==inizio objective==

Adjuvant intravescical therapy has an important role in the prevention of bladder cancer recurrence and progression after the first TURB (trans-urethral resection of bladder) in NMIBC (non-muscle invasive bladder cancer). Patients with BCG failure are unlikely to respond to further BCG therapy. Radical cystectomy should be proposed in these patients (1).
The aim of this study was to evaluate the use of the “COMBAT BRS (Combined Antineoplastic Thermotherapy Bladder Recirculation System) SYSTEM HIVEC (Hyperthermic Intra-Vesical Chemotherapy)TM” in the adjuvant treatment of high-grade non-muscle invasive bladder cancer (NMBC) after BCG (Bacillus Calmette–Guérin) failure.

==fine objective==

==inizio methodsresults==

From March 2017 to July 2017, 12 patients with high grade NMIBC (HG-NMIBC) after TURB and with BCG-refractory tumour (BCG failure) were enrolled. 4 out of 12 patients (33.3%) were twice BCG failure. Signed informed consent was obtained from all patients. The potential advantages and disadvantages of the HIVEC™ treatment were discussed with the patients. The current standard of care treatment according to guidelines, including radical cystectomy, was also offered. The treatment schedule consisted of six weekly intravesical instillations of HIVEC™ MMC (Mitomycin C) at a concentration of 40 mg MMC diluted in 50 mL of distilled water. The solution was heated to a target temperature of 43 °C and recirculated at 200 mL per min at stable pressure. The temperature inside the bladder was maintained at 43 °C ± 0.5 °C for the 60-min duration of the treatment. Five weeks after the end of the HIVECTM schedule, a cystoscopy under spinal or general anaesthesia (or RE-TURB) was performed. Patient tolerance of the procedure will be evaluated using the VAS (Visual Analogue Scale) scale. Mean values with standard deviations (±SD) were computed and reported for all items.

==fine methodsresults==

==inizio results==

The mean(±SD) age of the was 59.8±8.7 years. Out of the 12 patients, 9 were male and the remaining 3 were female. The mean(±SD) number of the tumours at the pre-treatment TURB was 7.3±1.5. Concurrent CIS (carcinoma in situ) was found in 4 out of 12 patients (33.3%). All patients had an high-risk bladder cancer according to EAU Guidelines and EORTC risk tables (2). No adverse events were observed during the HIVECTM treatment. The mean(±SD) VAS score was 0.7±1.2 At the follow-up cystoscopy 3 out of 12 patients (25%) experience a recurrence. In particular, two tumours (HG-NMIBC) with a maximum diameter of 2 cm and concurrent CIS were found in one patient. The patients was treated with a radical cystectomy. A recurrence [one tumor with a maximum diameter of 1.5 cm (HG-NMIBC) and two tumours of mean 2 cm of maximum diameter (LG-NMIBC), respectively] was found in two patients. They were enrolled to another cycle of HIVECTM (six weekly instillations). In three patients an acute and a chronic inflammation with reactive myofibroblastic proliferation was found. The others 9 patients were enrolled in a maintenance protocol (six instillations administered monthly). Red patches in the bladder were found at cystoscopy in 7 out of 12 patients (58.3%). The biopsy revealed a CIS only in the patient that underwent the radical cystectomy.

==fine results==

==inizio discussions==

In recent times, interesting data have been presented on enhancing the efficacy of MMC (Mitomycin-C) using microwave-induced hyperthermia or the efficacy of MMC using electromotive drug administration (EMDA) in patients with high-risk tumours including also patients with BCG failure. Despite this, these treatment modalities are still considered experimental (3). Compared to the microwave driven heating system the “COMBAT BRS SYSTEM HIVECTM” device seems to have less side effects without major complications. Treatment discontinuation was seen in 5% of the patients for Combat BRS System and about 40% of the patients for Synergo System (radiofrequency induced hyperthermia) (4).
The use of clinical hyperthermia in bladder cancer treatment has a clear rationale. First of all, the treatment at temperatures between 41 and 44 degrees C is cytotoxic for cancer cells because they cells are unable to manage the heat as well as good cells (5). Moreover MMC is 1.4 times more active at 43°C . The cytotoxicity increases by 10 times because the lipid-protein cellular membrane bilayer become more permeable to the MMC. Nevertheless hyperthermia does not increase the toxicity to the patient (6). Moreover hyperthermia inhibits the angiogenesis (7) and increases the activation of the natural killer cells that target heat stressed cancer cells as they signal heat shock proteins on the cancer cell surface (8).

==fine discussions==

==inizio conclusion==

In our experience, “COMBAT BRS SYSTEM HIVECTM” treatment is safe and effective for patients with NMIBC in adjuvant settings after BCG failure. Only one patients underwent a radical cystectomy. Moreover, in one patient we experienced a downgrading from HG-NMIBC to LG-NMIBC. In conclusion, the system can be a promising alternative to the radical cystectomy in a well-selected and well-informed group of patients. Some limitations of our study include the small cohort of patients and short follow-up time.

==fine conclusion==

==inizio reference==

1-Colombo R, et al. Radiofrequency-induced thermo-chemotherapy effect (RITE) for non muscle invasive bladder cancer treatment: current role and perspectives. Urologia. 2016 Oct 4;83(Suppl 2):7-17.
2- Sylvester, R.J., et al. Predicting recurrence and progression in individual patients with stage Ta T1 bladder cancer using EORTC risk tables: a combined analysis of 2596 patients from seven EORTC trials. Eur Urol, 2006. 49: 466.
3- Arends, T.J., et al. Combined chemohyperthermia: 10-year single center experience in 160 patients with nonmuscle invasive bladder cancer. J Urol, 2014. 192: 708.
4-Colombo R et al., Local microwave hyperthermia and intravesical chemotherapy as bladder sparing treatment for select multifocal and unresectable superficial bladder tumors. J Urol. 1998 Mar;159(3):783-7.
5-Teicher BA, et al., Enhancement by hyperthermia of the in vitro cytotoxicity of mitomycin C toward hypoxic tumor cells. Cancer Res. 1981 Mar;41(3):1096-9.
6- Roca C. et al. Hyperthermia inhibits angiogenesis by a plasminogen activator inhibitor 1-dependent mechanism. Cancer Res. 2003 Apr 1;63(7):1500-7.
7- Fuse T et al., Heat-induced apoptosis in human glioblastoma cell line A172. Neurosurgery. 1998 Apr;42(4):843-9.
8-Thomas Alexander Voegeli et al., First multicenter experience with thermotherapy and mitomycin of high risk NMIBC with a new recirculation system (COMBAT). J Clin Oncol 34, 2016 (suppl 2S; abstr 425)

==fine reference==

==inizio objective==

Bladder cancer ranks fifth as the most common cancer in the world. Many individuals with bladder cancer have undergone a surgical urostomy and often complain of being self-conscious of the unpleasant smell of their own urine. The focus of this study was to test the efficacy of a pouch cover made of a carbon and zeolite containing polyester material to inhibit the smell of urine by comparing two trained dogs’ response time in detecting volatile organic compounds (VOCs) in urine, with and without the fabric covering the samples.

==fine objective==

==inizio methodsresults==

This study used a randomized, blinded experimental design to evaluate the efficacy of a fabric to interfere with two highly trained dogs’ ability to detect specific VOCs present in the urine of prostate cancer patient. Ninety urine samples were analysed in this study. Prior to the experiment, both dogs accurately detected VOCs in the uncovered test urine samples of men with prostate cancer with a sensitivity and specificity of nearly 100%.

==fine methodsresults==

==inizio results==

Both dogs recognized the “uncovered” urine samples of men with prostate cancer within two seconds. When the test sample was covered with the study fabric, the test urine samples were detected within 30-40 seconds and in some instances the dogs were not able to identify the covered samples, whatsoever.

==fine results==

==inizio discussions==

The continuous worrying about the unintentional detachment of the urinary stoma plate or bag leads patients to live in a constant state of alert in order to cover such eventuality. In some cases, this fear restricts patients conditioning their social relations. Although episodes of detachment are drastically reduced over time because of a better and consolidated management of the external urine collection device, the fear of a possible unintentional detachment still remains. Another aspect that may affect patients’ QoL in the long term is the concern about losing their partners, who not only help them in the management of the stoma, but they represent a moral support of paramount importance.
Anyway the most relevant aspect reported by the patients even after many years after surgery is the renunciation of even short trips because of the fear of losing urine. Many patients must be sure to always have everything they need for a proper management of the ostomy in any situation[1]. Industry are working developing malodor-controlling compositions comprising microcapsules containing an active material and/or an optional odor control agent, an odor control agent outside of the microcapsules, and aqueous carrier. The malodor-controlling compositions can be applied to surfaces, such as fabrics, to reduce or remove malodor from the surface and to provide a controlled-release of the active material onto the surface or into the environment surrounding the surface. The active material is preferably a perfume and the composition controls malodor and provides a controlled-release scent.
The invention further relates to methods of using malodor-controlling compositions comprising the step of contacting a surface with the malodor-controlling compositions [2].

==fine discussions==

==inizio conclusion==

The findings of this study demonstrate that the carbon and zeolite containing polyester fabric did significantly interfere with the ability of the dogs to detect VOCs in urine of men with prostate cancer. The fabric may show promise as a pouch cover in controlling offensive urine odour which many urostomates experience.

==fine conclusion==

==inizio reference==

1. Maria Angela Cerruto, Carolina D’Elia, Giovanni Cacciamani, Davide De Marchi, Salvatore Siracusano, Massimo Iafrate, Mauro Niero, Cristina Lonardi, Pierfrancesco Bassi, Emanuele Belgrano, Ciro Imbimbo, Marco Racioppi, Renato Talamini, Stefano Ciciliato, Laura Toffoli, Michele Rizzo, Francesco Visalli, Paolo Verze, Walter Artibani
Behavioural profile and human adaptation of survivors after radical cystectomy and ileal conduit. Health Qual Life Outcomes. 2014; 12: 46.
2. H Uchiyama, J Cetti, M Alonso et al
Malodor-controlling compositions comprising odor control agents and microcapsules containing an active material US Patent App. 10, 2003

==fine reference==

==inizio objective==

Most cases of urogenital parasitosis are registered in Africa. However, migration movements and travellers moving from developed to developing countries are responsible for leading to an increased incidence of genitourinary infections caused by parasites in the western world including Italy having serious economic and health implications. The importance of its early detection and treatment also results from its potential risk for development of bladder cancer. The most common presentation symptom is terminal haematuria, and when diagnosed, praziquantel is the treatment of choice. In this work we report a rare case of urinary schistosomiasis that happened in our centre.

==fine objective==

==inizio methodsresults==

In march this year a 21-year-old African American man with recurrent episodes of gross hematuria for 6 months presented to the clinic for evaluation. A thorough history revealed that the patient emigrated from Senegal to our country 6 months ago. Urine culture was negative for a urinary tract infection. Ultrasound revealed several lesions in the bladder. Biopsy of the bladder lesion revealed severe cystitis and Schistosoma haematobium. The patient later confirmed that he used to swim in rivers and streams back in Africa.

==fine methodsresults==

==inizio results==

Praziquantel 40 mg/kg is the most studied drug for treating urinary schistosomiasis, and has the strongest evidence base. In this case we used praziquantel for two months. The gross hematuria was resolved. The patient performed ultrasounds to evaluate bladder wall every month. Endoscopic evaluation performed after therapy showed a complete resolution of bladder lesions.

==fine results==

==inizio discussions==

Bladder schistosomiasis, also known as bilharzia of the bladder, is a major health problem in developing parts of the world predisposing individuals to squamous cell carcinoma. Schistosomiasis is very common, affecting over 200 million people, with the vast majority (85%) in Africa. It is prevalent in tropical and subtropical areas, especially in rural regions.
There are five species of the blood fluke (trematode worm) Schistosoma species that cause disease in humans: Schistosoma haematobium, S. mansoni, S. japononicum, S. intercalatum, S. mekongi.
Larvae are released from snails (intermediate host) into water and penetrate human skin (definitive host) exposed to the infected water. These larvae travel to the lungs and liver of the human host, where they reside until they mature.
After maturation, the adult worm pairs travel to the pelvic veins. Eggs are deposited in the bladder wall vessels and incite a granulomatous response that results in polypoid lesions. The eggs may go on to incite a chronic inflammatory response and fibrosis, which is an important predisposing factor for squamous cell carcinoma (SCC).

==fine discussions==

==inizio conclusion==

In this abstract we report a case of urinary schistosomiasis that happened in our centre and reminds the importance of having the infection in mind in certain cases of haematuria. On average, the standard dose of praziquantel cures around 60% of people at one to two months after treatment, and reduces the number of schistosome eggs in the urine by over 95%.

==fine conclusion==

==inizio reference==

Smith JH, Christie JD. The pathobiology of Schistosoma haematobium infection in humans.
Hum Pathol 1986;17:333–45.
Alvarez Maestro M1, Rios Gonzalez E, Dominguez Garcia P, Vallejo Herrador J, Diez Rodriguez J, Martinez-Piñeiro L. Bladder schistosomiasis: case report and bibliographic review.
Arch Esp Urol. 2010 Sep;63(7):554-8.

==fine reference==

==inizio objective==

We previously demonstrated feasibility and safety of robot assisted radical cystectomy (RARC) with a completely intracorporeal Indiana Pouch. We report perioperative, oncologic and functional outcomes of first 10 patients with a minimum follow-up of 24 months.

==fine objective==

==inizio methodsresults==

Perioperative outcomes, 30-d/90-d/180-d complications were recorded and classified according to Clavien-Dindo classification system. Follow-up schedule included assessment of renal function at 3-mo intervals and CT scan at 6-mo intervals. Urinary continence was defined as absence of any urine leak from throw the stoma between catheterizations. Urodynamic evaluation was performed 3 months postoperatively.

==fine methodsresults==

==inizio results==

There were no intraoperative complications and all procedures were successfully completed. Median hospital stay was 9 days. Final pathology showed extravesical disease (pT stage>2) in 3 patients (30%) and nodal metastases in 4 patients (40%). All surgical margins were negative. The overall incidence of 30-d complications was 40% (0% of grade ≥3). At 3-mo evaluation two patients (20%) developed hydronephrosis due to ureterocecal stenosis, one requiring antegrade j-j stenting (Clavien grade 3A) and one (10%) requiring bilateral robotic ureterocecal reimplantation (Clavien grade 3B). Two patients developed metastases, one at 3 months after surgery (lung), one at 1 year (retroperitoneal nodes) . At a median follow-up of 28 months overall survival rate was 80% and disease free survival rate was 80%. At 3-mo follow-up evaluation urodynamic studies demonstrated a mean maximum capacity of 270mL without ureteral reflux and 9 patients (90%) reported a full continence 3 months after surgery. One patient required undiversion to ileal conduit due to inability to perform self-catheterization. At 2-yr functional outcomes evaluation, all patients (7) reported full continence and easiness to self catheterization; no patient developed urinary tract infections or pouch stones.

==fine results==

==inizio discussions==

We previously demonstrated feasibility and safety of robot assisted radical cystectomy (RARC) with a completely intracorporeal Indiana Pouch [1]. Safety and feasibility of intracorporeal IP, together with encouraging short term oncologic outcomes, support the potential role of RARC with intracorporeal continent cutaneous diversion as a viable option for patients with contraindication to orthotopic neobladders. Mid term functional outcomes are encouraging.

==fine discussions==

==inizio conclusion==

Safety and feasibility of intracorporeal IP, together with encouraging short term oncologic outcomes, support the potential role of RARC with intracorporeal continent cutaneous diversion as a viable option for patients with contraindication to orthotopic neobladders.

==fine conclusion==

==inizio reference==

1. Robotic Intracorporeal Continent Cutaneous Diversion.
Desai MM, Simone G, de Castro Abreu AL, Chopra S, Ferriero M, Guaglianone S, Minisola F, Park D, Sotelo R, Gallucci M, Gill IS, Aron M.
J Urol. 2017 Mar 21. pii: S0022-5347(17)40520-9. doi: 10.1016/j.juro.2017.01.091.

==fine reference==

==inizio objective==

The increase in life expectancy is an excellent goal, but it needs to consider that even if there is a gain of active life expectation, the end of life reserves a period of not good health and chronic/oncologic diseases with lack of self-sufficiency. This aging process creates a population “at risk”, worth of particular attention: fragile elderly people. They are subjects with advanced or very advanced age, instable health, high risk of disability and fast worsening of functional status. Furthermore loneliness and social-environmental factors can generate a condition of frailty regardless precedent conditions. The Home is the main place of life at all ages. Elderly fragile people has the civil right of assistance as long as possible. Management of fragile elderly patients is still largely debated. In the past economic assistance with low clinical content was encouraged; in this context find place an evaluation also based on ethical clinic. We don’t want to discuss surgical methods or clinical results, but we would like to demonstrate the way we answered an explicit (or sometimes tacit) question when we decided to perform surgery on a patient with these characteristics: “It really needs to perform surgery on him at his age?”

==fine objective==

==inizio methodsresults==

The word “fragile” identifies a condition of risk and vulnerability, with unstable equilibrium towards negative events. Elderly people, due to aging process and intercurrent diseases, become more vulnerable and many conditions can change homeostatic balance of their organism (1). It is defined essentially by two paradigms: Biomedical (2); BioPsychosocial (3,4). We applied the Multidimensional Oncological Geriatric Evaluation and the scale: Vulnerable Elders Survey and screening tool (5,6). We defined three categories of patients: FIT; UNFIT/VULNERABLE; UNFIT/FRAIL. We scanned the context in which patient live, the carried out activities and the potential “caregivers”. This anglo-saxon term is largely used, but we think that it’s better to talk about “the person that take care of”, that often is a familiar but not always. Cancer changes not only life of affected people, but also family architecture. Who take care of the sick person is a central figure in the journey of oncologic patients with significant assistance and ethical tasks (7).

==fine methodsresults==

==inizio results==

Between June 2016 and September 2017 we perform surgery on 409 patients (in SC Urologia of ASL CN1, SS Annunziata Hospital of Savigliano and Regina Montis Regalis Hospital of Mondovì) that can be defined fragile elderly people. The results of the interventions will be discussed at the congress. The caregiver identified by the patient in 380 cases was a family member and in 29 was chosen out of this context. In only 9 cases the patient did not own a family, while in the remaining 20 cases the choice was due to the refusal of the patient to address a family member (8 cases) or the refusal of the family member to take the responsibility for sharing the proposed path (12 cases). In 14 patients we offered a psychoanalytical support: it was refused in 10 cases and in 4 cases it was refused the even initial meeting. These data have also been analyzed from a purely philosophical point of view. The cases in which the oncologic patient refuses to address a family member, and the cases in which the family member refuses the responsibility for sharing the course of care have a common denominator: the difficulty of dealing with their own fragility and vulnerability within an existential context that prefers the amount of life to the quality of life. Working on the obsessive extension of lifetime without the awareness that we are constituently fragile because mortals and living so much is not of value in itself, It leads into a dynamic where figures involved – doctors, patients and family members – cannot understand their needs. It is likely that an oncologic patient, perceiving its enormous weakness that humiliates its independence, does not feel it weigh on a family member: in a society where fragility must not be contemplated, the embarrassment and the difficulty of communicating with the people to whom you are most affiliated increase. In addition, the disproportion between increased life expectancy and reduced psycho-physical well-being can make the elder patient feel like a burden – economically, but not only – for their loved ones. Therefore, working on the awareness that being fragile and vulnerable is a normal condition because it is due to our way of being mortals, and unfortunately, cancer falls into what defines our mortality. Where the family member refuses to take responsibility for sharing the care of the sick person, there is likely to be – in spite of the difficulties associated with a frustrating job world – a sense of inadequacy, which also comes from their own inability to face emotionally and practically a situation in which the end of life is highly probable. Being accustomed to never thinking of death, when we face an oncologic disease, we feel terrified, having no idea how to behave with the beloved person that is affected. A careful course of Death Education would help the oncologic patient to welcome the psycho-oncological support.

==fine results==

==inizio discussions==

Integrating the data obtained from the VMG and those obtained from the interview with caregivers, we have come to analyze everything from the point of view of clinical ethics (8), but in particular inspired by Bioethics of everyday life (9,10,11) that want to face daily life themes of professionals of care process so that ethics become an operative tool stimulating a change for improvement of health intervention.

==fine discussions==

==inizio conclusion==

We believe that Ethical consultation can be of assistance for any health worker, patient, caregiver who need advice in facing hard or suffered decisions. In particular helps care providers to answer the initial question: “It really needs to perform surgery on him at his age?”, not only according to guidelines indications (indispensable, but not to be used uncritically), but also in the perspective of total care so that the narrative medicine based approach (12,13,14) becomes increasingly important and widespread in nursing places.

==fine conclusion==

==inizio reference==

1) La fragilità nell’anziano: una prospettiva clinica. A.Giordano et all. G Gerontol 2007;55:2-6
2) Untangling the concepts of disability, frailty, and comorbidity: Implications for improved targeting and care. Journals of Gerontology. Series A: Biological and Medical Sciences; 59(3): 255-263; 2004 Fried LP et al.
3) Gobbens RJ et al. In search of an integral conceptual definition of frailty: opinions of experts. J AmMed Dir Assoc; 11(5): 338-43; Jun 2010
4) La fragilità dell’anziano. Linea guida Regione Toscana 2013
5) Tumori dell’anziano .Linee Guida AIOM 2016
6) Gestione del paziente unfil/trail : il punto di vista dell’Urologo. A.Giacobbe Convegno renal care Verona 7-8 Marzo 2014
7) Family caregivers, patients and physicians: ethical guidance to optimize relationships. Mitnick S, Leffler C, Hood VL J Gen Intern Med 2010; 25: 255-260.
8) Dalla parte della vita . Itinerari di Bioetica Vol. 1 E.Larghero . Effatà Editore 2010
9) Bioetica del Quatidiano. S.SpinsantiMedico e Bambino 1/1997 pag.59-64
10) Bioetica Quotidiana. G.Berlinguer. Giunti Editore 2000
11) La Bioetica del Quotidiano. E.SgrecciaVita e Pensiero Editore 2006
12) Bioetica e medicina narrativa: nuove prospettive di cura . E.Larghero Edizioni Camilliane 2013
13) Sia fatta la mia volontà. Marina Sozzi Chiarelettere editore 2014
14) Narrare la morte. Dal romanticismo al post umano . Davide Sisto. Boule’ Collana di Filosofia e scienze umane Edizioni ETS 2014

==fine reference==

==inizio objective==

The aim of our study was to evaluate 30 and 90-days complication rate using prospectively a standardize methodology and comparing medical, nurse and administrative records.

==fine objective==

==inizio methodsresults==

We analyzed records of 145 consecutive patients who underwent radical cystectomy and urinary diversion at our Institution from January 2015 to June 2017. All patients were treated following a standardized protocol. Complications were classified according Clavier-Dindo and related to previous medical history, ASA score, Age Adjusted Charlson Comorbidity Index (ACCI), operating surgeon, blood loss, operative time, transfusions rate, type of urinary diversion, pre-operative and 3-days post-operative blood count and creatinine levels. Postoperative patients’ mobilization time, nasogastric tube removal, free diet restarting were also evalueted. Furthermore complications were analyzed comparing medical and nurse records during hospital stay and at 30 and 90 days following patients’ discharge.

==fine methodsresults==

==inizio results==

Our population had 4.18 male: female ratio with a 69.25 years mean age (median 71 ± 10.41), and a 26.51 mean BMI (median 26.30 ± 3.64). Median ASA score was 2 in 87 patients (60%) while the other 40% were ASA score 3 or more. Median ACCI was 6 with 82.76% of Patients having ACCI >4 and 33.8% of Patients having ACCI > 6. In our population of patients undergoing cystectomy, 102 received a Wallace external urinary diversion (70.34%), 29 (20%) an orthotropic ileal Bladder (VIP: Vescica Ileale Padovana) and 12 an ureterocutaneus diversion (8.27%). Two patients (1.37%) didn’t received urinary diversion because radical cystectomy was associated to bilateral nephroureterectomy. Mean operative time was 349.75 min and mean blood loss 802.96 cc. Mean Patients’ hospital stay was 18.54 days (median 16 ±8.88) with 18.04 days in patients undergoing Wallace urinary diversion and 20.89 days in those undergoing VIP orthotopic ileal bladder. Among Patients submitted to VIP diversion, those living within 60Km from the hospital had a mean recovery length of 19.31 days while those living further had a longer (22.78 days) hospital stay. A significant difference in Patients’ mobilization was observed between medical and nurse records (mean 3.73 days ± 2.62 vs 4.6 ± 2.77; p= 0.006). Re-admission rate was 5.5% and 2.76% at 30 and 90-day after patients’ discharge. Relevant complications were observed in 56 patients (38.62%) during post operatory hospital time. 29 complications were Clavien-Dindo 1-2 (51.78%) while 27 (48.2%) were Clavien 3-4. No Clavien-Dindo complication 5 was observed. Clavien-Dindo complications 3-4 did not relate to preoperative characteristics, ASA score and ACCI or operatory parameters such as surgeon, operative time, blood loss and transfusion rate. Relevant complications were observed to be related to intestinal resection for urinary diversion. Post-operatory ileum was observed in 16 patients (11%), requiring surgery in 62.5% of cases. Post-operatory ileum was related to a longer bed rest following surgery. All patients with mechanical ileum were previously submitted to Wallace or VIP diversion and 60% had a previous abdominal surgery. Wound complication were observed in 11 patients (7.58%) and were associated to ACCI with 60% of Patients having ACCI > 6. No difference in complication rates was observed stratifying patients by urinary diversion type. Length of operative time was not associated with increased risk of intestinal or wound complication. Among patients re-admitted at 30 and 90 days we verified respectively a 37.5% and 50% rate of Clavien-Dindo 3-4 complications. Note worthy all patients readmitted at 90 days had a pre-operatory ACCI >6 .

==fine results==

==inizio discussions==

Radical cystectomy is a complex procedure with high risk of perioperative complications and high readmission rates (1,2). In our study early Clavien-Dindo 3-4 complications did not relate to preoperative or operatory parameters. Intestinal resection was the main reason of post-operatory Clavien-Dindo 3-4 complications, while pre-operatory ACCI >6 was related to wound problems. Operative time did not correlate to wound complication, probably because of a routine use of antibiotic recall after 4 hour of surgery. At our institution distance between patients’ residence and hospital influenced hospitalization length. We experienced a low rate of hospital readmissions and all patients readmitted at 90-days had an ACCI > 6.

==fine discussions==

==inizio conclusion==

Our study shows that even in fragile patients with Age Adjusted Charlson Comorbidity Index >6, radical cystectomy and urinary diversion is feasible with a limited complication rate.
Our reports show a mismatching between medical and nurse records apparently due to trivial logistic problems. This finding calls for a higher degree of interaction between healthcare providers with meticulous planning of all supportive care interventions. Noteworthy a longer hospitalization time may reduce 30-90 days readmissions and Clavien-Dindo 3-5 complication rate, with fragile patients with ACCI >6 being more at risk for 90-days hospital readmission.

==fine conclusion==

==inizio reference==

1. Definig early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Shabsigh A. Eur Urol. 2009 Jan;55(1):164-74
2. Critical review of outcomes from radical cystectomy: can complications from radical cystectomy be reduced by surgical volume and robotic surgery? Moschini M. Eur Urol Focus. 2016 Apr;2(1):19-29.

==fine reference==

==inizio objective==

The ureterocutaneostomy (UCN) is the preferred diversion in the patients with a lot of comorbidities, or in the patients who have tumor in the urethra or at the level of urethral dissection.The use of an ileal segment has been previously described in the treatment of long-segment ureteral strictures (1). The aim of this study was to evaluate our experience in the use of a skin and muscle flap tube as an alternative procedure to perform ureterocutaneostomy (UCN) in this group of patients.

==fine objective==

==inizio methodsresults==

At our institution, from January 2013 to January 2016, five male patients with muscle-invasive bladder cancer and severe monolateral ureteral stricture underwent radical cystectomy and bilateral ureterocutaneostomy. One patients had previously undergone a radical cystectomy with Bricker ileal conduit urinary diversion and developed a long-segment and severe unilateral ureteral stricture after four months. We report a surgical technique in the management of patients with muscle-invasive bladder cancer and severe ureteral stricture whose underwent radical cystectomy with UCN using a skin and muscle flap tube. All patients enrolled were not eligible for the use of bowel segments in the urinary diversion.

==fine methodsresults==

==inizio results==

Open transperitoneal radical cystectomy and bilateral pelvic lymphadenectomy were performed in all patients with a midline incision extending from the supraumbilical region to the symphysis pubis. In the patient with Bricker ileal conduit urinary diversion, the Bricker ileal conduit was first removed.
On the side of ureteral stenosis, an horizontal double-parallel incision was performed from the midline to the area of the ureterocutaneostomy creating a musculocutaneous flap. The flap was passed through the anterior abdominal wall and tubularized. The flap was finally anastomosed to the ureter using a Bracci ureteral splint and six interrupted 4-0 Vicryl sutures, Vicryl TM (Ethicon Inc., Sommerville, N.J.). The horizontal double-parallel incision was closed with silk sutures (Figure 1).
Mean age of the patients was 73.8(±1.9) years. Mean body max index(BMI) was 28.6 (±2.3). Mean operative time was 162(±13) minutes. Mean blood losses were 320(±130.4) milliliters. No intraoperative complications are reported according to Satava classification. The mean length of hospital stay was 8.6±3.1 days. One out of 5 patients (20%) experienced a postoperative complication according to CD system (wound infection, grade II CD). No anastomotic leaks and stenosis were reported at a mean follow-up of 16.4 (±6.2) months and the Bracci ureteral splints were changed every four weeks.

==fine results==

==inizio discussions==

Radical cystectomy is considered one of the most extensive urological procedure. The overall postoperative mortality rate is 0.3%-7.9%. The age and the comorbidity profile of the patient seems to be independent preoperative predictors for 90-d mortality (2).
Severe complications and the mortality rate are usually lower in the patients whose underwent an UCN diversion compared to patients receiving bowel for urinary diversion (3).
The functional role of a skin and muscle flap tube can be valued especially in patients whose ureters are not enough long to realize an UCN. This technique can be a feasible way to solve the loss of tissue, avoiding the placement of a permanent nephrostomy tube. Moreover the technique can avoids the high risk of recurrent ureteroileal stenoses in the patients who have previously experienced an ureteral or an ureteroileal stenosis.

==fine discussions==

==inizio conclusion==

The use of a skin and muscle flap tube, can be a feasible and safe procedure in case of long-segment and severe ureteral strictures in patients whose underwent radical cystectomy with UCN, in particular when the patients are not eligible for the use of bowel segments in the urinary diversion or when the patients are at high risk of morbidity and mortality.

==fine conclusion==

==inizio reference==

1-Chung BI, Hamawy KJ, Zinman LN, et al. The use of bowel for ureteral replacement for complex ureteral reconstruction: long-term results. J Urol. 2006 Jan;175(1):179-83;
2-Aziz A, May M, Burger M, et al. Prediction of 90-day mortality after radical cystectomy for bladder cancer in a prospective European multicenter cohort. Eur Urol. 2014 Jul;66(1):156-63.
3-Berger I, Wehrberger C, Ponholzer A, et al. Impact of the use of bowel for urinary diversion on perioperative complications and 90-day mortality in patients aged 75 years or older. Urol Int. 2015;94(4):394-400. doi: 10.1159/000367853. Epub 2015 Jan 20.

==fine reference==