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Purpose: To evaluate the relationship between warm ischemia time (WIT) duration and renal function after robot-assisted partial nephrectomy (RAPN)., Methods: The CLOCK trial is a phase 3 randomized controlled trial comparing on- vs off-clamp RAPN. All patients underwent pre- and postoperative renal scintigraphy. Six-month absolute variation of eGFR (AV-GFR), rate of relative variation in eGFR over 25% (RV-GFR > 25), absolute variation of split renal function (SRF) at scintigraphy (AV-SRF). The relationships WIT/outcomes were assessed by correlation graphs and then modeled by uni- and multivariable regression., Results: 324 patients were included (206 on-clamp, 118 off-clamp RAPN). Correlation graphs showed a threshold on WIT equal to 10 min. The differences in outcome measures between cases with WIT < vs ≥ 10 min were: AV-GFR - 3.7 vs - 7.5 ml/min (p < 0.001); AV-SRF - 1% vs - 3.6% (p < 0.001); RV-GFR > 25 9.3% vs 17.8% (p = 0.008). Multivariable models found that AV-GFR was related to WIT ≥ 10 min (regression coefficient [RC] - 0.52, p = 0.019), age (RC - 0.35, p = 0.001) and baseline eGFR (RC - 0.30, p < 0.001); RV-GFR > 25 to WIT ≥ 10 min (odds ratio [OR] 1.11, p = 0.007) and acute kidney injury defined as > 50% increase in serum creatinine (OR 19.7, p = 0.009); AV-SRF to WIT ≥ 10 min (RC - 0.30, p = 0.018), baseline SRF (RC - 0.76, p < 0.001) and RENAL score (RC - 0.60. p = 0.028). The main limitation was that the CLOCK trial was designed on a different endpoint and therefore the present analysis could be underpowered., Conclusions: Up to 10 min WIT had no consequences on functional outcomes. Above the 10-min threshold, a statistically significant, but clinically negligible impact was found., (© 2023. The Author(s).)

Background: To evaluate the ability of therapeutic intensity score (TIS) in predicting the clinical outcomes of partial (PA) and total adrenalectomy (TA) for UPA., Methods: Between 2011 and 2022, a four-center adrenalectomy dataset was queried for "unilateral adrenal mass" and "UPA" (n = 90). Preoperative TIS of each antihypertensive medication were individually calculated and merged to create a single, cumulative variable. Probability of complete clinical, partial, and absent pooled success rates according to TIS were assessed for the overall cohort by Kaplan-Meier. Cox analyses were used to identify predictors of complete clinical and partial/absent success, respectively. For all analyses, a two-sided p < 0.05 was considered significant., Results: At a median follow-up of 42 months (IQR 27-54) complete partial, and absent clinical success were observed in 60%, 17.7%, and 22.3%, respectively. On Kaplan-Meier analysis, TIS < 1 predicted higher complete success rates ( p < 0.001), while TIS ≥ 1 was predictor of either partial and absent clinical success ( p = 0.008). On multivariable analysis, TIS < 1 (HR 0.25; 95% CI 0.11-0.57; p = 0.001) and adenoma size (HR 1.11; 95% CI 1-1.23; p = 0.0049) were independent predictors of complete clinical success, while TIS ≥ 1 (HR 2.84; 95% CI 1.32-6.1; p = 0.007) was the only independent predictor of absent clinical success., Conclusions: TIS score and adenoma size may help to identify patients who are likely to be at risk of persistent hypertension after surgery.

Rectal perforations during pelvic surgery are rare but serious complications. The occurrence of rectal involvement is generally lower than that of the involvement of other portions of the bowel. The urologic field is responsible for the majority of iatrogenic rectal injuries from pelvic surgery; general and gynecologic surgeries are prone to the occurrence as well, the latter especially in the case of rectal shaving for deep infiltrating endometriosis. Attention should be posed to the prevention of rectal injuries, especially in case of challenging or salvage procedures; some tricks may be recommended to avoid thermal and mechanical damages and to realize a safe dissection. Intraoperative detection of rectal injuries is of paramount importance; once confirmed, immediate management with the closure of the defect is recommended. In general, rectal injuries diagnosed after surgery are liable to significantly worse outcomes than those detected and managed intraoperatively., Patient Summary: Rectal perforation is a rare but possible complication of pelvic surgeries. The more challenging the procedure (ie, surgery for locally advanced tumors or after radiation therapy), the higher the risk of rectal lesion. Intraoperative management of the injury should be attempted, with direct repair of the defect with or without fecal diversion., (© 2022 The Author(s).)

Objectives: To compare the functional outcomes of on- vs off-clamp robot-assisted partial nephrectomy (RAPN) within a randomized controlled trial (RCT)., Materials and Methods: The CLOCK study (CLamp vs Off Clamp the Kidney during robotic partial nephrectomy; NCT02287987) is a multicentre RCT including patients with normal baseline function, two kidneys and masses with RENAL scores ≤ 10. Pre- and postoperative renal scintigraphy was prescribed. Renal defatting and hilum isolation were required in both study arms; in the on-clamp arm, ischaemia was imposed until the completion of medullary renorraphy, while in the off-clamp condition it was not allowed throughout the procedure. The primary endpoint was 6-month absolute variation in estimated glomerular filtration rate (AV-GFR); secondary endpoints were: 12, 18 and 24-month AV-GFR; 6-month estimated glomerular filtration rate variation >25% rate (RV-GFR >25); and absolute variation in ipsilateral split renal function (AV-SRF). The planned sample size was 102 + 102 cases, after taking account crossover of cases to the alternate study arm; a 1:1 randomization was performed. AV-GFR and AV-SRF were compared using analysis of covariation, and RV-GFR >25 was assessed using multivariable logistic regression. Intention-to-treat (ITT) and per-protocol analyses (PP) were performed., Results: A total of 160 and 164 patients were randomly assigned to on- and off-clamp RAPN, respectively; crossover was observed in 14% and 43% of the on- and off-clamp arms, respectively. We were unable to find any statistically significant difference between on- vs off-clamp with regard to the primary endpoint (ITT: 6-month AV-GFR -6.2 vs -5.1 mL/min, mean difference 0.2 mL/min, 95% confidence interval [CI] -3.1 to 3.4 [P = 0.8]; PP: 6-month AV-GFR -6.8 vs -4.2 mL/min, mean difference 1.6 mL/min, 95% CI -2.3 to 5.5 [P = 0.7]) or with regard to the secondary endpoints. The median warm ischaemia time was 14 vs 15 min in the ITT analysis and 14 vs 0 min in the PP analysis., Conclusion: In patients with regular baseline function and two kidneys, we found no evidence of differences in functional outcomes for on- vs off-clamp RAPN., (© 2021 The Authors BJU International © 2021 BJU International.)

Background: To propose a trifecta that summarizes endpoints and predicts their maintenance after adrenalectomy ( n = 90) for unilateral primary aldosteronism (UPA)., Methods: Trifecta was defined as coexistence of: ≥50% antihypertensive therapeutic intensity score reduction (∆TIS), no hypokalemia at 3 months, and no Clavien grade 2-5. Logistic regression was used to identify predictors of trifecta. Probability of clinical, biochemical, and simultaneous success according to trifecta were assessed by Kaplan-Meier. Cox regression was used to identify predictors of long-term clinical, biochemical, and simultaneous success. For all analyses, a two-sided p < 0.05 was considered significant., Results: Simultaneous success rate was 50%. On multivariable analysis, TIS was an independent predictor of trifecta achievement (HR 3.28; 95% CI 1.07-10.9; p = 0.03). At Kaplan-Meier, trifecta predicted higher success for all endpoints (each p < 0.03). On multivariable Cox analysis, adenoma size (AS) ≥6 cm and trifecta were independent predictors of biochemical (AS: HR 2.87; 95% CI 1.53-5.36; trifecta: HR 2.1; 95% CI 1.13-3.90; each p < 0.02) and simultaneous success (AS: HR 3.81; 95% CI 1.68-8.65; trifecta: HR 4.29; 95% CI 2.08-8.86; each p < 0.01), while trifecta was an independent predictor of complete clinical success (HR 2.84; 95% CI 1.45-5.58; p < 0.01)., Conclusions: Trifecta and AS are independent predictors of either long-term complete clinical, biochemical, or combined success after adrenalectomy for UPA.

Introduction: Several predictive scores to evaluate outcomes of adrenal surgery for unilateral primary aldosteronism (UPA), have been conceived. We compared a novel trifecta that summarizes outcomes of adrenal surgery for UPA with the clinical cure proposed by Vorselaars., Material and Methods: Between March 2011 and January 2022, a multi-institutional dataset was queried for UPA. Baseline, perioperative and functional data were collected. Clinical and biochemical complete and partial success rates according to Primary Aldosteronism Surgical Outcome (PASO) criteria were assessed for the overall cohort. Clinical cure was defined either as normotension without antihypertensive medications or normotension with lower or equal use of antihypertensive medications. Trifecta was defined as the coexistence of ≥50% antihypertensive therapeutic intensity score (TIS) reduction (ΔTIS), no electrolyte impairment at 3-months and no Clavien-Dindo (2-5) complications. Cox regression analyses were used to identify predictors of long-term clinical and biochemical success. For all analyses, a two-sided p <0.05 was considered significant., Results: Baseline, perioperative and functional outcomes were analyzed. Out of 90 patients, at a median follow-up of 42 months (IQR 27-54) a complete and partial clinical success was observed in 60% and 17.7% of cases while a complete and partial biochemical success was achieved in 83.3% and 12.3% of cases, respectively. Overall trifecta and clinical cure rates were 21.1% and 58.9%, respectively. On multivariable Cox regression analysis, trifecta achievement (HR 2.87; 95% CI 1.45-5.58; p = 0.02) was the only independent predictor of complete clinical success at long-term follow-up., Conclusions: Despite its complex estimation and more restrictive criteria, trifecta but not clinical cure allows to independently predict composite PASO endpoints on the long run., Competing Interests: The authors declare no conflicts of interest., (Copyright by Polish Urological Association.)

Background: Determination of success after adrenal-sparing surgery for primary aldosteronism (PA) is limited by the lack of standardized definitions of outcomes., Objective: To evaluate the safety and effectiveness of minimally invasive partial adrenalectomy (MIPA) for PA by comparing perioperative and functional outcomes with minimally invasive total adrenalectomy (MITA) according to the Primary Aldosteronism Surgical Outcome (PASO) criteria., Design, Setting, and Participants: Between March 2011 and April 2020, a multicenter adrenalectomy dataset was queried for "unilateral adrenal mass, PA, MIPA (n = 29), or MITA (n = 61)"at four participating Institutions., Intervention: MITA and MIPA for PA., Outcome Measurements and Statistical Analysis: Differences between continuous variables were assessed with the Wilcoxon rank sum test, while Pearson's χ 2 test was used for categorical data. Complete, partial, and absent clinical success rates were assessed for the overall cohort and compared between groups., Results and Limitations: The median tumor size was significantly higher in the MITA group (4.2 vs 2.7 cm; p = 0.001), while preoperative hypertension rate was significantly higher in the MIPA series (82.8% vs 57.4%, p = 0.01). The median length of hospital stay was increased in the MITA cohort (4 vs 3 d; p = 0.038). Overall, at a median follow-up of 42 mo (interquartile range 27-54 mo), complete, partial, and absent clinical success was observed in 60%, 17.7%, and 22.3% of cases, respectively. The complete clinical success rate was higher in the MIPA group (72.4% vs 54.1%), while a partial clinical success was higher in the MITA series (23% vs 6.8%). The absence of clinical success was comparable between groups (MITA 23% vs MIPA 20.7%)., Conclusions: MIPA showed excellent perioperative results with a complete clinical success rate of 72.4%. Owing to the heterogeneity of the PASO criteria in the assessment of partial or absent success, the quest for a univocal definition of satisfactory clinical outcomes in the treatment of PA remains open., Patient Summary: We compared minimally invasive partial adrenalectomy (MIPA) and minimally invasive total adrenalectomy for the treatment of unilateral primary aldosteronism, assessing the outcomes with the Primary Aldosteronism Surgical Outcome (PASO) criteria. MIPA seems to provide comparable perioperative outcomes and midterm clinical success rates., (Copyright © 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: The aim, of this study was to investigate recurrence rates in patients with T1 renal cell carcinoma (RCC) undergone partial nephrectomy (PN), radiofrequency ablation (RFA) or cryoablation (Cryo)., Methods: We retrospectively evaluated data from 665 (81.4%), 68 (8.3%) and 83 (10.3%) patients who underwent PN, RFA and Cryo, respectively. Kaplan-Meier curves depict recurrence-free survival (RFS) rates in the overall population and after stratifying according to tumor's histology (namely, clear cell RCC and non-clear RCC) and size (namely <2 cm and 2-4 cm). Multivariable Cox regression model was used to identify predictors of recurrence. Cumulative-incidence plots evaluated disease recurrence and other causes of mortality (OCM)., Results: Patients referred to PN experienced higher RFS rate compared to those treated with RFA and Cryo at 60-month in the overall population (96.4% vs. 79.4% vs. 87.8%), in patients with clear cell RCC (93.3% vs. 75% vs. 80.4%) and in those with tumor of 2-4 cm (97.3% vs. 78% and 84.4%; all P≤0.01). In patients with non-clear cell RCC and with tumor <2cm, PN showed higher RFS rate at 60-month as compared to RFA (97.9% vs. 84.4% and 95.1% vs. 78.1%, respectively: all P≤0.02). At multi-variate analysis, ablative techniques (RFA [HR=4.03] and Cryo [HR=3.86]) were independent predictors of recurrence (all P<0.03). At competing risks analysis, recurrence rate and OCM were 7.3% and 1.3% vs. 25% and 7.2% vs. 19.9% and 19.9% for PN, RFA and Cryo, respectively., Conclusions: PN and Cryo showed similar RFS rates in patients with non-clear cell RCC and with renal mass <2cm.

Background: The aim of this study was to investigate the impact of computer aided diagnostic (CAD) system on the detection rate of prostate cancer (PCa) in a series of fusion prostate biopsy (FPB)., Methods: Two prospective transperineal FPB series (with or without CAD assistance) were analyzed and PCa detection rates compared with per-patient and per-target analyses. The χ 2 and Mann-Whitney test were used to compare categorical and continuous variables, respectively. Univariable and multivariable regression analyses were applied to identify predictors of any and clinically significant (cs) PCa detection. Subgroup analyses were performed after stratifying for PI-RADS Score and lesion location., Results: Out of 183 FPB, 89 were performed with CAD assistance. At per-patient analysis the detection rate of any PCa and of cs PCa were 56.3% and 30.6%, respectively; the aid of CAD was negligible for either any PCa or csPCa detection rates (P=0.45 and P=0.99, respectively). Conversely in a per-target analysis, CAD-assisted biopsy had significantly higher positive predictive value (PPV) for any PCa versus MRI-only group (58% vs. 37.8%, P=0.001). PI-RADS Score was the only independent predictor of any and csPCa, either in per-patient or per-target multivariable regression analysis (all P<0.029). In a subgroup per-patient analysis of anterior/transitional zone lesions, csPCa detection rate was significantly higher in the CAD cohort (54.5%vs.11.1%, respectively; P=0.028), and CAD assistance was the only predictor of csPCa detection (P=0.013)., Conclusions: CAD assistance for FPB seems to improve detection of csPCa located in anterior/transitional zone. Enhanced identification and improved contouring of lesions may justify higher diagnostic performance.

Background: Incidence of small renal masses (SRMs) has increased over the last decade: in order to reduce overtreatment of benign lesions, renal tumor biopsy (RTB) has been advocated. The primary aim of this study were to establish the rate of diagnostic biopsies and the concordance rate between RTB and surgical pathology with regard to tumor histology. The secondary aim was to identify what predictive factors are associated with an initial diagnostic biopsy., Methods: We retrospectively analyzed RTB performed in our center in patients with SRMs between 2015 and 2017. We assessed patient demographics and clinical status, lesion characteristics and procedural factors. The categorical variables were tested with the chi-square test. We used univariate and multivariate analysis to identify what factors are indicative of non-diagnostic biopsies. We used the SPSS statistics v. 23., Results: We performed a total of 100 RTBs to management 94 patients. The initial biopsy was diagnostic in 88 patients (67 malignant and 21 benign lesion). The six remaining patients had repeat biopsies, of which four were diagnostic. Complications rate was 5% prevalently local hematoma treated with surveillance. Agreement between biopsy and surgical histology was found in 94% of cases. On contingency analysis and on univariate and multivariate analysis, these factors (age, tumor size, exophytic location, and type of imaging used) were not predictive with diagnostic biopsy., Conclusions: RTB for SRMs helps establish pre-treatment diagnosis, reduce overtreatment, with a low risk of complications and high diagnostic rate. In our experience, we did not find predictive factors more likely associated with a diagnostic biopsy.

Introduction: Percutaneous treatment of persistent urinary fistula after partial nephrectomy using N-butyl-2-cyanoacrylate and gelatin sponge (Spongostan®) is an effective and relatively non-invasive procedure that should be considered when a conservative approach fails. Three successful cases of percutaneous embolization by using N-butyl-2-cyanoacrylate have been reported in the literature. To our knowledge, the use of Spongostan for the treatment of urinary fistula after partial nephrectomy has not been previously described., Case Report: We present the case of an 82-year old man who underwent percutaneous closure of a urinary fistula following partial nephrectomy by using gelatin sponge (Spongostan®) and N-butyl-2-cyanoacrylate., Conclusions: We encourage the use of this technique in selected cases. Collaboration amongst urologists and skilled interventional radiologist is strongly recommended.

Purpose: To compare the safety of on- vs off-clamp robotic partial nephrectomy (RAPN)., Methods: 302 patients with RENAL masses ≤ 10 were randomized to undergo on-clamp (150) vs off-clamp (152) RAPN (CLOCK trial-ClinicalTrials.gov NCT02287987) at seven institutions by one experienced surgeon per institution. Intra-operative data, complications, and positive surgical margins were compared., Results: Due to a relevant rate of shift from the assigned treatment, the per-protocol analysis only was considered and the data from 129 on-clamp vs 91 off-clamp RAPNs analyzed. Tumor size (off-clamp vs on-clamp, 2.2 vs 3.0 cm, p < 0.001) and RENAL score (5 vs 6, p < 0.001) significantly differed. At univariate analysis, no differences were found regarding intra-operative estimated blood loss (off- vs on-clamp, 100 vs 100 ml, p = 0.7), post-operative complications rate (19% vs 26%, p = 0.2), post-operative anemia (Hb decrease > 2.5 g/dl 26% vs 27%, p = 0.9; transfusion rate 3.4% vs 6.3%, p = 0.5; re-intervention due to bleeding 1.1% vs 4%, p = 0.4), acute kidney injury (4% vs 6%, p = 0.8), and positive surgical margins (3.5% vs 8.2%, p = 0.1). At multivariate analysis accounting for tumor diameter and complexity, considering the on-clamp group as the reference category, a significant difference was noted in the off-clamp group exclusively for blood loss (OR 0.3, 95% CI 0.09-0.52, p = 0.008)., Conclusions: The on-clamp and off-clamp approaches for RAPN showed a comparable safety profile.

Purpose: To compare the outcomes of PN to those of RN in very elderly patients treated for clinically localized renal tumor., Patients and Methods: A purpose-built multi-institutional international database (RESURGE project) was used for this retrospective analysis. Patients over 75 years old and surgically treated for a suspicious of localized renal with either PN or RN were included in this database. Surgical, renal function and oncological outcomes were analyzed. Propensity scores for the predicted probability to receive PN in each patient were estimated by logistic regression models. Cox proportional hazard models were estimated to determine the relative change in hazard associated with PN vs RN on overall mortality (OM), cancer-specific mortality (CSM) and other-cause mortality (OCM)., Results: A total of 613 patients who underwent RN were successfully matched with 613 controls who underwent PN. Higher overall complication rate was recorded in the PN group (33% vs 25%; p = 0.01). Median follow-up for the entire cohort was 35 months (interquartile range [IQR] 13-63 months). There was a significant difference between RN and PN in median decline of eGFR (39% vs 17%; p < 0.01). PN was not correlated with OM (HR = 0.71; p = 0.56), OCM (HR = 0.74; p = 0.5), and showed a protective trend for CSM (HR = 0.19; p = 0.05). PN was found to be a protective factor for surgical CKD (HR = 0.28; p < 0.01) and worsening of eGFR in patients with baseline CKD. Retrospective design represents a limitation of this analysis., Conclusions: Adoption of PN in very elderly patients with localized renal tumor does not compromise oncological outcomes, and it allows better functional preservation at mid-term (3-year) follow-up, relative to RN. Whether this functional benefit translates into a survival benefit remains to be determined.

The aim of the study was to perform a comprehensive investigation of clinical outcomes of robot-assisted partial nephrectomy (RAPN) or laparoscopic partial nephrectomy (LPN) in elderly patients presenting with a renal mass. The REnal SURGery in Elderly (RESURGE) collaborative database was queried to identify patients aged 75 or older diagnosed with cT1-2 renal mass and treated with RAPN or LPN. Study outcomes were: overall complications (OC); warm ischemia time (WIT) and 6-month estimated glomerular filtration rate (eGFR); positive surgical margins (PSM), disease recurrence (REC), cancer-specific mortality (CSM) and other-cause mortality (OCM). Descriptive statistics, Kaplan-Meier, smoothed Poisson plots and logistic and linear regression models (MVA) were used. Overall, 216 patients were included in this analysis. OC rate was 34%, most of them being of low Clavien grade. Median WIT was 17 minutes and median 6-month eGFR was 54 ml/min/1.73 m 2 . PSM rate was 5%. After a median follow-up of 20 months, the 5-year rates of REC, CSM and OCM were 4, 4 and 5%, respectively. At MVA predicting perioperative morbidity, RAPN relative to LPN (odds ratio [OR] 0.33; p <0.0001) was associated with lower OC rate. At MVA predicting functional outcomes, RAPN relative to LPN was associated with shorter WIT (estimate [EST] -4.09; p <0.0001), and with higher 6-month eGFR (EST 6.03; p = 0.01). In appropriately selected patients with small renal masses, minimally-invasive PN is associated with acceptable perioperative outcomes. The use of a robotic approach over a standard laparoscopic approach can be advantageous with respect to clinically relevant outcomes, and it should be preferred when available., Competing Interests: The authors declare no conflicts of interest., (Copyright by Polish Urological Association.)

Background: The aims of this study are to evaluate the prognostic factors of extracorporeal shockwave lithotripsy in patients with ureteric stones, and to identify which patients might directly benefit of an endoscopic treatment., Methods: We performed a prospective study from January 2013 and July 2016 on patients with single ureteric stone and undergoing extracorporeal shockwave lithotripsy (SWL). We divided patients into two groups: first group (success group) included cases resolved with SWL only, and a second group (failure group) including patients with stone not resolved by SWL and requiring an endoscopic treatment. We evaluated age, weight, height, body mass index, stone size, hydronephrosis, laterality, location, days elapsed from onset of symptoms to SWL and stone density when computed tomography was performed. In case of stone fragments >4 mm, the procedure was repeated up to a maximum of three times. SWL was considered as failed if patients had a residual stone of any size after a follow-up of 3 months or if a complication occurred., Results: 274 patients completed follow-up and were enrolled in the study. Mean age was 53.22 years (standard deviation: 13.98). SWL overall success rate was 84.3% (231 patients successfully treated with shockwaves) and failure rate was 15.7% (43 patients underwent auxiliary endoscopic procedure). At the univariate analysis, we observed a statistically significant difference for hydronephrosis (P=0.006), time elapsed from symptoms onset (P=0.013), patients' age (P=0.06) and mean stone density (0.023). In the multivariate logistic regression, patients' age (OR: 1.517), and time elapsed from obstruction to SWL (OR: 3.005) were independent predictive factors for SWL failure. Furthermore, moderate and severe hydronephrosis seemed to be independent predictive factors for SWL failure, presenting an OR of 2.451 and 4.207 respectively. High stone density resulted to be a predictive factor for SWL failure (OR: 2.293 if density was higher than 1100 Hounsfield Units)., Conclusions: We report a large series of patients undergone primary SWL for ureteric stones. Our data demonstrated the role of hydronephrosis, time elapsed from obstruction onset to treatment and stone density as independent predictive factors of SWL failure.

Competing Interests: None declared.

Purpose: We sought to identify predictive factors of the transition from off clamp to on clamp robotic partial nephrectomy following an intraoperative decision., Materials and Methods: In the multicenter, randomized, prospective CLOCK (CLamp vs Off Clamp the Kidney during robotic partial nephrectomy) trial 152 and 149 of the 301 patients with a localized renal mass were assigned to undergo off clamp and on clamp robotic partial nephrectomy, respectively. Surgery was done at a total of 7 referral institutions by 1 surgeon per institution. A localized renal mass was defined as having a R.E.N.A.L. (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, location relative to polar lines, hilar) score less than 10. Surgeons had similar experience with at least 100 previous robotic partial nephrectomies. All patients underwent a preoperative and a 6-month renal scan. The current study deals with one of the secondary end points of the trial, comparing cases finalized as clampless (off robotic partial nephrectomy group) with those which were converted (shift robotic partial nephrectomy group)., Results: Of the 152 patients randomized to off clamp 61 (40%) were shifted to clamp with a median ischemia time of 15 minutes. In the shift robotic partial nephrectomy group the masses were larger (3.5 vs 2.2 cm) and more complex (R.E.N.A.L. score 7 vs 6). A significant association with transition was found for tumor diameter (OR 1.4) and the R.E.N.A.L. score continuously (OR 1.4) and when recoded in groups, including 4-no risk (referent OR 1), 5-6-low risk (OR 1.8), 7-8-intermediate risk (OR 3.6) and 9 or greater-high risk (OR 6.6). The shift robotic partial nephrectomy group had longer operative time, higher blood loss and increased performance of 2-layer renorrhaphy. No significant differences were noted in postoperative complications or renal function after 6 months., Conclusions: The transition from off to on clamp robotic partial nephrectomy is associated with renal mass diameter and complexity. Under the specific conditions of the current trial no harm was related to this decision.

Background: In the era of minimally invasive surgery, partial adrenalectomy has certainly been underused. We aimed to report surgical technique and perioperative, pathologic, and early functional outcomes of a two-center robot-assisted partial adrenalectomy (RAPA) series., Objective: To detail surgical technique of RAPA for unilateral aldosterone-producing adenoma (UAPA), and to report perioperative and 1-yr functional outcomes., Design, Setting, and Participants: Data of 10 consecutive patients who underwent RAPA for UAPA at two centers from June 2014 to April 2017 were prospectively collected and reported., Surgical Procedure: RAPA was performed using a standardized technique with the da Vinci Si in a three-arm configuration., Measurements: Baseline and perioperative data were reported. One-year functional outcomes were assessed according to primary aldosteronism surgery outcome guidelines. A descriptive statistical analysis was performed., Results and Limitations: All cases were completed robotically. Median nodule size was 18mm (interquartile range [IQR] 16-20). Intraoperative blood loss was negligible. A single (10%) postoperative Clavien grade 2 complication occurred. Median hospital stay was 3 d (IQR 2-3). Patients became normotensive immediately after surgery (median pre- and postoperative blood pressure: 150/90 and 120/70mmHg, respectively). At both 3-mo and 1-yr functional evaluation, all patients achieved biochemical success (aldosterone level, plasmatic renin activity, and aldosterone-renin ratio within normal range). Complete clinical success was achieved in nine patients, but one required low-dose amlodipine at 6-mo evaluation. At a median follow-up of 30.5 mo (IQR 19-42), neither symptoms nor imaging recurrence was observed., Conclusions: We demonstrated feasibility and safety of RAPA for UAPA; this technique had very low risk of complications and excellent functional results. Increased availability of robotic platform and increasing robotic skills among urologists make RAPA a treatment option with potential for widespread use in urologic community., Patient Summary: Robot-assisted partial adrenalectomy is a safe, feasible, and minimally invasive surgical approach. Promising perioperative and functional outcomes suggest an increasing adoption of this technique in the near future., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To report and compare the peri-operative outcomes of patients undergoing open (ORC) and robotic-assisted radical cystectomy (RARC) for bladder cancer performed with a radiofrequency seal and cut device (Caiman®)., Materials and Methods: Data of patients undergoing ORC or RARC between January 2015 and March 2016 at 6 Italian institutions were prospectively recorded and analyzed. Thirty-and 90-day complications were stratified according to the Martin's criteria and graded according to the Clavien-Dindo classification. Data on operative time, blood loss, transfusion rate, complications, and length of stay were evaluated and compared between the ORC and RARC groups., Results: Thirty-three (66%) and 17 (34%) patients were treated with ORC and RARC, respectively. The median age was 72 (64-78) years. Overall operative time was longer in RARC compared to ORC (389 ± 80.1 vs. 242 ± 62.2 min, p < 0.001), while the estimated blood loss during cystectomy was higher after ORC (370 ± 126.8 vs. 243.3 ± 201.6 ml, p = 0.03). The transfusion rate was significantly higher in the ORC compared to RARC (24.2 vs. 5.9%, p = 0.04). Eight (19%) and 7 (16.7%) patients experienced 30- and 90-day post-operative complications, with no significant difference between ORC and RARC. Length of stay was significantly shorter in RARC group (median 7 vs. 14 days, p < 0.001)., Conclusion: Open and robot-assisted procedures were safely performed by using a new advanced bipolar seal and cut technology (Caiman®). RARC demonstrated to be superior to ORC in terms of bleeding, transfusion rates and length of hospital stay, despite longer operative time.

To outline the design and rationale of clock, a large, phase III randomized controlled trial which examines the role vascular clamping during robot-assisted partial nephrectomy (RAPN) for localized renal cancer. To be eligible for study entry, patients must have normal coagulative function, preoperative estimated glomerular filtration rate (eGFR) >60 mL/min, normal contralateral kidney and a single renal mass with RENAL Score ≤10. Eligible patients are to be randomized in a 1:1 ratio between two arms. Randomized allocation was assigned by a permuted block design, stratified by center. Allocation arm was notified by the study internet-based e-form, managed by an independent software house. Arm A=RAPN with ischemia; Arm B=RAPN without ischemia. At any moment, from randomization to the end of the procedure, the investigators could amend the indication given by randomization and shift to the alternative clamping option, detailing the timing and reasons of their decision. CLOCK is a randomized controlled trial, which addresses two questions relating to the management of localized renal cancer treated by RAPN with or without ischemia: 1) what is the impact of the surgical technique on long-term renal function; 2) what are the factors influencing the shift from one technique to the other. The study will be completed 24 months after the last enrollment.

Introduction: Inguinal lymphadenectomy is an integral part in the management of penile cancer. Video endoscopic in-guinal lymphadenectomy (VEIL) is emerging as a minimally invasive treatment to reduce postoperative complications., Materials and Methods: 62 years old man underwent glansectomy for a squamous cell carcinoma (pT1b). At the physical examination one left inguinal lymph node was detectable (cN1). The chest-abdomen-pelvis CT was negative for me-tastasis. A 10-mm optical trocar and two 5mm operating trocar were placed. The optical trocar was placed in the apex of Scarpa's triangle after a skin incision and after the creation of a subcutaneous space by blunt finger dissection. The pCO2 was 8-10mmHg. The surgical technique involved the removal of superficial lymph nodes according to the scheme described by Deseler and of the deep lymph nodes. Sparing main venous structures and closing lymphatic vessels is im-portant to reduce post operative complications. At the end of the procedure, a suction drain was placed per side., Results: Operative time was 90 minutes per side. Drains were removed on the seventh postoperative day. Hospital stay was 8 days and no postoperative complications occurred. The total number of nodes removed was 16 (8 per side) with 2 superficial positive nodes on the left side., Conclusion: ILND is burned by a high complication rate. VEIL provides a less invasive approach and a saphenous-sparing technique ensures a lower complication rate, reducing lymphorrhea, skin necrosis and wound complications (1-3). In experienced laparoscopic hands, VEIL is a safe and effective treatment., Competing Interests: Conflict of interest: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Objective: To present a novel surgical concept by using the trans-Douglas approach to perform a robotic-assisted simple prostatectomy (RASP) for high-volume benign prostate hyperplasia. This transposition from oncological surgery enables performance of a better bladder neck sparing adenomectomy with good functional results., Materials and Methods: The index patient is a 67-year-old man with a history of severe urinary flow outlet obstruction. Combination medical therapy is not effective. Transrectal ultrasound scan detected a 130-cm 3 enlarged prostate with middle lobe. The International Prostate Symptoms Score (IPSS) was 30. The patient was scheduled for a RASP with a trans-Douglas approach to preserve the bladder neck. The patient was put in 30° Trendelenburg position. Six ports were placed across the lower abdomen: four 8-mm robotic trocars and 2 assistant trocars (12 and 5 mm). The parietal peritoneum was incised at the anterior surface of the Douglas space, according to the access to the prostate described by Bocciardi. The Denonvillier fascia was opened, seminal vesicles were exposed, and above the vesicles, the prostatic capsule was incised. The adenoma, together with the middle lobe, was split by the capsule from the base to the verumontanum. The bladder neck was advanced and remodeled to the distal urethral mucosa and then closed to the prostatic capsule by a double-layer suture. The peritoneal breach was closed., Results: The operation time was 120 minutes. Blood loss was 80 cc. There was no perioperative or postoperative complication. The catheter was removed after 4 days. Uroflowmetry showed a peak flow of 30 mL/s. Pathologic examination was negative for tumor. After 60 days, the IPSS score was 8., Conclusion: Trans-Douglas-RASP is a safe and effective minimally invasive treatment for benign prostate hyperplasia. It is a novel technique to perform bladder neck sparing prostatic adenomectomy and could be 1 more field of application of robotic technology., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The treatment of ureteral strictures represents a challenge due to the variability of aetiology, site and extension of the stricture; it ranges from an end-to-end anastomosis or reimplantation into the bladder with a Boari flap or Psoas Hitch. Traditionally, these procedures have been done using an open access, but minimally invasive approaches have gained acceptance. The aim of this study is to evaluate the safety and feasibility and perioperative results of minimally invasive surgery for the treatment of ureteral stenosis with a long-term follow-up. Data of 62 laparoscopic (n = 36) and robotic (n = 26) treatments for ureteral stenosis in 9 Italian centers were reviewed. Patients were followed according to the referring center's protocol. Laparoscopic and robotic approaches were compared. All the procedures were completed successfully without open conversion. Average estimated blood loss in the two groups was 91.2 ± 71.9 cc for the laparoscopic and 47.2 ± 32.3 cc for the robotic, respectively (p = 0.004). Mean days of hospitalization were 5.9 ± 2.4 for the laparoscopic group and 7.6 ± 3.4 for the robotic group (p = 0.006). No differences were found in terms of operative time and post-operative complications. After a median follow-up of 27 months, the robotic group yielded 2 stenosis recurrence, instead the laparoscopic group shows no cases of recurrence (p = 0.091). Minimally invasive approach for ureteral stenosis is safe and feasible. Both robotic and pure laparoscopic approaches may offer good results in terms of perioperative outcomes, low incidence of complications and recurrence.

Introduction: Laparoscopic partial nephrectomy is still one of the more challenging procedures in urology. Minimizing warm ischemia time (WIT) and bleeding requires efficient intracorporeal suturing. In addition, achieving negative surgical margins requires complete excision of the tumor. Robotic-assisted partial nephrectomy (RALPN) adds the advantages offered by the "Da Vinci system" to laparoscopy, such as the 3-D vision, and the better degree of freedom of surgical instruments., Objective: The objective of this study is to report our experience with RALPN., Methods: From August 2009 to October 2012, 60 patients underwent RALPN for kidney cancer. The average age of the patients (35 female, 25 male) was 63 (range 48-80) years. Average BMI was 25 (range 21.8-29.7) kg/m2. Average tumor size was 3.2 cm (range 2-6.7 cm). All the procedures were performed by a transperitoneal approach. Ilar clamping was used in all cases: in 47 patients by one intracorporeal tourniquet for the artery and one for the vein; in three cases, ilar clamping was "en block" by Satinsky., Results: Mean operative time was 167.2 min (140-250) with a WIT of 23.8 min (15-28). The mean estimated blood loss was 260 mL (50-300). In one case, nephrectomy was necessary because the tumor involved the renal pedicle. One patient had pulmonary embolism and one urinary leakage conservatively managed.Pathologic examination revealed clear cell renal cell carcinoma in 58 patients, oncocytoma in one patient, and angiomyolipoma in one patient. All resection margins were free from tumor., Conclusions: Partial nephrectomy, facilitated by robotic technology, is more and more frequently performed as a safe and effective minimally invasive procedure.

Ureteral stent placement may be needed in patients undergoing robot-assisted radical prostatectomy (RARP) in cases of a large median lobe or previous transurethral surgery to prevent damage to the ureteral orifices. Unpredictable anatomic variants or technical difficulties in bladder neck section may necessitate intraoperative stent placement. We describe our original, simple, and feasible transurethral stent placement technique during RARP, which could be a valid option to preoperative technique.

We reviewed a large number of patients from 2000 to 2010 that underwent varicocoele correction using the retrograde sclerotization approach. Three hundred and seventy-six of them were included in the study, as they met the inclusion criteria. Mean age at the time of surgery was 32 years (SD: 6.5); 32% of them were 35 years and older. Patients were classified according to the clinical classification (GC) and Sarteschi's Doppler ultrasound classification (GS). The patients showed up at the clinic after an average time of 30 months of referred infertility related (SD: 28.54). Patients underwent pre-operative assessment with physical examination, sperm analysis and Doppler ultrasound, and again the same assessment at least 3 months after surgery. We evaluated the following parameters: sperm concentration (millions/mL, CONC), percentage motility (a+b, MOT) and the percentage of morphologically typical spermatozoa (MOR). Univariate and Multivariate analysis were performed. The research of Pearson's coefficients was performed to test the correlation between sperm parameters and age, SG, CG. Semen specimens were evaluated according to WHO 1999 criteria. Mean CONC varied from 34.5 to 47.0 millions/mL (+12.5; p < 0.001); MOT from 27.2 to 34.5% (+7.3%; p < 0.001); and MOR from 44.0 to 47.6% (+3.6%; p = 0.001). Univariable and multivariable analysis of variance related to age showed no significant difference of parameters improvement. Pearson's correlation coefficient for pre-operative and post-operative sperm MOT related to patients' age was respectively -0.11 (p < 0.001) and -0.18 (p = 0.04). No other significance was found. Usefulness of treating infertile patients affected by varicocoele is confirmed: varicocoele correction leads to significant sperm parameters improvement. There is no evidence of different improvement related to patients' age. The decline in sperm motility related to age of the patients seems to be only age-dependent: the usefulness of treating patients affected by varicocoele is not influenced by their age: treatment should also be offered to older patients., (© 2014 American Society of Andrology and European Academy of Andrology.)

Neovaginal prolapse is a rare and distressing complication after male-to-female sexual reassignment surgery. We retrospectively analysed the prevalence of partial and total neo-vaginal prolapses after sexual reassignment surgery in our institute. During the years, two different techniques have been adopted with the aim of fixing the neovaginal cylinder. In the first, two absorbable sutures are placed at the top of the penoscrotal cylinder and fixed to the Denonvilliers fascia. In the second, two additional sutures are added from the posterior/midpoint of the flap to the prerectal fascia. We enrolled 282 consecutive transsexual patients. 65 (23.04%) out of the 282 were treated with the first technique and the following 217 (76.96%) with the last technique. In the first technique, 1 case (1.53%) of total prolapse and 7 cases (10.76%) of partial prolapse were observed, while in the other 217 patients treated with the second technique only 9 cases of partial prolapse were observed (4.14%) and no cases of total prolapse. All prolapses occurred within 6 months from the procedure. In our experience, the use of 4 stitches and a more proximal positioning of the sutures to fix the penoscrotal apex with the Denonvilliers fascia guarantees a lower risk of prolapse.

Objectives: To determine whether there are differences in sperm parameters improvement after different varicocele correction techniques. To determine the role of age in sperm parameters improvement., Methods: 2 different European centers collected pre- and postoperative sperm parameters of patients undergoing varicocele correction. Among 463 evaluated patients, 367 were included. Patients were divided in procedure-related and age-related groups. Ivanissevich inguinal open surgical procedure (OS), lymphatic-sparing laparoscopic approach (LSL) and retrograde percutaneous transfemoral sclerotization (RPS) were performed. As outcome measurements sperm count (millions/mL, SC) and percentage of mobile sperms were analyzed. Univariate and multivariate regression between the defined groups; bivariate regression analysis between age and sperm count and motility., Results: Number of patients: OS 78; LSL 85; RPS 204. Mean age 30.2 (SD 6.83); postoperative SC increased from 18.2 to 30.1 (CI 95% 27.3-32.9; p < 0,001); motility from 25.6 to 32.56% (30.9-34.2; p < 0.001). OS: SC varied from 16.9 to 18.2 (p < 0.001); sperm motility from 29% to 33% (p < 0.001). LSL: SC from 15.5 to 17.2 (p < 0.001); motility from 27 to 31% (p < 0.001). RPS: SC from 18.9 to 36.2 (p < 0.001); motility from 24% to 32% (p < 0.001). Univariate and multivariate analysis confirmed the significant difference of SC variation in RPS, compared to the other groups (p < 0.001). No significance between LSL and OS (p = 0.826). No significant differences regarding motility (p = 0.8)., Conclusions: Varicocele correction is confirmed useful in improving sperm parameters; sclerotization technique leads to a better sperm improvement compared to other studied procedures; improvement in seminal parameters is not affected by age of the patients treated.

Objectives: To determine the relationship between renospermatic basal reflow at color Doppler ultrasound (CDU) evaluation and the improvement in seminal quality after sclerotization of varicocele, and the role of patients' age. No clear predictive factors are available for selecting patients who will show a better seminal improvement after varicocele correction., Methods: Between 2002 and 2008 we selected 113 patients with left unilateral varicocele, meeting the criteria of low sperm density, no endocrinological failures and no varicocele recidivating. Varicocele correction was performed using the retrograde sclerotization technique or, if not possible, the anterograde one. Patients underwent a physical examination, follicle-stimulating hormone assessment, sperm analysis (density, motility, and morphologic analysis), scrotal ultrasound, and CDU evaluation. Patients were divided into 5 groups using the CDU classification (Sarteschi). Three months postoperatively, they were assessed with the same protocol. Mean age was 32.2 years., Results: We found improvement in seminal quality among the entire population. We found no significance in differences among semen quality improvement in patients of different ages. Patients with basal renospermatic reflow at preoperative CDU evaluation (groups 3, 4, and 5) showed a better improvement in sperm density (+139%) than patients with no basal reflow (groups 1 and 2; +61%)., Conclusions: The presence of a basal reflow at preoperative CDU is a strong predictive factor of a better seminal quality improvement after varicocele correction. On the contrary, patient's age showed no significant relationship., (Copyright 2010 Elsevier Inc. All rights reserved.)