Publications by authors named "Antonello De Lisa"

34 Publications

How Can the COVID-19 Pandemic Lead to Positive Changes in Urology Residency?

Front Surg 2020 24;7:563006. Epub 2020 Nov 24.

Department of Urology, IEO European Institute of Oncology IRCCS, Milan, Italy.

The COVID-19 outbreak, in a few weeks, overloaded Italian hospitals, and the majority of medical procedures were postponed. During the pandemic, with hospital reorganization, clinical and learning activities performed by residents suffered a forced remodulation. The objective of this study is to investigate how urology training in Italy has been affected during the COVID-19 era. In this multi-academic study, we compared residents' training during the highest outbreak level with their previous activity. Overall 387 (67.1%) of the 577 Italian Urology residents participated in a 72-h anonymous online survey with 36 items sent via email. The main outcomes were clinical/surgical activities, social distancing, distance learning, and telemedicine. Clinical and learning activity was significantly reduced for the overall group, and after categorizing residents as those working only in COVID hospitals, both "junior" and "senior" residents, and those working in any of three geographical areas created (Italian regions were clustered in three major zones according to the prevalence of COVID-19). A significant decrease in outpatient activity, invasive diagnostic procedures, and endoscopic and major surgeries was reported. Through multivariate analysis, the specific year of residency has been found to be an independent predictor for all response modification. Being in zone 3 and zone 2 and having "senior" resident status were independent predictors associated with a lower reduction of the clinical and learning activity. Working in a COVID hospital and having "senior" resident status were independent predictors associated with higher reduction of the outpatient activity. Working in zone 3 and having "senior" resident status were independent predictors of lower and higher outpatient surgical activity, respectively. Working in a COVID hospital was an independent predictor associated with robotic surgical activity. The majority of residents reported that distance teaching and multidisciplinary virtual meetings are still not used, and 44.8% reported that their relationships with colleagues decreased. The COVID-19 pandemic presents an unprecedented challenge, including changes in the training and education of urology residents. The COVID era can offer an opportunity to balance and implement innovative solutions that can bridge the educational gap and can be part of future urology training.
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http://dx.doi.org/10.3389/fsurg.2020.563006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732553PMC
November 2020

Blood clots evacuation from the renal pelvis: How to perform it?

Int J Urol 2019 05 17;26(5):587-588. Epub 2019 Feb 17.

Department of Urology, University of Cagliari, Cagliari, Italy.

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http://dx.doi.org/10.1111/iju.13922DOI Listing
May 2019

Massive migration of embolization coils inside the renal pelvis. A rare complication that can be approached through percutaneous surgery.

Cent European J Urol 2018 27;71(4):467-469. Epub 2018 Dec 27.

University of Cagliari, Department of Urology, Cagliari, Italy.

Percutaneous nephrolithotripsy (PCNL) has become a common procedure performed in patients with large renal calculi. Hemorrhage is the most frequent complication of this procedure. Transcatheter renal artery embolization is an effective and minimally invasive treatment option for acute renal bleeding but it is not without risks. In the case we describe, a big stone originated on embolization coils which migrated inside the renal pelvis after a previous PCNL and transcatheter artery embolization. We show that a new percutaneous approach is feasible and allows for the fragmentation of the stone and full clearance of fragments and coils.
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http://dx.doi.org/10.5173/ceju.2018.1795DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6338816PMC
December 2018

PCNL in the prone position VS PCNL in the modified supine Double-S position: is there a better position? A prospective randomized trial.

Urolithiasis 2020 Feb 19;48(1):63-69. Epub 2018 Nov 19.

Department of Urology, University of Cagliari, Via Is Mirrionis 92, 09121, Cagliari, Italy.

The study was performed to evaluate the efficacy of our modified supine position (called "Double-S") in percutaneous nephrolithotripsy (PCNL) and to make a contribution to the question: "Is there a better position in PCNL?". The superiority of one position is still under debate in the scientific community. In our study, we described and compared our position with the standard prone one to evaluate the possible benefits. This is a prospective randomized clinical trial conducted for 17 months. It consisted of two sub-studies: trial A (patients with stones approachable with a single anterograde access) and trial B (patients with stones approachable with a single anterograde access combined with a retrograde access). A 1:1 randomization was performed in both trials to compare the supine Double-S position with the prone one. We found that the Double-S position presents the same safety and efficacy outcomes as the standard prone one. Moreover, we proved that this particular position can reduce the patient positioning time and effort sustained by professional nurses if compared to the prone one. The same outcomes were found in trial A and in trial B. Trial B confirms the efficacy of our position also when a combined access is needed. We proved that the Double-S position is safe and effective both in anterograde treatments and in combined anterograde-retrograde procedures with benefits in the positioning time and effort level.
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http://dx.doi.org/10.1007/s00240-018-1088-0DOI Listing
February 2020

A smart trick to perform a flexible renoscopy during percutaneous nephrolithotripsy.

Indian J Urol 2018 Jul-Sep;34(3):233-234

Department of Urology, University of Cagliari, Cagliari, Italy.

Fluid leakage from the Ampltz sheath during flexible nephroscopy after PCNL prevents dilatation of the pelvi-calyceal system and adequate visualization. This video demonstrates a simple technique to prevent such leakage.
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http://dx.doi.org/10.4103/iju.IJU_17_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6034403PMC
July 2018

Surgical approach to adrenal ganglioneuroma: Case report and literature review.

Arch Ital Urol Androl 2018 Jun 30;90(2):145-146. Epub 2018 Jun 30.

Clinica Urologica, Università degli Studi di Cagliari, Ospedale SS. Trinità, Cagliari.

Objective: Ganglioneuroma (GN) is a benign tumor with a slow growth that can originate from any paravertebral sympathetic plexus. It is usually asymptomatic or with nonspecific symptoms. TC and RM scan are helpful to study GN. It is usually represented by an ovalshaped retroperitoneal mass or, in case of adrenal impairment, by low radiologic contrast media attenuation. Surgical treatment is mandatory. Literature shows how the laparoscopic approach is the most used, especially in lesions that are 6 cm or smaller. Our purpose is to describe our experience on an incidental adrenal GN of about 5 cm treated by the laparoscopic transperitoneal approach.

Materials And Methods: A 33-year-old male had ultrasound occasional finding of an about 4 cm adrenal mass. TC and RM scan identified a retroperitoneal mass (max diameter 48 mm). The lesion was removed with a transperitoneal laparoscopic approach.

Results: No intraoperative or postoperative complications occurred. The patient was discharged 3 days after surgery.

Conclusions: Up to the present laparoscopic surgery is the best approach for GN treatment.
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http://dx.doi.org/10.4081/aiua.2018.2.145DOI Listing
June 2018

Skin flap squamous cell carcinoma developed after urethroplasty.

Arch Ital Urol Androl 2018 Jun 30;90(2):141-142. Epub 2018 Jun 30.

Clinica Urologica, Università degli Studi di Cagliari, Ospedale SS. Trinità, Cagliari.

Objectives: To describe our experience in diagnosis and treatment of urethral carcinoma following urethroplasty with a Orandi penile skin flap.

Material And Methods: Our patient underwent to Orandi penile skin flap urethroplasty then developed a urethral epidermoid carcinoma on the flap approximately 15 years later. We treated this case with a partial penectomy surgery and perineostomy. Surgery was followed by chemotherapy with cisplatin and 5-fluorouracil. The progression of the disease led to a salvage surgery of total penectomy and asportation of testicles and scrotum.

Results: Despite the success of the surgery, the disease progressed and three months after the last surgical operation the patient died.

Conclusions: Urethral carcinoma on skin flap is a rare complication of the urethroplasty surgery but with severe consequences, so we recommend to undertake a long-term urological follow up in patients undergone such kind of surgery.
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http://dx.doi.org/10.4081/aiua.2018.2.141DOI Listing
June 2018

Early Repair of Post-hysterectomy Vesicovaginal Fistulae Through a Laparoscopic Transperitoneal Extravesical Approach. Experience of a Single Center.

Urology 2018 Sep 7;119:44-48. Epub 2018 Jun 7.

Department of Urology, University of Cagliari, Cagliari, Italy.

Objective: To verify the feasibility and effectiveness of the correction of vesicovaginal fistulae (VVF) through a laparoscopic transperitoneal extravesical approach and TachoSil application as interposition tissue. VVF are the most common fistulae of the urinary tract and even today there is no agreement over the preferred approach to treat this kind of pathologic condition.

Methods: We retrospectively analyzed the data of women who, from July 2010 to July 2017, underwent early laparoscopic transperitoneal extravesical VVF repair. Patients were placed in the lithotomy position. Five operating ports were placed. After the resection of the VVF, the vesical and vaginal edges were closed in two layers. Finally two layers of TachoSil (4 cm x 4 cm) were placed between the sutures. Several variables were considered in the perioperative period. Patients were re-evaluated at 1 and 3 months after surgery.

Results: Sixteen patients underwent VVF repair. Mean duration of the surgery was 106 minutes, mean length of stay was 3.2 days. No high grade complications according to Clavien-Dindo were reported. At 1 month all patients showed complete continence and at 3 months they reported a good quality of life.

Conclusion: The laparoscopic approach described enables adequate repair of VVF. The use of Tachosil is straightforward and atraumatic, and may be considered as an alternative to tissue flap interposition. Finally, we confirm that the early approach is not a hazard in such a disabling disease and can be adopted to restore as soon as possible the good quality of life for patients.
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http://dx.doi.org/10.1016/j.urology.2018.05.021DOI Listing
September 2018

Supine Percutaneous Nephrolithotripsy in Double-S Position.

Adv Urol 2018 11;2018:7193843. Epub 2018 Mar 11.

Department of Urology, University of Cagliari, Via Is Mirrionis 92, 09121 Cagliari, Italy.

Background: At present, the percutaneous nephrolithotripsy (PCNL) is performed both in supine and in prone position. The aim of this paper is to describe an innovative position during PCNL.

Methods: We describe a supine position. The patient's legs are slightly abducted at the hips. The thorax is laterally tilted (inclination 30°-35°) and kept in the right position by one or two gel pads placed between the scapula and the vertebrae. External genitalia can be accessed at any time, so that it is always possible to use flexible instruments in the upper urinary tract. We used this position for a period of 12 months to treat with PCNL 45 patients with renal lithiasis.

Results: All the procedures were successfully completed without complications, using the position we are describing. The following are some of its benefits: an easier positioning of the patient; a better exposure of the flank for an easier access to the posterior renal calyces of the kidney; a lower risk of pressure injuries compared to positions foreseeing the use of knee crutches; the possibility of combined procedures (ECIRS) through the use of flexible instruments; and a good fluoroscopic visualization of the kidney not overlapped by the vertebrae.

Conclusions: This position is effective, safe, easy, and quick to prepare and allows for combined anterograde/retrograde operations.
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http://dx.doi.org/10.1155/2018/7193843DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5866850PMC
March 2018

The Lithocatch (TM) by Boston Scientific: how to use it and how to solve a common problem.

Int Braz J Urol 2018 Nov-Dec;44(6):1262

Department of Urology, University of Cagliari, Cagliari, Italy.

Introduction: The Lithocatch (TM) basket is a immobilization device commercialized by Boston Scientific. It allows to collect multiple stone fragments from the ureter. The ability of the basket to capture a large number of stone fragments, is however responsible for a problem connected to its usage: the entrapment of the basket inside the ureter. In this video we explain how to use it and how to solve this problem.

Material And Methods: After positioning the Lithocatch (TM) over the fragments, the basket is opened and it is rotated through a special handle to collect stones. One frequent problem occurs when too many fragments are collected at once, preventing the extraction of the device. We research our archives to extrapolate the total number of procedures carried out with the Lithocatch (TM) in the last two years and the total number of complications occurred.

Results: We experienced the above mentioned complication in 16 procedures (14% of the total) of 114 surgeries performed. The way described to solve this complication was efficient and did not produce any damage to the ureter or to the basket.

Conclusion: The Lithocatch (TM) has an excellent ability to capture small stones so it allows to reduce the length of the procedure. Paying attention to limit the amount of fragments collected, it is possible to avoid the entrapment of the basket. If this complication occurs, the problem can be solved by reducing the size of the stone fragments. The preferable type of energy is the ballistic one.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2018.0105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6442164PMC
February 2019

Percutaneous Approach to a Complicated Case of Nephrolithiasis in a Pregnant Woman: A Case Study.

J Endourol Case Rep 2016 1;2(1):84-6. Epub 2016 Apr 1.

Department of Urology, University of Cagliari , Cagliari, Italy .

Background: Lithiasis during pregnancy can be a serious problem representing a danger to both the mother and the fetus. Surgical intervention is needed in approximately one-third of patients reporting pain despite analgesia and/or signs of persistent infection and obstruction, but there is a lack of consensus in the scientific literature as to the use of the most appropriate procedure to treat this condition.

Case Presentation: We describe our experience in the treatment of a complicated reno-ureteral lithiasis in a 27-year-old patient in the first trimester of pregnancy. The patient had a calcified ureteral stent with associated stone formation in the right kidney and a bladder stone at the distal extremity of the stent. She was treated by a combined approach by percutaneous nephrolithotripsy and transurethral cystolithotripsy. The procedure we performed was effective.

Conclusion: Our experience reinforces the feasibility and safety of the kidney stone removal by the percutaneous approach also in a pregnant patient and supports the recommendations of the European guidelines: "in experienced centers, where necessary, percutaneous nephrolithotripsy should be considered." The technical precautions taken have proven to be valid and are supported by the current literature. Therefore, we feel they can be recommended.
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http://dx.doi.org/10.1089/cren.2016.0040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4996601PMC
August 2016

Regional differences of energetics, mechanics, and kinetics of myosin cross-bridge in human ureter smooth muscle.

Int J Physiol Pathophysiol Pharmacol 2015 20;7(1):34-43. Epub 2015 Mar 20.

Department of Surgery Sciences, Section of Urology, University of Cagliari Italy.

This study provides information about baseline mechanical properties of the entire muscle and the molecular contractile mechanism in human ureter smooth muscle and proposed to investigate if changes in mechanical motor performance in different regions of isolated human ureter are attributable to differences in myosin crossbridge interactions. Classic mechanical, contraction and energetic parameters derived from the tension-velocity relationship were studied in ureteral smooth muscle strips oriented longitudinally and circularly from abdominal and pelvic human ureter parts. By applying of Huxley's mathematical model we calculated the total working crossbridge number per mm(2) (Ψ), elementary force per single crossbridge (Π0), duration of maximum rate constant of crossbridge attachment 1/f1 and detachment 1/g2 and peak mechanical efficiency (Eff.max). Abdominal longitudinal smooth muscle strips exhibited significantly higher maximum isometric tension and faster maximum unloaded shortening velocity compared to pelvic ones. Contractile differences were associated with significantly higher crossbridge number per mm(2). Abdominal longitudinal muscle strips showed a lower duration of maximum rate constant of crossbridge attachment and detachment and higher peak mechanical efficiency than pelvic ones. Such data suggest that the abdominal human ureter showed better mechanical motor performance mainly related to a higher crossbridge number and crossbridge kinetics differences. Such results were more evident in the longitudinal rather than in the circular layer.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4446387PMC
June 2015

[Repair of post-hysterectomy vesicovaginal fistulae: the state of the art].

Urologia 2015 Jan-Mar;82(1):10-21

In western countries, vesicovaginal fistulae (VVF) are mostly iatrogenic and in the majority of cases are secondary to hysterectomy. The golden standard for the treatment of VVF has remained largely unchanged since 1953 (Couvelaire): good visualization, good dissection, good approximation of the margins, and good urine drainage. However, several aspects are still being debated, including whether or not to pursue conservative repair, the timing for surgical repair, whether to perform excision of the fistula tract, the best type of surgical access, and whether or not to use tissue interposition. We decided to review the state of the art in the treatment of VVF, which are exclusively of a traumatic nature and non-radiated, by performing a bibliography search carried on Pubmed using keywords such as "vesicovaginal fistula". The search focused on recent articles and was largely restricted to the past 10 years.
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http://dx.doi.org/10.5301/uro.5000112DOI Listing
December 2016

[Use of Amplatz cannula through cystostomy].

Urologia 2012 Dec 30;79 Suppl 19:96-8. Epub 2012 Dec 30.

Clinica Urologica - Università degli Studi di Cagliari - Italy.

Introduction: Bladder tamponade is an uncommon complication of post-TURP bleeding and, for its resolution, it may require a long and complex process when conducted transurethrally.

Material And Methods: From 2001 to 2011, 20 patients were treated endoscopically by transurethral combined use of Amplatz percutaneous suprapubic cannula. Blood clots were detected above the average size of 5 cm. The technique has required a transurethral access with resector, dissection and resection of clots. In cases where the techniquet has proved insufficient, an Amplatz cannula was introduced by suprapubic access. The resector allows controlling the technique and a constant irrigation, and is also necessary for the final evaluation of the clinical picture. The procedure has been completed with the application of a suprapubic catheter left in site for 24 hours, together with a transurethral one for 48 hours.

Results: In all the cases that we treated, the condition was solved between 15 and 25 minutes, and the evacuation of blood clots was entirely performed. There were no complications. The final control by transurethral way allowed executing hemostasis in all cases. The post-TURP vesical tamponade can represent a dramatic event in terms of pain and alteration of renal function for patients with renal insufficiency. The combined technique, which might appear bloody, represents a valid alternative to the classic transurethral endoscopic technique, which still represents the gold standard in the case of small bleeding and not organized blood clots.

Conclusions: The use of a suprapubic approach with this technique allows for a rapid, efficient and secure resolution of, otherwise, a long and difficultly treatable disease as it is the case with bladder tamponade due to clots for non-neoplastic diseases.
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http://dx.doi.org/10.5301/RU.2012.9732DOI Listing
December 2012

[Laparoscopic nephrectomy treatment of renal tumors over 7 cm: our experience].

Urologia 2012 Dec 30;79 Suppl 19:91-5. Epub 2012 Dec 30.

Clinica Urologica - Università degli Studi di Cagliari - Italy.

Introduction: Radical nephrectomy by open surgery is the gold standard treatment for localized renal cancers. Several studies can demonstrate the efficacy and safety of laparoscopic radical nephrectomy for tumors in stage T1.

Materials And Methods: From June 2004 to June 2011 we studied 132 patients undergoing videolaparoscopic radical nephrectomy, and analyzed the following parameters: cancer site, cancer dimension, eventual lymphadenectomy and surrenectomy, approach used (transperitoneal or retroperitoneal), surgery time, pre- and post-surgery (24h) hemoglobin and creatinine. Patients were then divided in 2 groups: Group A (78 patients): T1 cancer (dimension less than 7 cm); Group B (54 patients): T2-T3 cancer (dimension equal or larger than 7 cm) (T2 = 62%; T3 = 38%).

Results: There were no significant statistic differences between the 2 groups about number of patients, decrease of hemoglobin and increase of creatinine. On the other side, significant differences were found about surgery time: 127 min for Group A against 170 min for Group B.

Conclusions: Laparoscopic radical nephrectomy shows a lower morbidity compared to open surgery, although this is confirmed by a few studies; cancer controls seem equivalent between the T1 and T2 tumors. Radical nephrectomy by laparoscopy was and is still recommended for T1 and T2 cancers, but there is no enough evidence that it can be useful in the same way for T3 cases. Our study supports the thesis that laparoscopic radical nephrectomy is a safe and effective approach for tumors at and above 7 cm and not just those smaller, with an equal number of complications compared to an increase in the average surgery time.
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http://dx.doi.org/10.5301/RU.2012.9731DOI Listing
December 2012

[Endoscopic prostate resection by bipolar gyrus resector for prostates over 80 ml: our experience after a 12-month follow-up].

Urologia 2012 Dec 30;79 Suppl 19:30-6. Epub 2012 Dec 30.

Clinica Urologica - Università degli Studi di Cagliari - Italy.

Introduction: The open surgery approach is the gold standard for the treatment of prostatic adenoma with a volume over 80 mL.

Patients And Methods: We studied 180 patients from June 2004 to June 2011, affected by prostatic adenoma >80 mL, and who underwent endoscopic resection performed with bipolar technique by a single operator. We considered the following data: surgery duration, bleeding, absorption of irrigating fluids, resected tissue quantity, clinical stay, and catheterization time. Resections up to the surgical capsule were performed with bipolar Gyrus resector and the fragments were collected with prostate Ellik-type conveyor. Next step was the positioning of the bladder catheter with cystoclysis. We evaluated early and late complications and performed clinical reassessment of the patients at 1, 3, 6 and 12 months.

Results: Surgery average time was 118 min. The average resected tissue volume was 92 g. The post-surgery hemoglobin was 13.2 g/dL. In 15 patients a revision of the lodge was performed within 24 hours after resection; no blood transfusions were performed. The catheter was removed after 3.2 days and the average recovery time was 4 days. There were eight cases of cicatricial stenosis of the bladder neck treated with endoscopic laparotomy. There were no cases of post-TURP syndrome. The IPSS parameters varied from 20.7 to 3.8, the IIEF5 from 19.3 to 21.2. The average QoL decreased from 4 to 1.5, Qmax from 22.2 7.7 mL/sec. The total PSA values decreased from 6.39 ng/mL to 1.0 ng/mL.

Conclusions: TURP for prostatic adenomas greater than 80 mL in volume, is a valid alternative in terms of efficacy and safety to open surgery, considered the gold standard treatment.
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http://dx.doi.org/10.5301/RU.2012.9735DOI Listing
December 2012

[Laparoscopic ureteral reimplantation surgery according to Lich-Gregoir].

Urologia 2012 Dec 30;79 Suppl 19:27-9. Epub 2012 Dec 30.

Clinica Urologica - Università degli Studi di Cagliari - Italy.

Introduction: Terminal ureteral stenosis can occur as a consequence of gynecological diseases or surgical treatment of simple or radical hysterectomy and pelvic endometriosis.

Materials And Methods: We evaluated 5 patients aged between 30 and 52 years, who underwent ureterocystoneostomy for ureteral stenosis due to several factors: 2 cases of pelvic endometriosis; 2 cases of surgery treatment of pelvic endometriosis, and 1 case of simple hysterectomy. Patients were placed supine in Trendelemburg position of about 30°. After pneumoperitoneum induction, the following equipment was introduced through four different laparoscopic accesses: the optic tool into the umbilicus access, 5-mm operative accesses on the lesion side, and one of 10-11 mm in the contralateral site. Once we incised the peritoneum and isolated the distal ureter until the stenotic tract, we proceeded with the dissection, performing a 2 cm serum-muscle incision of the bladder, showing the mucosa after previous distension with 200 mL of saline. A little operculum in the mucosa was created by a spatula. After applying a DJ ureteral catheter with the distal end introduced into the bladder, the direct ureteral-vesical anastomosis was made. The application of serum-detrusor sutures next to the ureter created the antireflux barrier. The peritoneum was closed.

Results: Surgery was performed by laparoscopy without conversion into open surgery. Average performing time was 205 min. Clinical stay was 5 days and DJ ureteral catheter was removed after 3 weeks following cystography and absence of spillage around the bladder. The ultrasound controls performed after three and six months did not show any complication.

Conclusions: Laparoscopy is a valid alternative to open surgery, also yielding better esthetic results, particularly in cases where the classical approach is difficult to perform, as for example in obese patients.
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http://dx.doi.org/10.5301/RU.2012.9764DOI Listing
December 2012

[Laparoscopic transmesocolic pyeloplasty: our technical notes on the application of intrasurgical ureteral DJ catheter].

Urologia 2012 Dec 30;79 Suppl 19:24-6. Epub 2012 Dec 30.

Clinica Urologica - Università degli Studi di Cagliari.

Introduction: The ureteral stent used for laparoscopic pyeloplasty can be placed pre-surgically, intra-surgically or post-surgically. The intra-surgical application can be carried out by anterograde or retrograde techniques.

Materials And Methods: 23 patients affected by pelviureteric junction disease (14 males, 9 females), aged between 10 and 55 years, underwent laparoscopic pyeloplasty with Anderson Hynes technique. No patient had a pre-surgery DJ ureteral catheter. Surgery was performed on lateral decubitus with external genitals. A sterile field including a flexible cystoscope was prepared to apply the ureteral catheter. Pyeloplasty was performed. After placing the first 4 ureteropelvic anastomosis stitches, flexible cystoscopy was performed by applying a leading probe 0.038 or 0.035 stiff Lubriglide flexible straight tip, depending on the ureter caliber. A ureteral catheter 6 or 4.8 Ch was used. The guide was followed by laparoscope until the renal pelvis or superior renal calices were reached. After extracting the cystoscope, the ureteral catheter was inserted with a suitable pusher up to the pelvis. After guide extraction, J modeling was performed. The time elapsed from the beginning of cystoscopy until the end of the procedure was calculated.

Results: The procedure was easily performed in all patients. The application time varied between 5 and 8 minutes for males, and from 6 to 10 minutes for females. The DJ catheter in laparoscopic pyeloplasty was applied by retrograde way. An alternative is the laparoscopic access or application in a previous moment with the need of two different surgical fields. This provides a reasonable execution time, the only difficulty being the finding of the external urethral meatus.

Conclusions: The intra-surgical application of DJ ureteral stent is a good alternative to the supine anterograde or retrograde technique.
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http://dx.doi.org/10.5301/RU.2012.9733DOI Listing
December 2012

[The Endovision technique in renal percutaneous lithotripsy].

Urologia 2012 Dec 30;79 Suppl 19:125-7. Epub 2012 Dec 30.

Urologic Clinic, University of Cagliari-Cagliari - Italy.

Introduction: In order to achieve a safer percutaneous access to the kidney, even if not systematically, it is possible to combine the use of eco-fluoro-guided puncture with the endoscopic retrograde vision through flexible ureteroscopy. Our experience has been conducted in order to standardize the technique and highlight advantages and limitations. 


Materials And Methods: 26 patients (15 M-11 F), mean age 46 years, underwent flexible ureterorenoscopy as first percutaneous access for pyelic or pyelocaliceal stones.
20 cases were conducted in the prone and 6 in the supine position. 
We proceeded with the study of the caliceal topography and the choice of the calyx suitable for puncture, studying the orientation of the main axis of the papilla of the lower or middle group. Leaving the endoscopic instrument in place, we proceeded with the contrast injection and the eco-fluoro-guided puncture. The retrograde instrument followed the puncture and access dilatation.


Results: In 16 cases we identified a papilla of the lower caliceal group with a correct orientation for the renal puncture; in the other 10, we chose a papilla of the middle group, because it was more favorable. In 10 cases the puncture was made at the center of the papilla with its axis in favor; in 16 it was necessary to correct the puncture because the needle had penetrated the fornix (no. 14) or had punctured the other side of the calyx (no. 2). 
In 10 cases the puncture correction caused some bleeding, which required a careful washing in order to clear the field of vision and repeat the procedure; in other 6 cases, this was not possible: the Endovision procedure was interrupted and completed according to the conventional method. There was no difference in technique between the supine and the prone position.


Discussion: It is not always likely to find a papilla of lower calyx suitable to correct puncture.
The Endovision technique is related to an inevitably blind moment linked to the displacement of the kidney, which is not followed by the flexible instrument, and to the limitations related to the visibility. The technique can be used both in the prone and supine position; chances are that it might not always be completed.
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http://dx.doi.org/10.5301/RU.2012.9521DOI Listing
December 2012

[Endoscopic combined intra renal surgery (ECIRS) in prone position].

Urologia 2012 Dec 30;79 Suppl 19:121-4. Epub 2012 Dec 30.

Urologic Clinic, University of Cagliari - Cagliari, Italy.

Introduction: E.C.I.R.S. is currently used in Galdakao-modified supine Valdivia position, since it is thought to be capable of allowing the retrograde approach to the high urinary diseases. Our school developed some good experience in percutaneous procedures in the prone position, with no significant anesthetic complications; we have performed an evaluation of flexible retrograde endoscopy with percutaneous nephrolithotripsy in this position.

Materials And Methods: 21 patients (14 M - 7 F), with a mean age 44.5 years (range 27-62), with complex urolithiasis, underwent percutaneous nephrolithotripsy associated with flexible retrograde endoscopy (E.C.I.R.S.) in the prone position. The technique has followed these steps: patient's positioning in the prone position; flexible cystoscopy and insertion of guide 0.038" stiff Lubriglide flexible tip; ureteral sheath 11/13 Ch until the lumbar ureter; fixing the end of the sheath to the surgical drape with sutures or surgical instrument; catheter Nelaton transurethral 10 Ch to the side of the sheath; renal puncture and routine procedure for the nephrolithotripsy assisted by the flexible instrumentation by retrograde approach. The procedure ended with the application of a Re-entry Malecot nephrostomy tube (Boston Scientific).

Results: The ureteral sheath was easily applicable in the prone position for all patients, with no difference between males and females; its presence made it easier to enter and the progression of the flexible instrument by retrograde approach. Idem come sopra. There was no lengthening of operative time associated with retrograde instrumentation. The "stone free" status was obtained in 100% of cases. There were no complications.

Discussion: The stabilized ureteral sheath allows for the comfortable and secure combined endorenal prone procedure, with flexible instruments both in men and women, through a safe and effective technique.
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http://dx.doi.org/10.5301/RU.2012.9520DOI Listing
December 2012

[Use of TachoSil in laparoscopic enucleoresection of renal masses smaller than 4 cm: our preliminary experience of 41 cases].

Urologia 2012 Dec 30;79 Suppl 19:131-3. Epub 2012 Dec 30.

Urologic Clinic, University of Cagliari, Cagliari - Italy.

Introduction: In nephron-sparing surgery the use of new and various hemostatic materials has provided a significant support in the control of intraoperative hemostasis of resection bed. Objective of this study is to demonstrate the use of hemostatic material TachoSil in laparoscopic treatment of renal masses <4 cm.

Materials And Methods: 41 patients underwent laparoscopic renal enucleoresection. In all patients one or more hemostatic TachoSil sponges were used, affixed to the bed of resection; we retrospectively evaluated the efficacy and safety of this technique. Transperitoneal access in 39 patients with antero-lateral mass and retroperitoneoscopic access in 2 patients with middle-posterior mass. After performing a warm ischemia, we proceeded to mass enucleoresection by cold blade, and to hemostasis control by suturing open vessels on the resection bed with "central suturing" technique. After unclamping the renal artery, one or more hemostatic sponges of TachoSil were always used (fibrinogen and human thrombin) affixed to the bed section.

Results: No significant variations of Hb, BUN and Crs. 3 cases (6.9% of renal units) of intraoperative hemorrhage requesting blood transfusion, 2 cases (4.6% of renal units) of urinary leakage at low pressure, treated conservatively with retrograde application of ureteral stent DJ for 21 days; 2 patients underwent new laparoscopy and suture. The mean time to hemostasis, evaluated in terms of the absence of macroscopic intraoperative bleeding after the application of TachoSil, was 5.5 (3-16) minutes. Average hospital stay: 5.5 (4-11) days.

Follow-up: 37.6 (5-84) months.

Discussion: The control of hemostasis is the key problem inherent to laparoscopic technique and can be approached using hemostatic agents. Currently hemostatic agents such as TachoSil ® are used increasingly as an adjuvant agent in the control of bleeding, having an excellent application in laparoscopic renal enucleoresection, and proving safe and effective in the treatment of tumors below 4 cm.
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http://dx.doi.org/10.5301/RU.2012.9523DOI Listing
December 2012

[Treatment of lithiasis with infundibular axis at an acute angle to the calyx entry in PCNL].

Urologia 2012 Dec 30;79 Suppl 19:128-9. Epub 2012 Dec 30.

Urologic Clinic, University of Cagliari - Cagliari - Italy.

Introduction: In the treatment of pyelo multi calyceal renal lithiasis, although we utilize both rigid and flexible instruments, the greatest challenge when trying to achieve a stone-free status after the procedure with a single access, is represented by the presence of residual caliceal stones difficult to reach for the length of the infundibular system in which they are localized, and major axis of it at an acute angle with respect to the axis of the cannula entrance. We describe our technique of treatment in these cases with no second access.

Materials And Methods: 55 cases of multiple lithiasis of the lower calyx at the end of PCNL for complex lithiasis were treated with the following technique. Using ultrasound and fluoroscopic guidance a puncture of the calyx adjacent to the cannula was performed. A standard Lubriglide guide (0.038", right or J) was introduced until the renal pelvis. Through a nephroscopic guidance, the guide was retrieved with a clamp and was taken out from the cannula; then the two leaders were locked together by a mosquito-mounted clamp. The guide traction towards the cannula allowed identifying, through the rigid nephroscope, the infundibulum where the lithiasis was located. The infundibulum was sectioned with monopolar electrode and it was possible to access the calyx affected by the lithiasis.

Results: In all treated cases it was possible to reach the lithiasis from the single initial percutaneous access and to eliminate them. Small bleedings were dominated by monopolar electrode. The Urography or uro-CT performed after three months showed no residual lithiasis; the infundibulum resumed its morphological characteristics.

Discussion: The described technique allows for a complete resolution of the lithiasis with no need of a second access or a retrograde approach, in situations where the combined use of flexible instruments does not allow solving the pathology.
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http://dx.doi.org/10.5301/RU.2012.9522DOI Listing
December 2012

Impact of case volumes on the outcomes of percutaneous nephrolithotomy.

Eur Urol 2012 Dec 16;62(6):1181-7. Epub 2012 Mar 16.

Department of Urology, AMC University Hospital, Amsterdam, The Netherlands.

Background: Previous studies have demonstrated relationships between case volumes and outcomes in surgery. Little is known about the impact of case volumes on the outcomes of percutaneous nephrolithotomy (PCNL).

Objective: To investigate the influence of case volumes on the efficacy and safety outcomes of PCNL.

Design, Setting, And Participants: From November 2007 to December 2009, prospective data were collected by the Clinical Research Office of the Endourological Society from consecutive patients over a 1-yr period in 96 centers globally. Data of 3933 patients in the Global PCNL study database were included in this study.

Outcome Measurements And Statistical Analysis: Patients were divided into low- and high-volume groups based on the median annual case volume of their respective treatment center. Preoperative characteristics and outcomes were compared between the two groups. Case volume was treated as a continuous variable. The relationship between case volume and stone-free (SF) rate, complication rate, and duration of hospital stay was explored using multivariate regression analysis.

Results And Limitations: SF rates were higher in high-volume centers (82.5% vs 75.1%; p value <0.001). Complication rates were lower in high-volume centers (15.9% vs 21.7%; p value 0.002), whereas the mean (standard deviation [SD]) duration of stay was shorter in high-volume centers (3.4 [2.6] vs 4.9 [3.7] d; p value <0.001). SF rate increased with case volume, whereas complication rate and duration of stay diminished with increasing case volumes after adjusting for stone burden, urine culture status, American Society of Anesthesiologists score, and the presence of staghorn stones. The highest SF rates were observed in centers with >120 cases per year.

Conclusions: Centers that perform high numbers of PCNLs per year achieve better results. Both the efficacy and safety outcomes of PCNL improve with the number of surgeries performed in a given center per year.
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http://dx.doi.org/10.1016/j.eururo.2012.03.010DOI Listing
December 2012

[Origin of motion in the human ureter: mechanics, energetics and kinetics of the myosin molecular motors].

Urologia 2012 Apr-Jun;79(2):123-9

Dip. di Scienze della Vita e dell'Ambiente, Università di Cagliari, Cagliari, Italy.

Background: Ureteral peristalsis is the result of coordinated mechanical motor performance of longitudinal and circular smooth muscle layer of the ureter wall. The main aim of this study was to characterize in smooth muscle of proximal segments of human ureter, the mechanical properties at level of muscle tissue and at level of myosin molecular motors.

Methods: Ureteral samples were collected from 15 patients, who underwent nephrectomy for renal cancer. Smooth muscle strips longitudinally and circularly oriented from proximal segments of human ureter were used for the in vitro experiments. Mechanical indices including the maximum unloaded shortening velocity (Vmax), and the maximum isometric tension (P0) normalized per cross-sectional area, were determined in vitro determined in electrically evoked contractions of longitudinal and circular smooth muscle strips. Myosin cross-bridge (CB) number per mm2 (Ψ) the elementary force per single CB (Ψ) and kinetic parameters were calculated in muscle strips, using Huxley's equations adapted to nonsarcomeric muscles.

Results: Longitudinal smooth muscle strips exhibited a significantly (p<0.05) faster Vmax (63%) and a higher P0 (40%), if compared to circular strips. Moreover, longitudinal muscle strips showed a significantly higher unitary force (Ψ) per CB. However, no significant differences were observed in CB number, the attachment (f1) and the detachment (g2) rate constants between longitudinal and circular muscle strips.

Conclusions: The main result obtained in the present work documents that the mechanical, energetic and unitary forces per CB of longitudinal layer of proximal ureter are better compared to the circular one; these preliminary findings suggested, unlike intestinal smooth muscle, a major role of longitudinal smooth muscle layer in the ureter peristalsis.
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http://dx.doi.org/10.5301/RU.2012.9110DOI Listing
October 2012

[Fluorescence cystoscopy with hexaminolevulinate: our preliminary experience of 184 procedures].

Urologia 2011 Jul-Sep;78(3):187-9

Clinica Urologica, Università degli Studi di Cagliari, Italy.

Introduction: Fluorescence cystoscopy (FC) with hexaminolevulinate (HAL) is a recently introduced technique of photodynamic diagnosis (PDD), which aims to improve the accuracy of white light cystoscopy (WLC) in the diagnosis of superficial bladder tumors (NMIBC), and especially of flat urothelial lesions (dysplasia and Ca in situ). We report our experience of a number of cases of WLC and FC in a single moment with HAL in the diagnosis and follow-up of NMIBC.

Materials And Methods: The method was applied to 184 selected patients with a diagnosis or clinical suspicion - instrumental or early recurrence of bladder neoplasia. The lesions found in white light (WL) and/or blue light (FC) were sampled separately for histological examination. We evaluated the results in terms of diagnostic gain compared to treatment with one WL, false positivity and recurrence-free survival compared to historical reference group treated with WL only.

Results: 26.1% of the lesions were found only by the PDD method. The false positivity due to the method adopted was 21.2%. The gain in terms of recurrence-free survival (compared with historical reference group treated only with WL) was 22.3% at 12 months and 24.4% at 20 months. It did not show any systemic side effects.

Discussion: The PDD is a technique that can significantly increase the diagnostic accuracy of NMIBC.
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http://dx.doi.org/10.5301/RU.2011.8667DOI Listing
February 2012

[Conservative endoscopic retrograde treatment of upper urinary tract tumors: retrospective analysis of the last 105 cases].

Urologia 2011 Jul-Sep;78(3):233-5

Clinica Urologica, Università degli Studi di Cagliari, Cagliari, Italy.

Introduction: Modern flexible ureterorenoscopy allows a retrograde approach to urothelial tumors in the upper urinary tract (UUTT) of small dimensions (<1.5 cm), of low grade and non-invasive. The percutaneous renal approach, although more invasive, provides an alternative treatment in case of larger dimension neoplasia or difficult retrograde access. The key to the success of endoscopic treatment of UUTT is an accurate patient selection. We will bring our experience in the treatment of UUTT by conservative endoscopic retrograde treatment.

Materials And Methods: Treatment through endoscopic retrograde approach with rigid or flexible ureterorenoscopy has been applied to 105 patients; lesions were treated with electrocution or lasers using thin laser fibers type Ho:YAG. We evaluated the recurrence rate and the intra- and perioperative complications.

Results: The recurrence rate was equal to 30.4%. In no case was it necessary to recur to blood transfusion; 15% of wall perforations treated in a conservative manner occurred without following complications.

Discussion: Technological innovations, miniaturization and the increase of energy sources, such as fiber laser Holmium, have improved the management of endoscopic instruments for upper urinary tract tumors. The endoscopic retrograde conservative treatment is considered a valid alternative approach in the case of low-stage tumors, low-grading and small in dimensions.
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http://dx.doi.org/10.5301/RU.2011.8668DOI Listing
February 2012

The clinical research office of the endourological society percutaneous nephrolithotomy global study: staghorn versus nonstaghorn stones.

J Endourol 2011 Aug 20;25(8):1263-8. Epub 2011 Jul 20.

Department of Urology, Muljibhai Patel Urological Hospital , Nadiad, India.

Purpose: The study compared characteristics and outcomes in patients with staghorn or nonstaghorn stones who were treated with percutaneous nephrolithotomy (PCNL) within the Clinical Research Office of the Endourological Society (CROES) PCNL Global Study.

Patients And Methods: Data over a 1-year period from consecutively treated patients from 96 centers worldwide were collated. The following variables in patients with staghorn or nonstaghorn stones were compared: National prevalence, patient characteristics, access method, puncture frequency and outcomes, including bleeding rates, operative time, and duration of hospital stay.

Results: Data from 5335 eligible patients were collated; 1466 (27.5%) with staghorn and 3869 (72.5%) with nonstaghorn stones. Staghorn stone presentation varied between centers from 67% in Thailand to 13% in Argentina. The frequencies of previous procedures were similar between groups, but shockwave lithotripsy was less frequent in patients with staghorn stones compared with nonstaghorn (16.8% vs 22.6%) and positive preoperative urine cultures were more frequent in patients with staghorn than nonstaghorn stones (23.4% vs 13.1%). Patients with staghorn stones underwent multiple punctures more frequently than those with nonstaghorn stones (16.9% vs 5.0%). Postoperative fever, bleeding, and the need for blood transfusion were more frequent, the median operative time and duration of hospital stay were longer, while the proportion of patients remaining stone free was lower (56.9% vs 82.5%) in patients with staghorn than nonstaghorn stones.

Conclusions: The proportion of patients with staghorn stones varies widely between centers. Stone-free rates were lower, complications more frequent, and operative time and hospital stay were longer in patients with staghorn stones.
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http://dx.doi.org/10.1089/end.2011.0055DOI Listing
August 2011

Immunoreactivity of the salivary protein statherin in human male accessory sex glands.

Prostate 2011 May 13;71(6):671-4. Epub 2010 Oct 13.

Department of Cytomorphology, University of Cagliari, Italy.

Background: Statherin is a small phosphoprotein chiefly studied for its protective roles towards teeth and oral tissues. Although generally considered as exclusively secreted by salivary glands, circumstantial evidences suggested that other tissues also produce it. This article first demonstrates statherin immunoreactivity in human prostate and seminal vesicles.

Methods: Surgical samples of prostate and seminal vesicles were fixed in a mixture of paraformaldehyde and glutaraldehyde, and embedded in Epon resin without previous osmication. Ultrathin sections were treated for the intracellular localization of statherin by means of an immunogold staining method.

Results: Reactive statherin was revealed in secreting cells of both seminal vesicle and prostate epithelia: labeling was found in secretory granules of seminal vesicle cells and in cytoplasmic vesicles of prostatic cells.

Conclusions: The different staining patterns suggested that the two glands secrete statherin through different pathways. Prostate 71:671-674, 2011. © 2010 Wiley-Liss, Inc.
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http://dx.doi.org/10.1002/pros.21290DOI Listing
May 2011

PCNL: tips and tricks in targeting, puncture and dilation.

Arch Ital Urol Androl 2010 Mar;82(1):32-3

Unità Operativa Complessa di Urologia, Università degli Studi di Cagliari, Italy.

Getting an effective and safe percutaneous access is the cornerstone in performing a successful and uneventful PCNL. The choice of the puncture site, according to our experience, is one of the most important factors that may influence the outcome of the procedure Preoperative imaging has a preliminary role in choosing the kind of approach but the most important role has to be given to intraoperative retrograde pyelography following occlusion balloon catheter placing. Ultrasound-guided renal puncture as well may show adequate anatomic details of the collecting system if a retrograde dilation is performed We routinely perform a single subcostal lower pole access. In our opinion, when the skin incision is located into the four-sided space between 12thrib, spine muscles, iliac crest and posterior axillary line, the risk of most non-haemorrhagic complications may be reduced. When the needle is proceeding towards its target, some radiological sign may confirm its correct insertion Dilation and operative sheath placing are the last steps of the percutaneous tract creation. Amongst the wide offer of dilating devices, our choice usually goes to the Amplatz fascial dilators associated to the "one-shot" technique and to the balloon hydraulic dilators.
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March 2010

Oxytocin immunoreactivity in the human urethral (Littrè's) glands.

J Reprod Dev 2010 Feb 5;56(1):94-7. Epub 2009 Nov 5.

Department of Cytomorphology, University of Cagliari.

Oxytocin is a cyclic nonapeptide whose best known effects are stimulation of uterine smooth muscle cells during labor and of milk ejection during lactation. Circulating oxytocin originates from the hypothalamus, but its production has also been documented in peripheral tissues. Furthermore, seminal plasma also contains oxytocin, but its functional role is still unknown, although its secretion is generally ascribed to the prostate. In this study, we investigated the possibility that seminal oxytocin is also secreted by other exocrine glands of the human male genital tract. Intramural (Littrè's) glands isolated from bioptic specimens of normal urethrae were processed for immunogold localization of oxytocin. Immunostaining was detected in principal cells, with gold particles specifically found on secretory granules. Basal and endocrine cells were unstained. The present findings suggest that urethral glands not only produce the mucinous layer that protects and lubricates the urethral wall, but also are potential sources of other seminal components, such as oxytocin, which probably play still unclear roles in reproductive physiology.
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http://dx.doi.org/10.1262/jrd.09-063eDOI Listing
February 2010