==inizio objective==

To review our experience and suggest our definition of success of robotic Pyeloplasty.

==fine objective==

==inizio methodsresults==

We reviewed our single surgeon experience with robotic transperitoneal pyeloplasty. 25 cases between 2013 and 2017 found elegible for our study, each patient underwent 99mTcdiethylenetriaminepentacetate (99mTc-DTPA) scintigraphy in order to assess kidney function before and after the procedure.

==fine methodsresults==

==inizio results==

Only 18 of the 25 patients had a clear improvement on the scintigraphic criteria. Mean DRF was 35% before, 34.4 % after the procedure (4 months later, 1 month after the removal of the ureteric stent). 1 significant bleeding reported. 19 of the 25 patients had pain before the procedure but only 8 had pain/mild discomfort after.

==fine results==

==inizio discussions==

The limitations of our study clearly include the retrospective nature of the analysis, an absence of pain scale and
the short term follow-up. Despite that we feel confident to say that there is no imaging method able to really
assess the success of the procedure.

==fine discussions==

==inizio conclusion==

Renal scintigraphy findings alone is not enough in order to define the success of Robotic transperitoneal pyeloplasty. The persistence of discomfort/pain after the procedure should be evaluated as well.

==fine conclusion==

==inizio reference==

1- Influence of early (F + 0) intravenous furosemide injection on the split renal function using 99mTc-DTPA renography. Ahmed A. Kandeel, Salwa A. Elhossainy and Nahla D. Elsayed – Nuclear Medicine Communications 2013, 34:354–358
2- Demirel BB, Balci TA, Tasdemir B, Koc ZP. Comparison of DTPA and MAG3 renal scintigraphies in terms of differential renal function based on DMSA renal scintigraphy. Pak J Med Sci 2012; 28(5):795-799
3- Zeki Dostbil, Necmettin Pembegül, Mehmet Küçüköner, Yaar Bozkurt, Ahmet Ali SancaktutarI. Ismail Yildiz, Güven Tekba – Comparison of split renal function measured by 99m Tc-DTPA, 99m Tc-MAG3 and 99m Tc-DMSA renal scintigraphies in paediatric age groups – Clinical Reviews and Opinions Vol. 3(2), pp. 20-25, February 2011

==fine reference==

==inizio objective==

We describe our initial experience with robotic ureteral reimplantation for ureteroenteric anastomotic strictures in patients previously treated with robotic radical cystectomy (RARC) and intracorporeal neobladders with the use of near infrared fluorescence (NIRF) imaging after transnephrostomic injection of indocyanine green (ICG).

==fine objective==

==inizio methodsresults==

From April 2015 to October 2017, nine consecutive patients underwent robotic ureteral reimplantation in one tertiary referral center. All patients previously underwent RARC-N with the same standardized technique [1].
All patients previously underwent percutaneous nephrostomy and at least one antegrade stenting and stricture dilatation attempt. Surgical steps were described: Steep trendelenburg position, transnephrostomic injection of ICG to identify the lombar ureter with NIRF (Figure 1A), careful ureteral dissection on the surface of the ureter/s to avoid injurying the iliac vessels with alternate use of conventional imaging and NIRF (Figure 1B), spatulation of the ureters, JJ stent insertion and finally uretero-ileal anastomosis.
Baseline, perioperative and functional outcomes data are reported.

==fine methodsresults==

==inizio results==

Median time from RARC to uretero-anastomotic stricture diagnosis was 5mo (IQR 2-6). 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. Neobladder Boari flap was created in all cases.
Intraoperative blood loss was negligible. One patient experienced a Clavien grade 2 complication (urinary tract infection requiring antibiotics). One patient required blood transfusion (Clavien grade 2). One patient underwent ileum resection and anastomosis due to perforation (Clavien IIIb). At a median follow-up of 7 mo (IQR 4-25) no patients developed recurrence (CT scan) or worsening of renal function (new onset CKD stage 3b-4).

==fine results==

==inizio discussions==

Robotic ureteral reimplantation for uretero-enteric strictures is a safe and highly effective procedure. NIRF imaging provides an easy guide to identify and progressively dissect the ureter. Thanks to the high success rate and to the excellent functional outcomes, robotic reimplantation has become a first treatment option in our center.

==fine discussions==

==inizio conclusion==

Transnephrostomic ICG Guided Robotic Ureteral Reimplantation for Ureteroileal Strictures after Robotic Cystectomy and Neobladder is a safe and highly effective procedure.

==fine conclusion==

==inizio reference==

1. Robotic Intracorporeal Padua Ileal Bladder: surgical technique, perioperative, oncologic and functional outcomes. Simone et al. Eur Urol. 2016 Oct 22. pii: S0302-2838(16)30721-7. doi: 10.1016/j.eururo.2016.10.018.

==fine reference==

==inizio objective==

Actinic cystitis (AC) is the manifestation of symptoms and signs such as hematuria, pain during urination, chronic pelvic pain , or clinical-pathological situations such as incontinence, hydronephrosis in impaired bladder capacity and renal failure following pelvic radiotherapy .
Pelvic radiotherapy produces both acute and chronic damage and such damage may have a devastating impact on the quality and on amount of life of the patient .
Patients with AC are 5-10% of patients subjected to radiotherapy [1,2]
The pathophysiology can be divided into three distinct phases:
1) a short acute phase that lasts until a few weeks after radiotherapy;
2) a symptoms free phase, physical well being;
3) a irreversible phase, characterised by a late chronic damage [3].
Clinical symptoms and signs such as hematuria, pain during urination, chronic pelvic pain, could begin until 15 years after radiotherapy [4].
AC is often associated with prolonged hospitalization and significant morbidity. It may require aggressive measures such as radical surgery like cystectomy and urinary diversion. This is successful to stop hematuria and reduces chronic pelvic pain [5].
We bring our experience in a high volume centre ( over 35 cystectomies /year).
Objectives are to evaluate the number of radical cystectomies that have become necessary in the last five years in our department for AC after radiation treatment; to evaluate the characteristics of the patients, and in particular the type of primitive cancer, the radiation dose used during radiotherapy, the time between radiotherapy and cystectomy, and the motivation that required the surgery.

==fine objective==

==inizio methodsresults==

From February 2012 to February 2017, 11 patients underwent
“open” cystectomy for AC.
All patients were studied with radiographic examinations
(cystogram and contrast-CT scan of abdomen) and endoscopy
prior to surgery.
We retrospectively evaluated the kind of primitive cancer,
the radiation dose administered, the time between radiation
treatment and cystectomy.
We also studied the related symptoms that required surgery.
To define symptomatology, we defined haemorrhagic
haematuria as the haematuria that required the administration
of more than two blood transfusions (with haemoglobin
values ≤8 g/dL). We defined incontinence as the use of more
than one diaper a day. We defined kidney failure as the situation
when glomerular filtration rate is below 60 mL/min.Chronic pelvic pain was evaluated by an anaesthesiologist
according to the multidimensional scale Brief Pain Questionnaire.
The data were collected at our hospital.

==fine methodsresults==

==inizio results==

The mean age at the time of cystectomy was 75 year old. In six patients (54.4%) radiotherapy was performed for prostate cancer, in two patients (18.1%) for rectal cancer, in three patients (27.2%) for endometrial cancer. Total radiant dose was different in different patients, and it depended to different kind and localization of cancer. The median time between radiotherapy and cystectomy was 111 months (24-256 months).All patients had symptoms before surgery. Seven patients (63.3%) with gross hematuria were treated with endoscopical clot evacuation and fulguration before be subjected to cystectomy.

==fine results==

==inizio discussions==

The first approach to patients with AC is often supportive care. Supportive or conservative therapy include: hyperhydration and continuous bladder irrigation with physiological solution, chondroitin sulfate, sodium hyarulonate, sodium pentosanpolysulphate prostaglandins, formalin, alum irrigation; systemic treatments such as hyperbaric oxygen therapy, estrogen administration, coagulation factors (VII or VIII) and aminocaproic acid; endoscopic therapy with evacuation of clots and fulguration. Surgery remains the most invasive treatment in the management of those patients who are not responsive to these treatments.

==fine discussions==

==inizio conclusion==

The first approach to patients with AC is often supportive care, AC could have a devastating impact on quality of life of the patient. Surgery remains the most invasive treatment in the management of those patients who are not responsive to conservative treatments.

==fine conclusion==

==inizio reference==

[1] Denton AS, Clarke NW, Maher EJ. Non-surgical interventions for late radiation cystitis in patients who have received radical radiotherapy to the pelvis. Cochrane Database Syst Rev. 2002.

[2] Sandhu SS, Goldstraw M, Woodhouse CR. The management of haemorrhagic cystitis with sodium pentosan polysulphate. BJU Int 2004; 94: 845–7.

[3]Zwaans BM, Chancellor MB, Lamb LE. Modeling and Treatment of Radiation Cystitis. Urology. 2016 Feb;88:14-21.

[4] Vilar DG, Fadrique GG, Martin IJ et al. Hyperbaric oxygen therapy for the management of hemorrhagic radio-induced cystitis. Arch Esp Urol 2011; 64: 869–74.

[5] Perez-Mendoza R, Martinez P, Solares M, Badillo M, Gallo M, Jimenez-Rios MA. Management of post-radiotherapy hemorrhagic cystitis refractory to conventional treatment. BMC Cancer 2007; 7 (Suppl.1): A44

==fine reference==

==inizio objective==

Open redo pyeloplasty is still considered the gold standard for managing recurrent ureteropelvic junction obstruction. With the advent of video-laparoscopy, minimally invasive redo pyeloplasty has become a realistic alternative to redo open pyeloplasty, even if this approach is still anecdotal in literature (1). The aim of this study was to describe our single surgical team experience with Anderson-Hynes transperitoneal laparoscopic pyeloplasty (LP) in the treatment of recurrent ureteropelvic junction obstruction (UPJO).

==fine objective==

==inizio methodsresults==

We enrolled 38 consecutive patients whose underwent transperitoneal laparoscopic redo pyeloplasty between January 2007 and January 2015 at our department. All patients were symptomatic and all patients had a T1/2>20 minutes at pre-operative renal scan. In all cases a transperitoneal pyeloplasty using the Anderson-Hynes technique was performed, by a single surgical laparoscopic team (2). Intraoperative and postoperative complications have been reported according to the Satava and the Clavien-Dindo system. All patients underwent a periodical clinical and radiological follow-up. Treatment success was evaluated by a 12 months postoperative renal scan. All data were collected in a prospectively maintained database and retrospectively analyzed. Descriptive statistics of categorical variables focused on frequencies and proportions. Means and standard deviation were reported for continuously coded variables.

==fine methodsresults==

==inizio results==

Mean stricture length was 0,99±0,45 cm (range, 0,2-2,2 cm) on IVU or retrograde pyelography.
Mean operating time was 103,16±30 minutes. The mean blood loss was 122,37±73,25 ml. The mean postoperative hospital stay was 4,47±0,86 days. No intraoperative complications occurred according the Satava system (3). 6 out of 38 patients(15,8%) experienced postoperative complications according Clavien-Dindo classification (4) (Table 1). The success rate was 97,4% for flank pain and 97,4% for hydronephrosis. Post-operative renal scan showed radiological failure in one out of 38(2,6%) patients, relative success in 2 out of 38(5,3%) patients and total success in 35 out of 38(92,1%) of patients. The radiologic failure, occurred in the patient that experienced the urine leakage. The patient underwent a laparoscopic pyeloplasty at our hospital for the third time with relative success at post-operative DTPA renal scan.

==fine results==

==inizio discussions==

Laparoscopic redo pyeloplasty is considered a very challenging procedure due to the possibility to find a lot of peripelvic and periureteric fibrosis. Moreover some adjuvant maneuvers may be required to success, like the use of a pelvis flap or ureterocalicostomy (5). The high rate of success in our series can be related to the short length of the failed stenosis without the need for additional challenging maneuvers. In the most complex cases we need to perform the isolation of all kidney and distal ureter in order to perform a tension free anastomosis and to avoid the twisting of the anastomosis. Some limitations of the study herein include, firstly, the short follow-up time. Another limitation is that all procedures were performed by a single surgical team with significant expertise in laparoscopic surgery, which may restrict the generalizability of our results to centers with more limited laparoscopic experience. Moreover this is a retrospective observational non-comparative study.

==fine discussions==

==inizio conclusion==

Laparoscopic redo pyeloplasty is a feasible procedure for the treatment of recurrent UPJO, with a low rate of post-operative complications and an high success rate in high laparoscopic volume centers.

==fine conclusion==

==inizio reference==

1- Sundaram CP, Grubb RL 3rd, Rehman J, Yan Y, Chen C, Landman J, et al. Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction. J Urol. 2003;169:2037-40.

2- Fedelini P, Verze P, Meccariello C, Arcaniolo D, Taglialatela D, Mirone VG. Intraoperative and postoperative complications of laparoscopic pyeloplasty: a single surgical team experience with 236 cases. J Endourol. 2013;27:1224-9.

3- Kazaryan AM, R.sok BI, Edwin B. Morbidity assessment in surgery: refinement proposal based on a concept of perioperative adverse events. ISRN Surg. 2013;2013:625093.

4- Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187-96.

5- Ross JH, Streem SB, Novick AC, Kay R, Montie J. Ureterocalicostomy for reconstruction of complicated pelviureteric junction obstruction. Br J Urol. 1990;65:322-5.

==fine reference==