressure of 12 mmHg by a carbon dioxide insufflator. An endoscopic applicator allowed spraying FG on the bleeding and raw surfaces of bladder mucosa.RESULTS: Five of 221 patients undergoing an HSCT developed a very severe, refractory HC and have been treated with endoscopic FG. The treatment was successful in 3 patients; the response was partial in 1 patient and transient in the last one, whose clinical course was severely complicated by acute graft-versus-host disease and multiple organ failure.CONCLUSIONS: FG therapy is a feasible procedure and this pilot study suggests that it may be an effective treatment for refractory HC. Its application could be considered also in Grade 1 or 2 HC to prevent progression of damaged mucosa. The use of FG for HC should be prospectively investigated in terms of therapeutic efficacy, transfusion support, length of hospitalization, quality of life, and costs.

PURPOSE We evaluated the collagen content and differentiation of the ureteropelvic junction (UPJ) of patients who underwent Anderson-Hynes dismembered pyeloplasty after failure of antegrade endopyelotomy. MATERIALS AND METHODS A total of 12 UPJ obstructions were examined more than 12 months after endopyelotomy with both histochemical staining to analyze total collagen content and immunohistochemical staining to analyze collagen types I and III. The specimens were compared with 12 primary UPJ obstructions and 6 normal UPJs. Statistical analysis was performed using Fisher's test and Wilcoxon matched-pairs signed-rank test. RESULTS Immunohistochemical staining revealed that collagen type I was located in the interfascicular space and collagen type III in the intrafascicular space in all UPJs. We found more collagen in obstructed than in normal UPJs. Collagen type III was more abundant in secondary than in primary UPJ obstructions (P < 0.01). In obstruction after endopyelotomy, the staining intensity of collagen type III was greater than the intensity of collagen type I (P < 0.01). CONCLUSION Our results suggest that the success of antegrade endopyelotomy was impaired by an inflammatory process. This condition determined a shift of collagen differentiation toward type III, which is more fibrous than type I.