ABSTRACT Objective: The purpose of this video is to present the laparoscopic repair of a VUF in a 42-year-old woman, with gross hematuria, in the immediate postoperative phase following a cesarean delivery. The obstetric team implemented conservative management, including Foley catheter insertion, for 2 weeks. She subsequently developed intermittent hematuria and cystitis. The urology team was consulted 15 days after cesarean delivery. Cystoscopy indicated an ulcerated lesion in the bladder dome of approximately 1.0cm in size. Hysterosalpingography and a pelvic computed tomography scan indicated a fistula. Materials and Methods: Laparoscopic repair was performed 30 days after the cesarean delivery. The patient was placed in the lithotomy position while also in an extreme Trendelenburg position. Pneumoperitoneum was established using a Veress needle in the midline infra-umbilical region, and a primary 11-mm port was inserted. Another 11-mm port was inserted exactly between the left superior iliac spine and the umbilicus. Two other 5-mm ports were established under laparoscopic guidance in the iliac fossa on both sides. The omental adhesions in the pelvis were carefully released and the peritoneum between the bladder and uterus was incised via cautery. Limited cystotomy was performed, and the specific sites of the fistula and the ureteral meatus were identified; thereafter, the posterior bladder wall was adequately mobilized away from the uterus. The uterine rent was then closed using single 3/0Vicryl sutures and two-layer watertight closure of the urinary bladder was achieved by using 3/0Vicryl sutures. An omental flap was mobilized and inserted between the uterus and the urinary bladder, and was fixed using two 3/0Vicryl sutures, followed by tube drain insertion. Results: The operative time was 140 min, whereas the blood loss was 100ml. The patient was discharged 3 days after surgery, and the catheter was removed 12 days after surgery. Discussion: Laparoscopy has advantages over open surgery in that it is associated with less pain, shorter length of hospital stay, better cosmesis, quicker recovery, and equal efficacy. Although cases of VUF are rarely noted, the laparoscopic skill obtained through other urological procedures suggest, that laparoscopic repair may be the procedure of choice for such cases (2). The reported operative time for the laparoscopic repair of VUF in the literature varies between 140 and 220 min (3). However, laparoscopic techniques should be considered as a mode of abdominal access and should not influence the method of surgical repair. Surgical success should depend on the adherence to good technique rather than the approach. Hence, this method appears to be a viable alternative for surgeons experienced with laparoscopic suturing techniques. Conclusion: Laparoscopic repair appears to be a viable alternative for surgeons experienced with laparoscopic suturing techniques.

OBJECTIVE: Compare the capacity of the PSA density (PSAD), Free PSA percentage (%FPSA) and PSA transition zone density (PSATZ) in improving the sensitivity and specificity of the PSA to detect prostate cancer (PCa) in men with a PSA between 4 and 10 ng/mL. MATERIALS AND METHODS: One hundred and forty five men with PSA between 4 and 10 ng/mL were prospectively studied. Blood collection for the total PSA and free PSA was performed as well as transrectal ultra-sound with prostate biopsy and measurement of the total prostate volume (TPV) and transition zone volume (TZV). Patients with initial negative biopsy were followed and the prostate biopsy was repeated in those that presented PSA increase. The capacity of the PSAD, %FPSA and PSADTZ in improving the sensitivity and specificity pf the PSA test to the detection of the PCa was assessed by univariate and multivariate analyses and through the ROC curve. RESULTS: Of the 145 patients, 38 (26.2%) had PCa and in 107 (73.8%) a benign prostate disease was diagnosed. No difference among the PSAD, %FPSA and PSADTZ was found. The multivariate analysis showed that the PSADTZ, %FPSA, TZV and age were those more powerful and highly significant PCa predictors. CONCLUSION:The determination of %FPSA and PSAD can allow a better discrimination between PCa and benign disease that the isolated use of PSA. The combination of PSADTZ, %FPSA, TZV and age promote a high accuracy for PCa detection.

PURPOSE: to determine the role of RPLND for residual masses following chiotherapy in patients with non-siinomatous germ cell tumors (NSGCT) stage T1N2 and T1N3 (IIB and IIC). MATERIALS AND METHODS: We have preformed retrospective analysis of 11 patients who underwent RPLND for residual masses following chiotherapy in an oncologic reference center between January 1997 and Deciber 2002. All patients harbored either pure nonsiinomatous or mixed tumors in the testis tissue and had undergone 4 cycles of primary chiotherapy with bleomycin, etoposide and cisplatin. The residual masses were assessed by abdominal computed tomography preoperatively. RESULTS: There were perioperative complications in 3 cases owing to vascular iatrogenic lesion. One of who died in the early postoperative period due to extensive iliac thrombosis. The other 2 patients had an inferior vena cava injury owing to the difficulty in rioving the attached lymph nodes. The injuries were repaired by continuous suture with Prolene 5-0. All patients had tumors in the final pathological report and were referred to other 2 cycles of chiotherapy with the same drugs. Seven patients (63.3%) had complete response and riained free of the disease in a mean follow up of 38.3 months (ranging from 12 to 72). The riaining 3 patients had disease progression, 2 of which died 6 and 12 months after surgery, respectively, and one patient missed the follow-up after salvage chiotherapy. CONCLUSION: Retroperitoneal lymph node dissection for residual masses after chiotherapy is a high-morbidity procedure, even by experienced surgeons, although it riains an efficient modality of treatment in advanced germ cell carcinoma. The high frequency of tumor found in the RPLFN following chiotherapy might have been caused by the small number of patients in this study.