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Background: More than 4% of the global greenhouse gas emissions are generated by healthcare system. Focusing on the environmental impact of minimally invasive surgery, we assessed and compared the CO2emissions between Robot-assisted (RALP) and Laparoscopic Radical Prostatectomy (LRP). Methods: In patients prospectively enrolled, we evaluated the age, surgical and anesthesiologic time, postoperative intensive care unit and hospital stay, blood transfusion, pre- and postoperative hemoglobin and Gleason score, open conversion need, and complications (Clavien–Dindo classification). We assessed the life cycle to estimate the energy consumption for surgical procedures and hospital stays. We reported the materials, CO2produced, and fluid quantity infused and dispersed. Disposable and reusable materials and instruments were weighed and divided into metal, plastic, and composite fibers. The CO2consumption for disposal and decontamination was also evaluated. Results: Of the 223 patients investigated, 119 and 104 patients underwent RALP and LRP, respectively. The two groups were comparable as regards age and preoperative Gleason score. The laparoscopic and robotic instruments weighed 1733 g and 1737 g, respectively. The CO2emissions due to instrumentation were higher in the laparoscopic group, with the majority coming from plastic and composite fiber components. The CO2emissions for metal components were higher in the robotic group. The robot functioned at 3.5 kW/h, producing 4 kg/h of CO2. The laparoscopic column operated at 600 W/h, emitting ~1 kg/h of CO2. The operating room operated at 3,0 kW/h. The operating time was longer in the laparoscopic group, resulting in higher CO2emissions. CO2emissions from hospital room energy consumption were lower in the robot-assisted group. The total CO2emissions were ~47 kg and ~60 kg per procedure in the robot-assisted and laparoscopic groups, respectively. Conclusions: RALP generates substantially less CO2than LRP owing to the use of more reusable surgical supplies, shorter operative time and hospital stay.

With the exception of the FDA-approved valrubicin and pembrolizumab, there are no standard second-line treaments for BCG-unresponsive high-risk non-muscle invasive bladder cancer (NMIBC). To provide a systematic review of the novel intravesically administered therapeutic agents for the salvage treatment of BCG-unresponsive NMIBC. Online search of the PubMed, EMBASE and Web of Science databases was performed. The endpoints of this review were to evaluate the efficacy of the agents in terms of complete response rates (CR) and durability of CR, overall survival, recurrence-free survival and cancer-specific survival and to report on their toxicity profile. A search on Clinicaltrials.gov was performed to identify ongoing clinical trials. 14 studies were included in this review. The critical clinical need for the development of an effective, safe and durable intravesical drug for the salvage treatment of high-risk NMIBC seems to be met mainly by intravesical gene therapy; in fact, data support the FDA-approved nadofaragene firadenovec as a potentially important therapeutic advancement in this context. Promising results are also being obtained by the combination of N-803/BCG and by innovative drug delivery systems. Considering the plethora of novel intravesical treatments that have completed phase II evaluation, one can reasonably expect that clinicians will soon have at their disposal new agents and treatment options for BCG-unresponsive NMIBC. In the near future, it will be up to the urologist to identify, for each specific patient, the right agent to use, based on safety, results and cost-effectiveness.

Objective: Pudendal Nerve Entrapment (PNE) may determine chronic pelvic pain associated with symptoms related to its innervation area. This study aimed to present the technique and report the outcomes of the first series of robot-assisted pudendal nerve release (RPNR). Patients and methods: 32 patients, who were treated with RPNR in our centre between January 2016 and July 2021, were recruited. Following the medial umbilical ligament identification, the space between this ligament and the ipsilateral external iliac pedicle is progressively dissected to identify the obturator nerve. The dissection medial to this nerve identifies the obturator vein and the arcus tendinous of the levator ani, which is cranially inserted into the ischial spine. Following the cold incision of the coccygeous muscle at the level of the spine, the sacrospinous ligament is identified and incised. The pudendal trunk (vessels and nerve) is visualized, freed from the ischial spine and medially transposed. Results: The Median duration of symptoms was 7 (5, 5–9) years. The median operative time was 74 (65–83) minutes. The median length of stay was 1 (1–2) days. There was only a minor complication. At 3 and 6 months after surgery, a statistically significant pain reduction has been encountered. Furthermore, the Pearson correlation coefficient reported a negative relationship between the duration of pain and the improvement in NPRS score, − 0.81 (p= 0.01). Conclusions: RPNR is a safe and effective approach for the pain resolution caused by PNE. Timely nerve decompression is suggested to enhance outcomes.

Kidney-sparing surgery (KSS) for upper urinary tract urothelial carcinoma (UTUC) is a promising alternative to radical nephroureterectomy, especially for low-risk cases. However, due to the established risk of ipsilateral UTUC recurrence caused by the implantation of floating neoplastic cells after endoscopic resection, adjuvant endocavitary (endoureteral) instillations have been proposed. Instillation therapy may be also used as primary treatment for UTUC. The two most studied drugs that have been evaluated in both the adjuvant and primary setting of endocavitary instillation are mitomycin C and Bacillus Calmette-Guerin. The current paper provides an overview of the endocavitary treatments for UTUC, focusing on methods of administration, novel formulations, oncologic outcomes (in terms of endocavitary recurrence and progression), as well as on complications. In particular, the role of UGN-101 as a primary chemoablative treatment of primary noninvasive, endoscopically unresectable, low-grade, UTUC has been analysed. The drug achieved a complete response rate of 58% after the induction cycle, with a durable response independently of the maintenance cycle. The cumulative experience on the role of UUT instillation therapy appears encouraging; however, no definitive conclusions can be drawn about its therapeutic benefit. Given the current state of the art, any decision to administer adjuvant endoureteral therapy for UTUC should be carefully weighed against the potential adverse events. Nevertheless, newer investigations that improve visualization during ureteroscopy, genomic characterization, novel drugs and innovative strategies of improved drug delivery are under evaluation. The landscape of KSS for the treatment of the UTUC is evolving and seems promising.

For many decades, extended pelvic lymph node dissection has been an integral part during radical cystectomy for patients with muscle invasive bladder cancer. This practice was based on large retrospective meta-analyses suggesting an oncologic benefit to an extended dissection. This mini review and meta-analysis includes the two available randomized trials in the current literature. Therefore, it can be considered as the strongest level of evidence regarding the prognostic benefit of an extended pelvic lymphadenectomy. Based on current randomized data, standard pelvic lymph node dissection up to the level of iliac bifurcation is sufficient, and extension of the dissection above this level does not provide any additional oncologic benefit.

Introduction:This study evaluated the prevalence of transurethral catheter self-removal in critically-ill COVID-19 non-sedated adult patients compared with non-COVID-19 controls.Methods:COVID-19 patients who self-extracted transurethral or suprapubic catheters needing a urological intervention were prospectively included (group A). Demographic data, medical and nursing records, comorbidities and nervous system symptoms were evaluated. Agitation, anxiety and delirium were assessed by the Richmond Agitation and Sedation Scale (RASS). The control group B were non-COVID-19 patients who self-extracted transurethral/suprapubic catheter in a urology unit (subgroup B1) and geriatric unit (subgroup B2), requiring a urological intervention in the same period.Results:37 men and 11 women were enrolled in group A. Mean RASS score was 3.1 ± 1.8. There were 5 patients in subgroup B1 and 11 in subgroup B2. Chronic comorbidities were more frequent in group B than the COVID-19 group (P<0.01). COVID-19 patients had a significant difference in RASS score (P<0.006) and catheter self-extraction events (P<0.001). Complications caused by traumatic catheter extractions (severe urethrorrhagia, longer hospital stay) were greater in COVID-19 patients.Conclusion:This is the first study focusing on the prevalence and complications of catheter self-removal in COVID-19 patients. An increased prevalence of urological complications due to agitation and delirium related to COVID-19 has been demonstrated—the neurological sequelae of COVID-19 must be considered during hospitalisation.

Background: Identifying predictors of positive surgical margins (PSM) and biochemical recurrence (BCR) after radical prostatectomy (RP) may assist clinicians in formulating prognosis. Aim of the study was to report the midterm oncologic outcomes, to identify the risk factors for PSM and BCR and assess the impact of the PSM on BCR-free survival following robot-assisted laparoscopic radical prostatectomy (RALP). Methods: From 2005 to 2010, 1679 consecutive patients underwent transperitoneal RALP. Data was retrospectively collected by an independent statistical company and analyzed in 2014. Median postoperative follow-up was 33.5 mo. BCR was defined as any detectable serum prostate-specific antigen (PSA) ≥ 0.2 ng/mL in two consecutive measurements. BCR-free survival was estimated using the Kaplan–Meier method. Univariate and multivariate analysis were applied to identify risk factors for PSM and BCR. Results: In pN0/pNx cancers, pathologic stage was pT2 in 1186 patients (71.8%), pT3 in 455 patients (27.6%), and pT4 in 11 patients (0.6%). PSM rate was 17.4% and 36.9% of pT2 and pT3 cancers, respectively. Pathologic Gleason score was &lt; 7, = 7 and > 7 in 42.1%, 53% and 4.9% of the patients, respectively. Overall BCR-free survival was 73.1% at 5 years; the 5-year BCR-free survival was 87.9% for pT2 with negative surgical margins. PSA, Gleason score (both bioptic and pathologic), pathologic stage (pT) and surgeon's volume were significant independent predictors of PSM. PSA, pathologic Gleason score, pT and PSM were significant independent predictors of BCR-free survival. Seminal vesicle-sparing, nerve-sparing approach and the extent of nerve-sparing (intra vs interfascial dissection) did not negatively affect margin status or BCR rates. Conclusions: PSMs are a predictor of BCR. Being the only modifiable factor influencing the PSM rate, surgical experience is confirmed as a key factor for high-quality oncologic outcomes.

Post-prostatectomy urinary incontinence is an adverse event leading to significant distress. Our aim was to evaluate immediate urinary continence (UC) recovery in a single-surgeon prospective randomized comparative study between the traditional robot-assisted laparoscopic radical prostatectomy (TR-RALP) and the Retzius-sparing RALP (RS-RALP), for the treatment of the clinically localized prostate cancer (PCa). 102 consecutive PCa patients were prospectively randomized to TR-RALP (57) or RS-RALP (45). Postoperative continence was defined as patient-reported absence of leakage or use of 0 pads/day. The immediate continence rate and 95% confidence interval (CI 95%) were calculated for each treatment. Univariable and multivariate logistic regressions were used to assess predictors of immediate continence following RALP. Continence rates from 1 to 6 months were calculated by Kaplan–Meier curves; log-rank test was used for the curve comparison. Two analyses were performed, considering a per-protocol (PP) population regarding all randomized patients that received nerve-sparing RALP and an Intention-To-Treat (ITT) population regarding all randomized patients that received RALP. In the PP analysis, the rates of immediate continence were 12/40 (30%) (CI 95% 17–47%) for the TR-RALP and 20/39 (51.3%) (CI 95% 35–68%) for the RS-RALP (p= 0.05). In the ITT analysis, the corresponding rates were 12/57 (21%) (CI 95% 11–34%) for the TR-RALP and 23/45 (51%) (CI 95% 36–66%) for the RS-RALP (p= 0.001). Median time to continence was 21 days for the TR-RALP and 1 day for RS-RALP, respectively (p= 0.02). The relative Kaplan–Meier curves regarding continence resulted statistically different when compared with the log rank test (p= 0.02). In the multivariate analysis, lower age and the Retzius-sparing approach were significantly associated to earlier continence recovery. The Retzius-sparing approach significantly reduces time to continence following RALP. Further studies are required to confirm the reproducibility of our results and investigate the role of the RS-RALP as an additional “protective” factor for postoperative continence in the elderly population.

Airseal represents a new generation of valveless and barrier-free surgical trocars that enable a stable pneumoperitoneum with continuous smoke evacuation and carbon dioxide (CO2) recirculation during surgery. The aim of the current study was to evaluate the potential advantages of the Airseal compared to a standard CO2insufflator in the field of robotic partial nephrectomy (RPN). Between October 2012 and April 2015, two cohorts of 122 consecutive patients with clinically localized renal cell carcinoma underwent RPN by a single surgeon, with the use of a standard CO2pressure insufflator (Group A, 55 patients) or Airseal (Group B, 67 patients) and were prospectively compared. The two groups were similar in baseline, preoperative characteristics. The mean dimension of the lesion, as evaluated by contrast-enhanced CT scan, was 30 (median 28; IQR 2) and 39 mm (median 40; IQR 2) for Groups A and B, respectively (p< 0.05). The complexity of the treated tumors was similar, as indicated by the mean RENAL nephrometry score. Positive surgical margins rate was similar in both groups (3.6 vs 4.5 %, p= 0.8) as well as the need for postoperative blood transfusion (9.1 vs 4.5 %, p= 0.3) and the development of postoperative acute kidney injury (16.4 vs 10.4 %, p= 0.3). Mean operative time and warm ischemia time were significantly shorter in Group B. Moreover, a significant increase in the cases performed as “zero ischemia” was observed in Group B (7.3 vs 30 %, p< 0.01). This is the first study comparing the Airseal with a standard CO2insufflator system in the field of the RPN. The preliminary outcomes in terms of overall operative time, warm ischemia time and cases performed as “zero ischemia” are better with respect to standard insufflators. The feasibility, safety and efficacy of combining laser tumor enucleation with the valve-free insufflation systems should be evaluated.

The synthesis and characterization of the tetrathiomolybdatorhodium(I) monoanionic complexes [L2Rh(μ-S)2MoS2]−(L = CO (3), P(OPh)3(4), P(O-o-Tol)3(P(o-CH3C6H4)3; 5), P(OMe)3(6), P(OEt)3(7), P(O-i-Pr)3(8); L2= COD (1,5-cyclooctadiene; 2), cis-dppen (cis-Ph2PCHCHPPh2; 9), dppe (Ph2PCH2CH2PPh2; 10), dppb (Ph2P(CH2)4PPh2; 11)) is presented. The complex 2(NEt4+salt) was characterized by X-ray diffraction analysis. A detailed DFT study of the electronic structures of 2–4and 6–8has revealed the existence of extended electron delocalization over the four-membered Rh(μ-S)2Mo ring and hence the possibility of electronic communication between the metal centers. The electronic spectra were studied with TDDFT calculations, and the main absorption band in the visible region was assigned to ν(Rh→Mo) electron transfer transition, which is actually a HOMO–LUMO transition. The ν(Rh→Mo) transition was found to correlate linearly both with Tolman’s electronic parameter of the phosphite ligands and the calculated HOMO–LUMO gap of the complexes, rendering it a well-defined ligand electronic parameter, which describes the net donating ability of monodentate and bidentate ligands (CO, COD, phosphites, diphosphines). The study of the variation of Δδ(31P) and 1J(Rh–P) of the phosphite complexes with respect to the QALE model electronic parameters χd, πp, and Earhas succeeded in the assessment of the σ and π effects on these NMR spectral parameters.

Introduction The aim of this study was to investigate the effect of three major environmental variables (temperature, humidity, air pressure) on the probability of onset of renal colic (RC) in a large cohort of patients in Rome.Methods The records of 2682 patients discharged by the Emergency Department (ED) of the University Hospital of Tor Vergata, Rome, from January 2007 to November 2009 with the main diagnosis of reno-ureteric colic associated with a proven calculus, were retrospectively evaluated. The climatic parameters (average humidity, average air pressure and daily minimum, medium and maximum temperature) were recorded in a second, independent database. RC events were grouped by weeks and months and analysed for a total period of 35 months and 153 weeks.Results Two thousand five hundred and fourteen patients out of 2682 had a proven urolithiasis. RC events were observed more likely in the warmer months, from the second half of June to the first half of September, compared with the colder months. Although the weekly model showed a positive correlation (R2= 0.134) between the average increase of environmental temperature and RC incidence, the monthly model was much more convincing (R2= 0.373). We found no statistically significant correlation between humidity and air pressure and the incidence of RC.Conclusions This study demonstrates that an increase in average environmental temperature is associated with a significant increase in the number of episodes of RC seen in the ED at both weekly and monthly time intervals. The average humidity and air pressure were not found to be associated with an increased incidence of RC.

Laparoscopic nephrectomy (LN) in end-stage autosomic-dominant polycystic kidney disease (ADPKD) requires a large abdominal incision for the specimen extraction. The objective of this study was to describe our technique of LN for end-stage ADPKD followed by morcellation (LNM) of the specimen and extraction through a minimal abdominal incision. The medical records of 19 consecutive patients who underwent pretransplant LNM between 2008 and 2011 by a single experienced laparoscopic surgeon were analyzed. Morcellation was performed with the Gynecare Morcellex™ Tissue morcellator, Ethicon. All cases but one were completed laparoscopically. Mean specimen weight was 1,026.8 g. Mean duration of the procedure, estimated blood loss, and hospital stay were 131.3 min, 52.1 ml, and 7.9 days, respectively. Specimens were extracted through a 12-mm trocar in 10/18 patients and through a 3-cm incision in 9/18 cases. Postoperatively, three complications were observed (Clavien grades II, I, and II). The only case of incisional hernia was observed in the converted procedure. Major limitation of the study is its retrospective design. In our preliminary series and in the hands of a very experienced laparoscopist, LNM for ADPKD appears as a modern, mini-invasive, and safe technique. Specimen’s extraction through a small abdominal incision reduces postoperative pain and incisional hernias and guarantees the final cosmetic result of laparoscopy. The reduced overall morbidity could reduce the period between nephrectomy and transplantation.

This study aimed to compare the pentafecta rates between laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RALP) and to identify prognostic factors predicting the pentafecta for each technique.This prospective comparative study enrolled 248 consecutive male patients 70 years of age or younger with clinically localized prostate cancer [PCa: age ≤70 years, prostate-specific antigen (PSA) ≤10 ng/ml, biopsy Gleason score ≤7] who were fully continent, potent, and candidates for bilateral nerve-sparing (BNS) LRP or RALP. The pentafecta rates between LRP and RALP were compared. A logistic regression model was created to evaluate independent factors for achieving pentafecta.In the final analysis, 91 LRP and 136 RALP patients were evaluated. The median follow-up period was 21 months for the 91 LRP patients and 18 months for the 136 RALP patients (p= 0.07). Of the 227 patients, 87 reached pentafecta [25 LRP patients (27.5 %) vs 62 RALP patients (45.6 %), p= 0.006]. Of the 140 patients who failed pentafecta, 90 (64.3 %) missed a single parameter, and the difference between the groups was significant (80 % LRP vs 53.3 % RALP, p= 0.007). Lower age, lower pathologic stage, and RALP are significantly associated with pentafecta as independent factors. For the pT3 disease, the two techniques did not differ significantly.Patients submitted to BNS RP have low possibilities of achieving pentafecta. Use of the robotic platform by a single surgeon significantly enhances the possibility of achieving pentafecta independently of age and pathologic stage. Potency was the most difficult outcome to reach after surgery, and it was the main factor leading to pentafecta failure. LRP and RALP provide equivalent pentafecta rates for the pT3 disease and similar “tetrafecta” outcomes when potency recovery is not included among the postoperative expectations of the patient.

Various energy sources are available for tissue dissection and vessel sealing in laparoscopic colorectal surgery. The electrothermal bipolar vessel sealing system (EBVS) and ultrasonic energy (UE) devices are widely used to provide hemostatic dissection in laparoscopic procedures. Nevertheless, available evidenced-based data comparing their operative results still are scarce. This study conducted a metaanalysis of controlled clinical trials comparing EBVS and UE in terms of operative time and intraoperative blood losses in laparoscopic colorectal surgeryThe MEDLINE and Embase databases were searched using medical subject headings and free text words. All randomized controlled trials (RCTs) and controlled clinical trials using EBVS and UE in laparoscopic colorectal surgery were considered for inclusion in the study. Random effects models were used in case of heterogeneity to obtain summary statistics for the overall difference in operating time and blood loss between instruments.Four studies comparing EBVS with UE for 397 patients (200 EBVS vs. 197 UE patients) were included in the study. The findings showed that EBVS was associated with a significantly shorter operative time and less intraoperative blood loss than UE (p< 0.05).The metaanalysis indicated that EBVS is associated with a shorter operative time and less blood loss than UE in laparoscopic colorectal surgery. However, these results should be interpreted with caution due to the high heterogeneity of the included trials and the limited number of studies with a high level of evidence. More adequately designed RCTs with a larger number of patients are required to confirm the results of this metaanalysis.

Iatrogenic pelvic pseudoaneurysm with concomitant arteriovenous fistula has been described as a rare and challenging complication, which may occur during transurethral resection of the prostate. We provide the first report of this complication after holmium laser enucleation of the prostate for the treatment of benign prostatic hyperplasia. The attempt to control the bleeding by conversion to open surgery and placement of haemostatic stitches into the prostatic fossa failed. Angiography with superselective arterial embolization proved to be a modern, quick, safe, and efficient treatment of this uncommon complication.