Stavros Ioannis Tyritzis

Radical prostatectomy is a challenging operation demanding a high level of surgical expertise and experience. Urinary leakage at the urethrovesical anastomosis is one of the most common short-term complications of radical prostatectomy, reaching an incidence of 0.3% to 15.4%. In this review we investigate and discuss all matters directly related to urethrovesical anastomotic leak, specifically how to diagnose it properly, how to determine when it is clinically significant and when intervention is required, how to prevent or predict it and, finally, the possible long-term sequelae. We conducted a systematic analysis of the literature searching for English and nonEnglish language publications from a preidentified time frame (1985 to 2011) using primary search databases (PubMed®, Web of Science®). Manual selection was performed by 2 authors and the third reviewed the final common selection. We also created an algorithm for the diagnosis and management of urethrovesical anastomotic leak. A total of 72 studies were finally selected, including 48 (67%) observational case series, 16 (22.2%) prospective trials, 1 letter to the editor, 1 review and 1 systematic review which was focused only on laparoscopic radical prostatectomy. We also found 2 experimental studies performed in animal models and 3 case reports. Of these studies 7 reported results from fewer than 20 patients. No consensus was recorded on a strict definition of urethrovesical anastomotic leak. The factors determining possible definitions included postoperative day of urethrovesical anastomotic leak, amount of extravasation on cystography and the need for intervention. Urethrovesical anastomotic leak should be classified according to the Clavien classification system, depending on severity and the need for intervention. To our knowledge the role of the open, laparoscopic or robotic approach in the incidence of urethrovesical anastomotic leak has not been systematically investigated. Risk factors for urethrovesical anastomotic leak include obesity, prostate size, previous prostatic surgery, type of anastomosis technique, suture number and type, eversion of the mucosa, a difficult anastomosis or an anastomosis under tension, reconstruction of the musculofascial plate, blood loss, intraoperative flush test result and postoperative urinary tract infection. Diagnosis can be determined primarily by establishing the nature of the drain output. Retrograde cystography, computerized tomography cystography, transrectal ultrasound, contrast enhanced ultrasound and excretory urography are the indicated imaging modalities, and are not always necessary. Finally, the development of anastomotic stricture and incontinence due to urethrovesical anastomotic leak are additional complications. We gathered all relevant critical information concerning urethrovesical anastomotic leak to encourage standardization in the diagnosis and management of this common complication. Systematic meta-analysis of each debatable issue is required to provide definite answers.

Introduction The management of an anastomotic stricture after a radical prostatectomy can become a complex and difficult situation when an artificial urinary sphincter precedes the formation of the stricture. The urethral narrowing does not allow the passage of the routinely used urological instruments and no previous reports have suggested alternate approaches. Case presentation We present the case of a 68-year-old Greek man diagnosed as having a recurrent anastomotic stricture approximately two years after a radical prostatectomy and three years after the implantation of an artificial urinary sphincter, and propose novel alternate methods of treatment. Our patient was first subjected to stricture incision with the use of a rigid ureteroscope with a holmium:yttrium-aluminium-garnet laser fiber, which was followed by a second successful attempt with the use of a pediatric resectoscope. After a one-year follow-up, our patient is doing well, with no evidence of recurrence. Conclusions To the best of our knowledge, this is the first report of the management of recurrent urethral strictures following an artificial urinary sphincter implantation. Minimal invasive techniques with the use of small caliber instruments may offer efficient treatment options, diminishing the danger of urethral corrosion.

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Partial nephrectomy (PN) is the gold standard operation for small renal tumours. The decision for or against a PN has been based mostly on preoperative radiological evaluation of the tumour. Three nephrometry scoring systems have been recently proposed for prediction of postoperative complications of PN (RENAL, C‐index and PADUA). We validate externally the accuracy of the PADUA system and suggest for the first time a novel scoring system, based on the original PADUA system, which implements three other significant factors for the postoperative course of a partial. OBJECTIVE: To externally validate the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification of renal tumours managed by partial nephrectomy (PN). PATIENTS AND METHODS: Seventy‐four consecutive patients in a single academic tertiary institution underwent open PN. Incidence of 90‐day complications was stratified by several clinicopathological variables, such as gender, age of the patient, hospital stay, pathology report, tumour characteristics and positive surgical margins. PADUA scores were given to each case. The severity of complications was also categorized with the Clavien system. RESULTS: The optimal threshold of PADUA for the prediction of complications was 8 with a sensitivity equal to 90.9% and a specificity equal to 77.8% (area under the curve [AUC], 0.89; 95% confidence interval [CI], 0.73–1.00). Multivariate analysis revealed that that PADUA is an independent predictor for the risk of complications. Also, PADUA score ≥8 identified a group of patients with almost 20‐fold higher risk of complications (hazard ratio [HR]= 19.82; 95% CI, 1.79–28.35; P = 0.015). Patients with papillary histology had greater risk for complications than those with clear‐cell tumours (HR = 4.88; 95% CI, 1.34–17.76; P = 0.016). CONCLUSIONS: The PADUA score is a simple anatomical system that predicts the risk of postoperative complications. This is the first external validation of this system for open PN from a single centre. The authors believe that PADUA is an efficient tool, since the only variable of the present study that predicted a higher incidence of complications was the histology type, which is determined after surgery. However, it should be applied to laparoscopic and robot‐assisted series and it could also include the ischaemia time and surgeon experience in the overall scoring to be complete.

Ischemia–reperfusion injury can be detrimental to the solitary kidney, especially when it is accompanied by ablation. To the authors’ knowledge, the effects of partial nephrectomy with prolonged application of ischemia have never been described at the ultrastructural level. Therefore, the authors used an animal model and focused on putative structural effects in the glomerular basement membrane and the podocytes. They demonstrate the advantageous role of cold ischemia, even in up to 120 min. In contrast, more than 60 min of warm ischemia leads to catastrophic lesions in all the cellular structures, as is reflected by mortality due to acute renal failure.

Examine the beneficial effect of early nasogastric tube (NGT) removal in patients undergoing radical cystectomy with urinary diversion. 43 consecutive patients underwent radical cystectomy with urinary diversion and were randomized into 2 groups. In the intervention group (n = 22), the NGT was removed 12 hours after the operation. Comparatively, in the control group (n = 21), the NGT remained in place until the appearance of the first flatus. The appearance of ileus, patient ambulation, time to regular diet, and hospital discharge of the two patient groups were assessed. Patient discomfort due to the NGT was also recorded. The 2 groups showed statistical homogeneity of their baseline characteristics. Two patients (9.09%) from the intervention and 3 patients (14.3%) from the control group developed postoperative ileus and were treated conservatively. No significant differences in intraoperative, postoperative, bowel outcomes or other complications were found between the two groups. All patients preferred the NGT to be removed first in comparison to their other co-existing drains. This is the first randomized, prospective study, to our knowledge, to assess early NGT removal after radical cystectomy. We advocate early removal, independently of the selected type of urinary diversion, since it is not correlated with ileus and is advantageous in terms of patient comfort and earlier ambulation.

Introduction: Ductal adenocarcinoma is a rare variety of the common acinar adenocarcinoma. It usually presents with refractory symptoms, and during cystoscopy, it is seen as an exophytic lesion at the area of the verumontanum. Case presentation: An 82-year-old Caucasian man was diagnosed with ductal adenocarcinoma of the prostate after undergoing transurethral resection of the prostate for urinary retention. Immunohistochemistry confirmed the nature of the tumor. The patient was treated with triptorelin, 3.75 mg once/month, and bicalutamide, 50 mg 1 × 1. The serum prostate-specific antigen at three, six and 12 months after transurethral resection of the prostate was 0.1 ng/ml. The patient remains asymptomatic, and he entered a six-month follow-up protocol. Conclusion: Ductal adenocarcinoma often involves the central ducts of the gland and may present as an exophytic papillary lesion in the prostatic urethra. This is why it usually presents with refractory symptoms. The outcome for men with prostatic ductal adenocarcinoma is, in most studies, worse than the outcome for men with prostatic acinar adenocarcinoma. Aggressive management is indicated, even with low-volume metastatic disease.

There is a discrepancy in reporting biochemical recurrence (BCR) rates in patients with positive surgical margins (PSM) after a radical prostatectomy (RP), ranging between 19 and 61%. Our aim was to identify the parameters that contribute to the absence of BCR in patients with PSM by performing a multivariate analysis. From a cohort of 1163 patients who underwent open RP over a 6-year period, 69 exhibited PSM. Of the 69, 39 had and 30 did not have a BCR during a 3-year follow-up. The analysis comprised preoperative and postoperative PSA serum levels, age, weight of the prostate, pathology tumor grade, time of BCR, number and location of PSM. In the univariate analysis, the weight of prostate was statistically significantly associated with the odds of BCR (P = 0.027, 95% CI 1.00–1.06). Bladder neck and lateral locations of PSM were negatively associated with BCR, without exhibiting statistical significance in the multivariate analysis. Age was negatively associated with the odds of BCR whereas preoperative PSA, stage and Gleason score were positively associated, but did not exhibit statistical significance in both uni- and multivariate analysis. A low weight prostate, younger age, bladder neck and lateral location of PSM seem to protect patients from having a BCR. On the other hand, preoperative PSA, stage of the disease and Gleason score do contribute to the occurrence of BCR. Lack of statistical significance in the above results could be attributed to the small number of patients due to the study’s low PSM rate.

Background: The primary mucinous adenocarcinoma of the bladder is an extremely rare urologic entity, which is found in less than 2% of all urinary bladder tumours and is often presented as metastatic. Case presentation: A 69-year old male patient was diagnosed with a primary mucinous adenocarcinoma of the bladder after undergoing a transurethral resection of a bladder tumour and complete examination of the entire gastrointestinal tract to rule out other primary cites. Immunohistochemistry confirmed the nature of the tumour. The patient underwent a radical cystoprostatectomy with en block bilateral pelvic lymphadenectomy and urinary diversion with a Bricker ileostomy. Conclusion: The primary adenocarcinoma creates a diagnostic dilemma, since it cannot be easily differentiated by the adenocarcinoma that originates from the colon and the prostate. We advocate the radical surgical management, after exclusion of any primary malignant sites related to the gastrointestinal tract. The immunohistochemistry has a leading role, assisting with the differential diagnosis.

AIMS: To determine whether α1-blocker treatment, in chronic bladder outlet obstruction (BOO), influences bladder tissue ischemia. MATERIALS AND METHODS: This prospective study included 60 patients with BOO, of which 40 were under α1-blocker medication and 20 without treatment. Patients underwent transurethral resection of the prostate (TURP) or suprapubic prostatectomy (SPP). Ten patients with non-muscle invasive bladder cancer underwent transurethral resection of the bladder tumor and served as the control group. Tissue specimens were immunohistochemically stained for hypoxia inducible factor-1α (HIF-1α). RESULTS: Bladder tissue from obstructed subjects showed high immunoreactivity to HIF-1α. The specimens from the control group, showed no or weak, mainly cytoplasmic immunoreactivity to HIF-1α. Patients under α -blocker treatment did not differ in the number of HIF-1α positive cells compared to subjects with no treatment (median number 86.8 [20-150] and 88.6 [0-175], respectively) (p > 0.05). The lowest bladder pressure at which HIF-1α was up regulated, was detected at detrusor pressure Qmax (PdetQmax) = 60 cm H2O. CONCLUSIONS: Treatment with α-blockers in obstructed patients considered as non-responders, does not result in HIF-1α down regulation, thus bladder continues to be under chronic stress