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Uretroplastica Posteriore per via perineale combinata con accesso endoscopico sovrapubico

==inizio abstract==

Il Video mostra l’Uretroplastica Posteriore utilizzando un accesso chirurgico perineale progressivo combinato con un accesso endoscopico sovrapubico.
Paziente con rottura dell’uretra posteriore dopo trauma pelvico.
Attraverso una incisione perineale l’uretra bulbare viene isolata e staccata dai corpi cavernosi. La sezione del Centro Tendineo Perineale consente la mobilizzazione circonferenziale dell’uretra bulbare prossimale e membranosa. La separazione mediana dei corpi cavernosi facilita l’accesso all’apice prostatico. Queste manovre consentono l’isolamento del blocco uretra bulbare prossimale-uretra membranosa-apice prostatico. L’uretra membranosa viene sezionata quanto più vicino possibile all’apice prostatico.
Tramite l’accesso sovrapubico il cistoscopio è inserito in vescica e, attraverso il collo vescicale, nell’uretra prostatica. Il perineo è transilluminato dall’endoscopia ed il chirurgo, seguendo la luce, incide l’apice prostatico e identifica il lume uretrale prossimale. Dopo la resezione dei tessuti cicatriziali, i due monconi uretrali sono spatolati e viene confezionata l’anastomosi bulbo-prostatica.
Nell’uretroplastica posteriore l’approccio perineale progressivo consente un soddisfacente accesso all’apice prostatico.
L’accesso endoscopico sovrapubico è una manovra meno aggressiva rispetto all’impiego alla cieca del beniquè poiché:
1-facilita il ritrovamento per via perineale del lume uretrale prostatico,
2-preserva la continenza urinaria poiché riduce il rischio di danneggiamento del collo vescicale che è l’unico sfintere residuo dopo la compromissione dello sfintere distale dovuta al trauma.

==fine abstract==

Albugineal grafting and penile implant in the management of Peyronie’s disease with severe curvature

==inizio abstract==

In questo video mostreremo un intervento di impianto di protesi peniena tricomponente e grafting dell’albuginea in un paziente affetto da malattia di la Peyronie con severa curvatura dorsale (circa 80°)e deformità a clessidra. Il paziente presentava patologia stabile da circa 6 mesi. Nella fase di insorgenza della malattia (circa 18 mesi precendenti l’intervento) era stato trattato senza successo con 10 infiltrazioni di Verapamil. Al momento dell’intervento il paziente riferiva una disfunzione erettile responsiva a 20mg di Tadalafil.
La procedura avviene con un’incisione sub-coronale. Degloving penieno. Si procede con una singola incisione parauretrale della fascia di Buck e si isola il fascio vascolo-nervoso.
Una volta effettuata l’erezione passiva si marca con penna dermografia il punto di massima curvatura. Incisione a doppia Y. Si rimuovono placche calcifiche e si procede a grafting con patch di derma porcino (Permacol 0.5 mm, Covidien) che viene suturato con punti in polidiossanone 4.0. Chiusura della fascia di Buck. Plastica del prepuzio. L’impianto della protesi peniena tricomponente (Coloplast Titan®) viene effettuato con il classico approccio peno-scrotale. Si evidenzia la correzione della curvatura peniena e l’allungamento di circa 4 cm dell’asta.

==fine abstract==

Real penile lengthening and widening in patient with Peyronie’s disease. Penile implant and mesh grafting

==inizio abstract==

In questo video mostreremo un intervento di aumento della lunghezza e della larghezza del pene in paziente affetto da malattia di la Peyronie e disfunzione erettile utilizzando impianto di protesi peniena tricomponente e grafting dell’albuginea con mesh. Il paziente riferiva un accorciamento dell’asta di circa 5 cm e presentava una deformità distale con severo restringimento dei corpi cavernosi e curvatura dorsale di circa 90°.
La procedura avviene con un’incisione peno-scrotale. Si procede con l’isolamento della fascia di Buck e del fascio vascolo-nervoso da un solo lato e la si distacca completamente dalla tunica albuginea.
L’erezione passiva evidenzia deformità distale e curvatura dorsale. Incisione a doppia Y dorsale e grafting con patch di derma porcino (Permacol 0.5 mm, Covidien). Si effettuano due incisioni parauretrali sull’albuginea e grafting longitudinale con mesh parzialmente riassorbibile (Ethicon UltraPro™). Chiusura della fascia di Buck a copertura dei patch. L’impianto della protesi peniena tricomponente (Coloplast Titan®) viene dalla stessa incisione ed peno-scrotale. Si evidenzia la correzione della curvatura peniena e ripristino della normale morfologia dell’asta. Il pene risulta aumentato di 5 cm di lunghezza e di 5.5 di larghezza.

==fine abstract==

Management of failed hypospadias repair in adult

==inizio objective==

Hypospadias is one of the most prevalent anomalies of the male genitalia. Primary hypospadias repair is very successful, but in patients (pts) underwent multiple surgeries throughout their life the result can be unsuccessful. Complications from failed hypospadias repairs have a significant impact on patients both psychologically and physically.

==fine objective==

==inizio methodsresults==

10 pts with failed hypospadias repair were enrolled in this preliminary study. The complications include : hypospadias recurrence with an ectopic meatus (2 pts), fistula (2 pts), urethral stricture including meatal stenosis (7 pts), and persistence of penile curvature (4 pts). Pts underwent correction in a single stage (8 pts) and in two-stage repair (2 pts). Second stage repair was performed at 6 month. In pts with urethral stenosis a graft of buccal mucosa graft was used. Pts with residual penile curvature was performed a corporoplasty with incision and plication of the albuginea.

==fine methodsresults==

==inizio results==

At 6 months follow-up 1 patient required surgery revision for fistula, while 2 pts needed urethral calibration. All pts underwent uroflowmetry with a Qmax >15 ml/s. All pts were satisfied with aesthetic result.

==fine results==

==inizio discussions==

Failed hypospadias repair is a challenging procedure and still represents a complex problem for reconstructive urologists [1].
When counseling patients with failed hypospadias it is important to discuss the expected outcome as repairs directed towards a terminally positioned meatus with a straight phallus may require multiple surgeries due to post-operative complications as well as the necessity of proceeding in a staged approach.
In this study we tried to fix the penis in one surgery when possible.

==fine discussions==

==inizio conclusion==

Failed hypospadias is a complex disorder that can affect pts psychologically too [2].
Pts often require multiple surgeries to achieve a satisfactory outcome and they have to be well informed that there are a multitude of reconstructive options for management of the various complications that they can have after surgery

==fine conclusion==

==inizio reference==

1. Failed Hypospadias Repair Presenting in Adults. Barbagli, Guido et al. European Urology , Volume 49 , Issue 5 , 887 – 895
2. Management of Adults with Prior Failed Hypospadias Surgery.” Craig, James R. et al. Translational Andrology and Urology 3.2 (2014): 196–204. PMC. Web. 31 Dec. 2017.

==fine reference==

One-stage urethroplasty using buccal mucosa graft in patient with penile stricture and Lichen sclerosus

==inizio objective==

Lichen sclerosus (LS) is a disease of unknown etiology that affects the genitals.
It is characterized by atrophy of the epidermis.
This disease is characterized by atrophy of the mucosa of the glans and prepuce leading to trauma during intercourse, difficulty in preputial mobility, erectile dysfunction, phimosis and paraphimosis and urethral stricture [1].

==fine objective==

==inizio methodsresults==

7 patients (pts) with LS and urethral stricture were enrolled for this study. Patient mean was age 54 years.
All of the patients underwent physical examination, uroflowmetry, retrograde and voiding urethrography in order to evaluate the stricture. The mean Qmax was 5 ml/sec. Mean stricture length was 4.2 cm.
All pts underwent one-stage urethroplasty with buccal/labial mucosa graft.
A midline longitudinal, ventral incision was made starting from the urethral meatus. The penile urethra was exposed with minimal dissection. The urethra was opened along its ventral surface under the guidance of the guide wire, previously inserted. The urethra was spatulated up to normal caliber and pink urethral mucosa. The entire urethral plate affected by the LS was removed. Then the buccal mucosa graft was taken from the cheek an then it was spatulated in order to remove fatty tissues under the mucosa. Then it was sutured on the urethral plate with two lateral running sutures and many single stiches on the whole graft in 5.0 Vicryl suture.
The neo-urethra was incised laterally and tubularized with 5.0 Vicryl suture.
The glans was reconstruct on the tubularized urethra. Dartos fascia and skin were closed. A sovrapubic catheter and a 10 Fr urethral stent were inserted and left for two weeks post-operatively.
Pts were discharged from the clinic 2 days after surgery.

==fine methodsresults==

==inizio results==

At 1 year follow-up all pts underwent uroflowmetry in order to assess the voiding.
One patient needed a second surgery (Meatoplasty) in order to open the meatus.
Mean Qmax was 15 ml/sec. All pts were satisfied with the functional and aesthetic results of the surgery

==fine results==

==inizio discussions==

In pts with penile strictures caused by LS, the penis is fully involved in the disease : glans, meatus, skin, fibrotic dartos. For these pts two-stage repair would be less risky and for this reason it is normally recommended the two-stage repair [2]. On the other hands pts, between the two stages, complain about the appearance of the penis that is open ventrally. Some pts don’t make any physiotherapy post-operatively leading to scarring tissue on the urethral plate. The caliber of the neo-urethra should be wider than normal caliber due the fact that it will reduce after a while. At moment buccal mucosa graft represent the best tissue to replace the urethra.

==fine discussions==

==inizio conclusion==

Penile stricture with LS is a complex disease that needs to be treated with urethroplasty with buccal mucosa graft. This procedure in one-stage can give a good results just if the caliber of the neo-urethra is wide enough.
This procedure is the only technique that can treat LS and penile strictures.

==fine conclusion==

==inizio reference==

1) Kulkarni S, Kulkarni J, Surana S, Joshi PM. Management of Panurethral Stricture. Urol Clin North Am. 2017 Feb;44(1):67-75

2) Angulo JC, Arance I, Esquinas C, Nikolavsky D, Martins N, Martins F. Treatment of long anterior urethral stricture associated to lichen sclerosus. Actas Urol Esp. 2016 Nov 2.

==fine reference==

New technologies for old procedures when FireFly technologie improves Robotic Bladder Diverticulectomy

==inizio abstract==

Scopo del Lavoro
The video shows the peculiar advantage of using Firefly Fluorescence Imaging da Vinci System during bladder diverticula detection and dissection.

Materiali e metodi
Patient is placed in the lithotomic position and 30° Trendelenburg. Supraumbilical camera trocar is inserted. We use a four-arm robotic approach and a 5 to 6 ports placements. Pneumoperitoneum is established at 12 Hg mm. The bladder is accessed via a transperitoneal route. We perform a flexible cystoscopy with the Firefly Fluorescence Imaging System on for the diverticulum detection. The peritoneum over the bladder is then incised to expose the diverticulum. We use this near-infrared technology also as a guide in the diverticulum dissection. Using sharp and blunt dissection, the diverticulum is resected to its neck. Completion of diverticulectomy and hydraulic tightness test. Drainage placement in the Retzius space and peritoneum reconstruction.

Results
Several approaches have been described for intra-operative diverticulum identification and dissections. We developed a technique in which transperitoneal bladder diverticulectomy is performed under the Firefly guidance that provide real-time, image-guided identification of key anatomical landmarks.

Conclusions
In our experience, intra-operative use of Firefly makes identification and dissection of the diverticulum rapid, safe and effective with no additional cost, even in disadvantageous anatomic conditions such as lateral-posterior diverticula.

==fine abstract==

Transnephrostomic ICG Guided Robotic Ureretal Reimplantation for Ureteroileal Strictures after Robotic Cystectomy and Neobladder: step by step technique

==inizio abstract==

INTRODUCTION: In this video we describe our initial experience with robotic ureteral reimplantation for uretero-enteric anastomotic strictures in patients previously treated with robot assisted radical cystectomy and intracorporeal neobladders (RARC-N) with the use of near infrared fluorescence (NIRF) imaging after transnephrostomic injection of indocyanine green (ICG).
METHODS: From April 2015 to October 2017, 9 consecutive patients underwent robotic ureteral reimplantation in one tertiary referral center. All patients previously underwent RARC-N with the same standardized technique.
All patients previously underwent percutaneous nephrostomy and at least one antegrade stenting and stricture dilatation attempt.
This was a case of a 64 year old male, with a 2.5 centimeters left ureteral stricture, who underwent RARC-N 10 months ago.
As shown in the video, transnephrostomic injection of ICG was performed to identify the lumbar ureter.
Intravenous ICG was injected and allowed to easily identify the left iliac artery.
RESULTS: Median time from RARC to uretero-anastomotic stricture diagnosis was 5mo (IQR2-6). Median stricture length was 1,5 cm (IQR 1-2). Median operative time was 140 minutes (IQR 81-155) and median length of stay was 5 days (IQR 3-9).
All cases were completed robotically.
CONCLUSIONS:Near infrared fluorescence imaging provides an easy guide to identify and progressively dissect the ureter.

==fine abstract==

ENDOSCOPIC TREATMENT OF VESCICOURETERAL REFLUX IN ADULT PATIENTS: SUSPENSION TECNIQUE WITH VANTRIS

==inizio abstract==

The aim of this video is to describe an injection technique with polyacrylate polyalcohol copolymer (PPC, Vantris, Promedon, Cordoba, Argentina) using a guidewire to suspend the anterior wall of the ureter and show our results comparing them with the classic STING technique first described by O’Donnel and Kirsh.
Between 2013 and 2017 we performed 19 endoscopic bulking procedures in women with vescicoureteral reflux. We retrospectively compared the use of the classic STING technique and the suspension technique in terms of success rate.
The clinical case describes the treatment of VUR in a 48 years old woman with bilateral endoscopic injection of Vantris.
7 patients underwent the classic STING approach, 12 the suspension. Table 1 reports the results in terms of number of injections needed to achieve the correction of VUR. Success rate after 1 injection is 91.6% in the suspension group and 57.1% in the STING group.
This tecnique improves the efficacy of endoscopic treatment of VUR. Our preliminary experience with a small population and fourther studies with this tecnique must be encouraged to improve the correct and otherwise difficult treatment of VUR in adult patients.

Table 1
Tecnique Correction after 1 injection Correction after 2 injections Failure Tot.
STING 4 2 1 7
SUSPENSION 11 1 0 12

==fine abstract==

Reimpianto ureterale bilaterale videolaparoscopico per la gestione di idronefrosi ostruttiva iatrogena

==inizio abstract==

Il presente video mostrerà la gestione chirurgica di una complicanza in un paziente di anni 72 sottoposto a prostatectomia radicale videolaparoscopica nerve sparing per un tumore prostatico 3+3. In seguito all’intervento il paziente ha manifestato insufficienza renale acuta (creatinina 7.2 mg/dl) con idronefrosi bilaterale ed anuria per il quale è stato sottoposto a posizionamento di nefrostomia bilaterale e tentativo infruttuoso di stentaggio anterogrado a causa della presenza di stenosi dell’uretere terminale bilateralmente. Pertanto il paziente è stato sottoposto ad intervento di reimpianto ureterale bilaterale videolaparoscopico con approccio trans peritoneale, sono stati isolati gli ureteri bilateralmente sino al tratto stenotico e sono stati sezionati e spatulati. In seguito è stata effettuata una breccia sulla parete vescicale anteriore ed è stato effettuato un reimpianto diretto degli ureteri in sede ortotopica a livello del trigono vescicale, anastomosi effettuata con Vicryl 3-0. Sono stati infine posizionati 2 tutori ureterali tenuti in sede per circa un mese a protezione delle anastomosi.

==fine abstract==

Idronefrosi da fibrosi retroperitoneale, gestione laparoscopica

==inizio abstract==

Il presente video mostrerà la gestione chirurgica di un paziente di anni 76, inviato dal Pronto Soccorso per insufficenza renale acuta ed idronefrosi bilaterale. Il paziente è stato pertanto sottoposto a posizionamento di stent ureterali bilaterali in urgenza e successivamente, risolta l’insufficenza renale ha effettuato URO-TC che ha evidenziato la presenza di tessuto solido retroperitoneale, scarsamente vascolarizzato, che tendeva a circondare “a manicotto” l’aorta , l’emergenza dei principali vasi splancnici ed entrambi gli ureteri.
Pertanto il paziente è stato sottoposto ad intervento chirurgico in 2 tempi di peritonealizzazione degli ureteri. Per l’uretere dx il paziente è stato posizionato in decubito laterale sin per accesso transperitoneale, con posizionamento dell’ottica in sede periombelicale e delle operative in sede sottocostale ed inguinale dx. E’ stato poi isolato l’uretere dx e sbrigliato dalle aderenze sino al tratto iuxtavescicale ed è stato posizionato in sede intraperitoneale ed è stato chiuso il peritoneo a punti staccati. L’uretere sin è stato trattato in un secondo tempo con tecnica analoga e speculare.

==fine abstract==