Search

There are sex differences in vulnerability to Coronavirus disease 2019 (COVID-19). The coronavirus S protein mediates viral entry into target cells employing the host cellular serine protease TMPRSS2 for S-protein priming. The TMPRSS2 gene expression is responsive to androgen stimulation and it could partially explain sex differences. We hypothesized that men chronically exposed to 5-alpha reductase inhibitors (5ARIs) for benign prostate hyperplasia (BPH) have a lower risk of hospitalization for COVID-19.This is a population-based case-control study on consecutive patients positive for SARS-CoV-2 virus who required hospitalization for COVID-19 (cases), age-matched to beneficiaries of the Lombardy Regional Health Service (controls). Data were collected by two high-volume COVID-19 regional centers of Lombardy (Italy). The primary outcome was to compare the prevalence of patients chronically exposed to 5ARIs, who required hospitalization for COVID-19, with the one of controls.Overall, 943 males were enrolled; 45 (4.77%) were exposed to 5ARI. COVID-19 patients aged55 years under 5ARI treatment were significantly less than expected on the basis of the prevalence of 5ARI treatment among age-matched controls (5.57 vs. 8.14%; P=0.0083, 95% CI: 0.75-3.97%). This disproportion was higher for men aged65 (7.14 vs. 12.31%; P=0.0001, 95% CI: 2.83-6.97%). Eighteen 5ARIs-patients died; the mean age of men who died was higher than those who did not: 75.98±9.29 vs. 64.78±13.57 (P0.001). Cox-regression and multivariable models did not show correlation between 5ARIs exposure and protection against intensive care unit admission/death.Men exposed to 5ARIs might be less vulnerable to severe COVID-19, supporting its use in disease prophylaxis.

Purpose: This paper explores the feasibility of a new therapy for the treatment of hypospadias patients. Hypospadias is a very common congenital malformation of male genitals, with very high rate of recurrences after surgery. The field of regenerative medicine, which offers innovative solutions for many pathologies, still does not offer reliable solution for this pathology. Here, we propose quality, safety, and clinical feasibility assessment for an oral mucosa advanced therapy medicinal product (ATMP) grown on a biocompatible scaffold for a clinical study on urethral reconstruction of hypospadias patients. Methods: Urethral and oral mucosal epithelia from donor biopsies were cultivated between two fibrin layers, under clinical-grade conditions for cell and tissue characterization and comparison, aimed at tissue engineering. In addition, single-clone analyses were performed to analyze gene expression profiles of the two epithelia by microarray technology. Results: Oral mucosa appeared suitable for urethral reconstruction. The resulting ATMP was proven to maintain stem cells and regenerative potency. The preclinical safety studies were performed on human tissues to assess abnormalities and tumorigenicity, and confirmed the safety of the ATMP. Finally, the patient selection and the clinical protocol for the upcoming clinical trial were defined. Conclusions: Against this backdrop, in this paper, we are proposing a new reproducible and reliable ATMP for the treatment of hypospadias.

Introduction: Repair of post-TURP sphincter urethral strictures represents challenging problem, due to the risk of urinary incontinence after the repair. We described a surgical technique we use to repair these strictures preserving urinary continence in patients with incompetent bladder neck. Materials and methods: An observational, retrospective, study was conducted to include patients with post-TURP urethral strictures in the area of distal sphincter. We included only patients with complete clinical data and follow-up who previously underwent TURP or HOLEP or TUIP, and subsequently developed proximal bulbar urethral strictures close to the membranous urethra and the related distal urethral sphincter. Patients were included, if they were fully continent after TURP or other procedures to treat BPH. The primary outcome of the study was treatment failure, defined as the need for any post-operative instrumentation. Secondary outcome was post-urethroplasty urinary continence. Patients showing stricture recurrence or post-operative incontinence were classified as failure. Results: Overall, 69 patients were included in the study. Median patient’s age was 67years; median stricture length was 4cm. Thirty-tree patients (47.8%) underwent previous urethrotomy. Median follow-up was 52months. Out of 69 patients, 55 (79.7%) were classified as success and 14 (20.3%) as failure. Out of the whole cohort, thus, 11/69 (16%) have a risk of recurrent strictures and 3/69 (4.3%) have incontinence. Conclusions: The use of modified ventral onlay graft urethroplasty, using particular non-aggressive steps, is a suitable surgical technique for repair of sphincter urethral stricture in patients who underwent BPH transurethral surgery, using different procedures (TURP, HOLEP, TUIP).

Background Minimally invasive treatment of benign ureteral strictures is still challenging because of its technical complexity. In this context, robot-assisted surgery may overcome the limits of the laparoscopic approach. Objective To evaluate outcomes for robotic ureteral repair in a multi-institutional cohort of patients treated for ureteropelvic junction obstruction and ureteral stricture (US) at four tertiary referral centres. Design, setting, and participants This retrospective study reports data for 183 patients treated with standard robot-assisted pyeloplasty (PYP) and robotic uretero-ureterostomy (UUY) at four high-volume centres from January 2006 to September 2014. Surgical procedure Robotic PYP and robot-assisted UUY were performed according to previously reported surgical techniques. Outcome measurements and statistical analysis Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. Results and limitations No robot-assisted UUY cases required surgical conversion, while 2.8% of PYP cases were not completed robotically. The median operative time was 120 and 150min for robot-assisted PYP and robot-assisted UUY, respectively. No intraoperative complications were reported. The overall complication rate for all procedures was 11% ( n =20) and complications were mostly of low grade. The high-grade complication rate was 2.2% ( n =4). At median follow-up of 24 mo, the overall success rate was >90% for both procedures. The study limitations include its retrospective nature and the heterogeneity of the study population. Conclusions Robotic surgery for benign US is safe and effective, with limited risk of high-grade complications and good intermediate-term results. Patient summary In this study we review the use of robotic surgery at four different tertiary care centres in the treatment of patients affected by benign ureteral strictures. Our results demonstrate that robotic surgery is a safe alternative to the standard open approach in the treatment of ureteral strictures.

Background The ventral oral mucosal onlay graft is suggested in proximal bulbar strictures where the thick spongiosum provides excellent support to the graft. Some technical steps used in this technique are currently under debate in the literature. Objective To describe the surgical steps of this urethroplasty and investigate predictive factors of success using a multivariable logistic regression analysis. Design, setting, and participants This is a descriptive observational retrospective study of 214 patients who underwent urethroplasty for bulbar urethral strictures between May 1999 and November 2010 in a single high-volume center. Study inclusion criteria were patients presenting nontraumatic bulbar urethral strictures ranging from 1.3cm to 6.8cm in length. Exclusion criteria were traumatic strictures, panurethral strictures, lichen sclerosus, and failed hypospadias repair. Surgical procedure The oral graft was placed on the ventral bulbar urethral surface and pushed as proximally as possible using dedicated instruments and surgical techniques. Outcome measurements and statistical analysis The primary outcome measure was the objective result, defined as the absence of stricture recurrence at follow-up. The objective outcome was considered a failure when any postoperative instrumentation was needed. Multivariable logistic regression analysis was developed. All tests were two sided with a significance level set at 0.05. Results and limitations Median follow-up was 54 mo. Of the 214 patients, 183 (85.5%) were successful and 31 (14.5%) were failures. The preoperative maximum flow rate (Q max ) was a significant predictor of surgical outcome (odds ratio: 1.352; p = 0.001). Age, length, and type of stenosis, and previous treatment were not significant predictors of surgical outcome (all p > 0.05). The limitation of our survey is the absence of a subjective evaluation or the use of specific tools, such as a questionnaire. Conclusions Ventral oral graft urethroplasty represents a valid option in nontraumatic bulbar strictures. Preoperative Q max may be predictive of urethroplasty failure.

Background Repair of penile urethral strictures is a challenging problem for which different techniques have been suggested. Objective To describe a new surgical technique for one-stage penile urethroplasty using an oral graft and glue, and to assess its safety and efficacy. Design, setting, and participants A retrospective review of medical records for patients who underwent one-stage penile urethroplasty using oral mucosa and glue from February 2013 to October 2014 was performed. Surgical procedure The penile urethra was opened and the urethral plate was incised to create a wide window within which the oral graft was pasted with glue. The urethra was sutured over the catheter. Outcome measurements and statistical analysis Clinical data were collected in a database. Intraoperative and postoperative complications and outcomes were assessed. A descriptive statistical analysis was performed. Results and limitations Fourteen patients were included in the study. Median operative time was 60min. The median postoperative stay was 3 d. Three intraoperative and one postoperative complication occurred. In all patients, voiding cystourethrography 2 wk after surgery failed to show urethral fistula or sacculation. No patients complained of penile chordee or sexual dysfunction after surgery. Median follow-up was 16 mo. Among the 14 patients, 12 (85.7%) procedures were successful and two (14.3%) were failures. Study limitations include the small sample size and short follow-up. Conclusions An in vitro study and a one-stage reconstruction of penile urethral strictures with an oral mucosa graft and glue showed that the procedure is safe and efficient, but further studies including larger series of patients and longer follow-up are required. Patient summary We report on the repair of penile urethral stricture using one-stage urethroplasty with oral mucosa and glue. This new technique was safe and effective, with limited complications and satisfactory outcomes. We plan to increase the use of this technique in the future.

Introduction Data regarding long-term oncologic outcomes of laparoscopic renal cryoablation (LRC) as first treatment for small renal masses (SRMs) are lacking. We hypothesized that LRC might provide an effective long-term cancer control in patients with a single cT1a SRM without a previous history of renal cell carcinoma (RCC). Materials and methods The study design was a retrospective analysis of 174 consecutive patients who received LRC as first treatment for a single computed tomography or magnetic resonance imaging contrast-enhancing cT1a SRM between 2000 and 2013. Patients with a previous history of RCC were excluded. Treatment failure was evaluated 1 day after surgery. Local recurrence, metachronous SRM, systemic progression, disease relapse, cancer-specific mortality, and all-cause mortality were evaluated 10 years after surgery. Kaplan-Meier plots were used to depict outcome-free survival rate. Results Median patient age was 66 years. Median tumor size was 20 mm. Median follow-up was 48 months. Among patients with biopsy-proven RCC (63%, n = 109), the treatment failure–free rate was 98%. The 10-year recurrence-free survival rate was 95% and the 10-year metachronous SRM–free survival rate was 87%. The 10-year systemic progression–free survival rate was 100% and the 10-year disease relapse–free survival rate was 81%. The cancer-specific mortality–free survival rate was 100%, and the all-cause mortality–free survival rate was 61%. Conclusions LRC provides safe long-term cancer control in patients newly diagnosed with a single cT1a SRM. Treatment failure and local recurrence are uncommon. Systemic progression–free survival and cancer-specific–free survival are optimal.

Background Minimally invasive partial nephrectomy (MIPN) and laparoscopic renal cryoablation (LRC) are two treatment options increasingly used for small renal masses. Objective To compare perioperative, oncologic, and functional outcomes after MIPN and LRC. Design, setting, and participants We included 372 consecutive patients newly diagnosed with a single small renal mass and treated with either MIPN or LRC at a single institution. Intervention MIPN and LRC. Outcome measurements and statistical analysis Regression models were used to evaluate the impact of surgical treatment (MIPN vs LRC) on perioperative, oncologic, and functional outcomes. Results and limitations Overall, 206 patients (55%) underwent MIPN and 166 (45%) were treated with LRC. In multivariate analysis, the rate of postoperative complications was significantly lower in the MIPN compared to the LRC group (20% vs 28%; adjusted difference –11%; p =0.02) after adjusting for age at surgery, American Society of Anesthesiologists score (1 vs 2 vs 3), and tumor size. The median follow-up was similar in the two groups (43 and 39 mo for MIPN and LRC, respectively). In univariate Cox regression analysis, treatment type was not significantly associated with disease-free survival (hazard ratio 1.06, 95% confidence interval [CI] 0.45–2.52; p =0.9). The disease-free survival rate at 5 yr was 92% in MIPN and 93% in LRC patients. In multivariate linear regression analysis, LRC was significantly associated with a higher estimated glomerular filtration rate (eGFR) at 6 mo compared to MIPN (coefficient 4.68, 95% CI 0.06–9.30; p =0.047) after adjusting for age at surgery, tumor size, and preoperative eGFR. There was no significant association between surgical treatment and postoperative eGFR at 3 yr after surgery (coefficient –2.36, 95% CI –7.55 to 2.83; p =0.4). Limitations include the retrospective study design and selection bias. Conclusions MIPN and LRC provided similar cancer control and comparable renal function at intermediate-term follow-up. Both surgical techniques emerged as viable treatment options for patient newly diagnosed with a single small renal mass. Further multi-institutional studies with longer follow-up and nephrometry scores are needed to corroborate our findings. Patient summary In patients newly diagnosed with a single small renal mass, minimally invasive partial nephrectomy and laparoscopic renal cryoablation provided similar cancer control and comparable renal function at intermediate-term follow-up.

Introduction and Objectives: Seminal and prostate sparing cystectomy represents an alternative in young patients where preservation of urinary continence and sexual potency are fundamental. We present our preliminary experience with this procedure performed laparoscopically. Methods: Three men-53, 58 and 49 years old-suffering from recurrent superficial transitional cell carcinoma of the bladder, resistant to intravesical therapy, underwent laparoscopic nerve, prostate and seminal vesical sparing cystectomy. One week before surgery, TURP was performed to create an adequate prostate capsule. After pneumoperitoneum induction and the positioning of five/six trocars, the ureters were clipped and transected, the vas deferens and seminal vescicles were identified and prepared for the conservative procedure. Cystectomy was performed with vascular pedicles transection by EndoGia. The reconstruction of the bladder was obtained through a 7 cm longitudinal periumbilical incision using 60 cm of ileus and an orthotopic neobladder realized outside the abdomen. The ileocapsular anastomosis was performed laparoscopically after the re-induction of pneumoperitoneum. Results: No major complications were recorded. The surgical time was respectively 480, 450 and 410 min. Blood loss was 150, 220 and 300 ml respectively. Drains were removed after 4 days (two patients) and 6 days (one patient) and the patients were discharged after 8 days (two patients) and 9 days. The patients were fully continent after catheter removal with normal uroflowmetry. At the three month follow-up they had a normal sexual function, equivalent to the preoperative assessment. The patients reported adequate erections for intercourse. Conclusions: Laparoscopic prostate and seminal cystectomy with orthotopic ileal neobladder is a safe, feasible, reproducible surgical technique. In patients who desire to preserve sexual functioning and obtain complete continence it represents a valid alternative to classic radical cystectomy. (C) 2003 Elsevier B.V. All rights reserved.

Purpose: We performed a head-to-head comparison of the PHI (Prostate Health Index) and PCA3. Materials and Methods: We evaluated PHI and PCA3 performance in 211 patients undergoing initial (116) or repeat (95) prostate biopsy. Multivariable logistic regression analysis was done using the AUC to test the accuracy of PHI and PCA3 for predicting prostate cancer in the overall population and in each setting. Decision curve analysis was used to compare the clinical benefit of different models. Results: Overall, the AUC of the PHI (0.70) was significantly higher than the AUC of PCA3 (0.59), total prostate specific antigen (0.56) and free-to-total prostate specific antigen (0.60) (p = 0.043, 0.002 and 0.037, respectively). PHI was more accurate than PCA3 for predicting prostate cancer in the initial setting (AUC 0.69 vs 0.57) and in the repeat setting (AUC 0.72 vs 0.63), although no statistically significant difference was observed. Including PCA3 in the base multivariable model (prostate specific antigen plus free-to-total prostate specific antigen plus prostate volume) did not increase predictive accuracy in either setting (AUC 0.79 vs 0.80 and 0.75 vs 0.76, respectively). Conversely, including PHI in the base multivariable model improved predictive accuracy by 5% (AUC 0.79 to 0.84) and 6% (AUC 0.75 to 0.81) in the initial and repeat prostate biopsy settings, respectively. On decision curve analysis the highest net benefit was observed when PHI was added to the base multivariable model. Conclusions: PHI and PCA3 provide a significant increase in sensitivity and specificity compared to all other examined markers and they may help guide biopsy decisions. PCA3 does not increase the accuracy of predicting prostate cancer when PHI is assessed.