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Purpose: To investigate the inter-reader agreement of the Prostate imaging quality (PI-QUAL) for multiparametric magnetic resonance imaging (mpMRI).Methods: We included 66 men who underwent 1.5 T mpMRI in June 2020-July 2020 in center 1, with no exclusion criteria. mpMRI included multiplanar T2-weighted imaging (T2WI), Diffusion-weighted imaging (DWI), and dynamic contrast-enhanced imaging (DCE). Two readers from center 2 (experience < 1000 to > 1500 examinations), blinded to clinical history but not to acquisition parameters, independently assessed PI-QUAL qualitative/anatomical items of each mpMRI sequence, final PI-QUAL score (1-5), and the Prostate imaging reporting and data system version 2.1 (PI-RADSv2.1) category of the index lesion. Cohen's kappa statistics (k) or prevalence-adjusted-bias-adjusted kappa (PABAK) were used to calculate the inter-reader agreement in assessing the PI-QUAL (1-to-5 scale and 1-2 versus 3 versus 4-5), the diagnostic quality of each mpMRI sequence, qualitative/anatomical items, and PI-RADSv2.1 category.Results: The inter-reader agreement for PI-QUAL category was moderate upon 1-5 scale (k = 0.55; 95%CI 0.39-0.71) or 1-3 scale (k = 0.51; 95%CI 0.29-0.72), with 90.9% examinations categorized PI-QUAL > 3 by readers. The agreement in assessing a sequence as diagnostic was higher for T2WI (k = 0.76) than DCE (PABAK = 0.61) and DWI (k = 0.46), ranging moderate-to-substantial for most of the items. Readers provided comparable PI-RADSv2.1 categorization (k = 0.88 [excellent agreement]; 95%CI 0.81-0.96), with most PI-RADSv2.1 > 3 assignments found in PI-QUAL > 3 examinations (43/46 by reader 1, and 47/47 by reader 2).Conclusions: The reproducibility of PI-QUAL was moderate. Higher PI-QUAL scores were associated with excellent inter-reader agreement for PI-RADSv2.1 categorization.

Objectives: To compare the effect of different PSA density (PSAD) thresholds on the accuracy for clinically significant prostate cancer (csPCa) of the Prostate Imaging Reporting And Data System v.2.1 (PI-RADSv2.1). Methods: We retrospectively included 123 biopsy-naïve men who underwent multiparametric magnetic resonance imaging (mpMRI) and transperineal mpMRI-targeted and systematic prostate biopsy between April 2019 and October 2020. mpMRI, obtained on a 3.0T magnet with a PI-RADSv2.1-compliant protocol, was read by two radiologists (>1500/>500 mpMRI examinations). csPCa was defined as International Society of Urogenital Pathology grading group ≥2. Receiver operating characteristic analysis was used to calculate per-index lesion sensitivity, specificity, and area under the curve (AUC) of PI-RADSv.2.1 categories after adjusting for PSAD ≥0.10,≥0.15, and ≥0.20 ng/mL ml−1. Per-adjusted category cancer detection rate (CDR) was calculated, and decision analysis performed to compare PSAD-adjusted PI-RADSv.2.1 categories as a biopsy trigger. Results: csPCa prevalence was 43.9%. PSAD-adjustment increased the CDR of PI-RADSv2.1 category 4. Sensitivity/specificity/AUC were 92.6%/53.6%/0.82 for unadjusted PI-RADS, and 85.2%/72.4%/0.84, 62.9%/85.5%/0.83, and 92.4%/53.6%/0.82 when adjusting PI-RADS categories for a 0.10, 0.15, and 0.20 ng/ml ml−1 PSAD threshold, respectively. Triggering biopsy for PI-RADS four lesions and PSAD ≥0.10 ng/mL ml−1 was the strategy with greatest net benefit at 30 and 40% risk probability (0.307 and 0.271, respectively). Conclusions: PI-RADSv2.1 category four with PSAD ≥0.10 ng/mL ml−1 was the biopsy-triggering cut-off with the highest net benefit in the range of expected prevalence for csPCa. Advances in knowledge: 0.10 ng/mL ml−1 is the PSAD threshold with higher clinical utility in stratifying the risk for prostate cancer of PI-RADSv.2.1 categories.

Metabolic syndrome (MetS) is a clustering of several pathological medical conditions including hypertension, impaired glucose tolerance/diabetes, abdominal obesity and dyslipidemia. In the last two decades, MetS has reached an epidemic stage, with an estimated prevalence in the range of 30% among the American adult population and a constant increase for all age categories. The incidence of nephrolithiasis between different geographical areas, ranging 1% to 13%; however, a worldwide increase has been recently reported. There is consistent evidence in the literature both about the association between metabolic syndrome/metabolic syndrome traits and kidney stones. Conversely, less is known about the underlying mechanisms and the complex interplay between metabolic syndrome traits. In this work, we sought to review the literature and to summarize the available evidence regarding the association between metabolic syndrome and nephrolithiasis, the biological mechanisms linking metabolic syndrome and its trait to stone formation, and stone composition in individuals affected by metabolic syndrome. In conclusion, we would like to stress the concept of "appropriate" dietary habits and lifestyle as a key concept in the prevention of both metabolic syndrome and nephrolithiasis.

The management of a ureteral orifice injury occurring during robotic radical prostatectomy (RARP) represents a challenge for urologists. Several techniques have been proposed to treat an intraoperative injury, but intraoperative positioning of a DJ stent represents the most common treatment in cases of a partial injury of the ureteral orifice. We present a technique to ensure the successful outcome in cases of a partial detachment of the ureter during RARP. When the orifice is identified after the incision of the bladder neck and it appears very close to the anastomosis line setting up a partial detachment of the ureter, before implanting a DJ stent, one tip could be to perform a small incision of the anterior wall of the orifice to spatulate it and then proceeding to a short slip of the ureter: the eversion of the mucosa - thus creating a sort of "folded shirt cuff" - allows the fixation of the ureter to the bladder wall. We successfully performed this technique in two cases of RARP.

Objectives To assess perioperative outcomes, complications, and rate of uretero-ileal anastomotic stricture (UAS) in patients undergoing retrosigmoid ileal conduit after radical cystectomy (RC). Patients and methods Clinical records of consecutive patients receiving retrosigmoid ileal conduit after open RC for bladder cancer between March 2016 and June 2020 at two academic centres were prospectively collected. Two expert surgeons performed all cases. Operating room (OR) time, estimated blood loss (EBL), transfusion rate, and 90-day postoperative complications classified according to the Clavien-Dindo system, were assessed. In particular, rate of UAS, defined as upper urinary tract dilatation requiring endourological or surgical management, was evaluated. Results A total of 97 patients were analysed. The median (interquartile range [IQR]) OR time was 245 (215-290) min, median (IQR) EBL was 350 (300-500) mL, and blood transfusions were given to 15 (15.5%) cases. There were no intraoperative complications. There were 90-day postoperative complications in 33 patients (34%), being major (Grade III-V) in 19 (19.6%). Two patients died from early postoperative complications. At a median (IQR) follow-up of 25 (14-40) months, there was only one case (1%) of UAS, involving the right ureter and requiring an open uretero-ileal re-implantation. Conclusion The retrosigmoid ileal conduit is a safe and valid option for non-continent urinary diversion after RC, ensuring a very low risk of UAS at an intermediate-term follow-up.

The aim of this paper was to compare the accuracy of multiple abbreviated multiparametric magnetic resonance imaging (mpMRI)-derived protocols in detecting clinically significant prostate cancer (csPCa).One hundred and eight men undergoing staging 3.0T mpMRI with a Prostate Imaging - Reporting and Data System version 2 (PI-RADSv2)-compliant protocol before radical prostatectomy (RP) were retrospectively evaluated. Two readers (R1, R2) independently analyzed mpMRI, assigning a PI-RADSv2 category to each observation as appearing on each examination sequence. A study coordinator assessed final PI-RADSv2 category by combining readers' assignments according to four protocols: short MRI (sMRI) (diffusion-weighted imaging + axial T2-weighted imaging), contrast-enhanced short MRI (cesMRI) (sMRI + dynamic contrast-enhanced [DCE] imaging), biparametric MRI (diffusion-weighted imaging + multiplanar T2-weigthed imaging), and mpMRI. Using RP pathology as the reference standard for csPCa, we calculated the per-lesion cancer detection rate (CDR) and false discovery rate (FDR) for each MRI protocol (cut-off PI-RADSv2 category ≥3), and the per-PI-RADSv2 category prevalence of csPCa and false positives.Pathology after RP found 142 csPCas with median International Society of Urogenital Pathology grade group 2, and stage ≤pT2c in 68.6% of cases. CDR was comparable across the four MRI protocols (74.6% to 75.3% for R1, and 68.3% for R2). FDR was comparable as well (14.4%-14.5% for R1 and 11.1% for R2). sMRI was the minimum protocol equaling mpMRI in terms of CDR, although cesMRI, similarly to mpMRI, was associated with fewer PI-RADSv2 category 3 assignments and higher prevalence of csPCa within PI-RADSv2 category 3 observations (66.7% versus 76.9% for R1, and 100% versus 91.7% for R2, respectively).Among multiple abbreviated mpMRI-derived protocols, cesMRI was the one equaling mpMRI in terms of csPCa detection and minimizing PI-RADSv2 category 3 assignments.

Background To compare the accuracy of multiple abbreviated multiparametric magnetic resonance imaging (mpMRI)-derived protocols in detecting clinically significant prostate cancer (csPCa). Methods 108 men undergoing staging 3.0T mpMRI with a Prostate Imaging - Reporting and Data System version 2 (PI-RADSv2)-compliant protocol before radical prostatectomy (RP) were retrospectively evaluated. Two readers (R1, R2) independently analyzed mpMRI, assigning a PI-RADSv2 category to each observation as appearing on each examination sequence. A study coordinator assessed final PI-RADSv2 category by combining readers' assignments according to four protocols: short MRI (sMRI) (diffusion-weighted imaging + axial T2-weighted imaging), contrast-enhanced short MRI (cesMRI) (sMRI + dynamic contrast-enhanced [DCE] imaging), biparametric MRI (diffusion-weighted imaging + multiplanar T2-weigthed imaging), and mpMRI. Using RP pathology as the reference standard for csPCa, we calculated the per-lesion cancer detection rate (CDR) and false discovery rate (FDR) for each MRI protocol (cutoff PI-RADSv2 category ≥3), and the per-PI-RADSv2 category prevalence of csPCa and false positives. Results Pathology after RP found 142 csPCas with median International Society of Urogenital Pathology grade group 2, and stage ≤pT2c in 68.6% of cases. CDR was comparable across the four MRI protocols (74.6% to 75.3% for R1, and 68.3% for R2). FDR was comparable as well (14.4%-14.5% for R1 and 11.1% for R2). sMRI was the minimum protocol equaling mpMRI in terms of CDR, although cesMRI, similarly to mpMRI, was associated with fewer PI-RADSv2 category 3 assignments and higher prevalence of csPCa within PI-RADSv2 category 3 observations (66.7% versus 76.9% for R1, and 100% versus 91.7% for R2, respectively). Conclusions Among multiple abbreviated mpMRI-derived protocols, cesMRI was the one equaling mpMRI in terms of csPCa detection and minimizing PI-RADSv2 category 3 assignments.

Focus on the quality of magnetic resonance imaging (MRI) by radiologists is welcome, but the clinical impacts that arise from MRI scans still need urological expertise. The urologist perspective is required in a multidisciplinary team setting when making decisions on whether to repeat a scan or perform a biopsy. This can ensure effective use of the prostate MRI diagnostic pathway in delivering desired clinical benefits for patients.

Background Abbreviated magnetic resonance imaging (aMRI) protocols have emerged as an alternative to multiparametric MRI (mpMRI) to reduce examination time and costs. Purpose To compare multiple aMRI protocols for predicting pathological stage ≥T3 (≥pT3) prostate cancer (PCa). Material and Methods One hundred and eight men undergoing staging mpMRI before radical prostatectomy (RP) were retrospectively evaluated. 3.0-T imaging was performed with a 32-channel surface coil and a protocol including diffusion-weighted imaging (DWI), transverse T2-weighted (tT2W) imaging, coronal T2W (cT2W) imaging, sagittal T2W (sT2) imaging, and dynamic contrast-enhanced (DCE) imaging. Two readers independently assessed whether any MRI observation showed stage ≥T3 on each sequence (reading order: DWI, cT2W, tT2W, sT2W, DCE). Final stage was assessed by matching readers’ assignments to pathology, and combining them into eight protocols: DWI + tT2W, DWI + cT2W + tT2W, DWI + tT2W + sT2W, DWI + cT2W + tT2W + sT2W, DWI + tT2W + DCE, DWI + cT2W + tT2W + DCE, DWI + tT2W + sT2W + DCE, and mpMRI. Diagnostic accuracy and inter-reader agreement for aMRI protocols were calculated. Results Prevalence of ≥pT3 PCa was 31.5%. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV) of aMRI protocols were comparable to mpMRI for R1. Sensitivity was 74.3% (95% confidence interval [CI] 64.8–72.0) to 77.1% (95% CI 67.9–84.4), and NPV 86.8% (95% CI 78.6–92.3) to 88.1% (95% CI 80.1–93.3). All accuracy measures of the various aMRI protocols were similar to mpMRI also for R2, albeit all slightly lower compared to R1. On a per-protocol basis, there was substantial inter-reader agreement in predicting stage ≥pT3 (k 0.63–0.67). Conclusion When comparing the diagnostic accuracy of multiple aMRI protocols against mpMRI for predicting stage ≥pT3 PCa, the protocol with the fewest sequences (DWI + tT2W) is apparently equivalent to standard mpMRI.

the aim of this work is to assess whether renorrhaphy with the sliding-clip technique improves perioperative and early functional outcomes compared with traditional renorrhaphy in a contemporary series of patients undergoing open partial nephrectomy (PN).A single-center single-surgeon cohort of 107 consecutive patients treated with open PN between July 2013 and March 2017 was analyzed. A study group of 48 patients undergoing renorrhaphy with the sliding-clip technique was compared with a control group of 59 patients receiving traditional renorrhaphy. Outcome measures were operative room (OR) time, warm ischemia time (WIT), estimated blood loss (EBL), rate of overall 90-day postoperative complications, and percentage change in estimated glomerular filtration rate (PCE) 10% and20% 1 month postoperatively.OR time (p = 0.02), WIT (p = 0.01) and EBL (p 0.001) were significantly lower in the study versus control group. Overall 90-day postoperative complications were observed in 8 (16.7%) versus 21 (35.7%) patients in the study versus control group (p = 0.02). PCE 10% and20% 1 month postoperatively were observed in approximately 40% and 20% of patients, respectively, with no significant differences between groups. On multivariable analysis, a sliding-clip technique was an independent predictor of WIT 20 min and/or EBL 500 ml (OR 0.238, 95%CI 0.074-0.767; p = 0.01) and overall 90-day postoperative complications (OR 0.360, 95%CI 0.151-0.856; p = 0.02).In patients undergoing open PN, renorrhaphy with the sliding-clip technique was associated with better intraoperative and postoperative outcomes compared with traditional renorrhaphy. No significant differences were observed in terms of early renal function change.

Aim To report an endourology management of uretero-ileal anastomosis stricture after cystectomy and orthotopic neobladder reconstruction (Vescica Ileale Padovana, VIP). Materials and methods A nephrostomy was placed to provide a route of access for an anterograde canalization and a secure and working guide placement. These were than taken with a cystoscopy grasp and pulled out through the neobladder. Laser endoureterotomy of the stricture over a stiff working guide wire was than performed. A DJ stent was then placed in order to protect the urinary flow for the first month after surgery. Results No immediate and late complications occurred during a follow up of 1 year according to the Clavien Dindo classification. The patient continued to be asymptomatic with a renal function stable over the years. Discussion Endourological management of uretero-ileal anastomosis stricture after cystectomy and orthotopic neobladder (VIP) is safe and reproducible. It may avoid the difficulties and complications of invasive surgery and has durable results.

Technological advances in the field of surgery and medicine have increased the demand for minimally invasive surgery manifold. Robot assisted surgery is gaining popularity, overcoming the flaws of laparoscopic techniques; with improved surgical precision. The conservative nature of anaesthesia care has to face the challenges with respect to patient positioning, bulkiness of the operating system and being positioned far and away from the patient. Anaesthesiologist’s commitment to be the ‘best man’ for the patient during the perioperative period mandates him to familiarise with these challenges of robot assisted surgical system and provide best possible anaesthetic care and ensure patient safety. In this article, a systematic review of the development of surgical robots and the consideration of unique anaesthetic concerns thereof have been undertaken as any new technology is known to be accompanied by its risks and technical perplexity.

BACKGROUND It is unclear whether clinical models including the Partin tables (PT), the Memorial Sloan Kettering Cancer Center nomogram (MSKCCn), and the cancer of the prostate risk assessment (CAPRA) can benefit from incorporating multiparametric magnetic resonance imaging (mpMRI) when staging prostate cancer (PCa). PURPOSE To compare the accuracy of clinical models, mpMRI, and mpMRI plus clinical models in predicting stage ≥pT3 of PCa. STUDY TYPE Prospective monocentric cohort study. POPULATION Seventy-three patients who underwent radical prostatectomy between 2016-2018. FIELD STRENGTH/SEQUENCE 3.0T using turbo spin echo (TSE) imaging, single-shot echoplanar diffusion-weighted imaging, and T1 -weighted high-resolution-isotropic-volume-examination (THRIVE) contrast-enhanced imaging. ASSESSMENT We calculated the probability of extraprostatic extension (EPE) using the PT and MSKCC, as well as the CAPRA score. Three readers with 2-8 years of experience in mpMRI independently staged PCa on imaging. STATISTICAL TESTS Receiver operating characteristics analysis and logistic regression analysis to investigate the per-patient accuracy of mpMRI vs. clinical models vs. mpMRI plus clinical models in predicting stage ≥pT3. The alpha level was 0.05. RESULTS Median probability for EPE and MSKCCn was 27.3% and 47.0%, respectively. Median CAPRA score was 3. Stage ≥pT3 occurred in 32.9% of patients. Areas under the curve (AUCs) were 0.62 for PT, 0.62 for MSKCCn, 0.64 for CAPRA, and 0.73-0.75 for mpMRI (readers 1-3) (P > 0.05 for all comparisons). Compared with mpMRI, the combination of mpMRI with PT or MSKCCn provided lower AUCs (P > 0.05 for all the readers), while the combination with CAPRA provided significantly higher (P < 0.05) AUCs in the case of readers 1 and 3. On multivariable analysis, mpMRI by reader 1 was the only independent predictor of stage ≥pT3 (odds ratio 7.40). DATA CONCLUSION: mpMRI was more accurate than clinical models and mpMRI plus clinical models in predicting stage ≥pT3, except for the combination of mpMRI and CAPRA in two out of three readers. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1604-1613.

Objective To assess the accuracy of Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) in detecting clinically significant prostate cancer (csPCa) on multiparametric magnetic resonance imaging (mpMRI) using whole-mount sections after radical prostatectomy (RP) as reference standard. Methods Forty-eight patients undergoing mpMRI before RP were prospectively enrolled. Two experienced radiologists independently scored and mapped imaging findings according to PI-RADS v2. One experienced uropathologist mapped cancers detected on whole-mount sections using the PI-RADS v2 sector scheme. Per-lesion and per-patient analyses were run. Primary outcomes were sensitivity and false discovery rate (FDR) in detecting csPCa using PI-RADS v2 score ≥3 and ≥4 as thresholds. Secondary outcome was inter-reader agreement. Results On the per-lesion analysis, sensitivity and FDR at the PI-RADS v2 threshold score ≥3 were 0.75 and 0.17 for Reader 1, and 0.67 and 0.13 for Reader 2, respectively. At the PI-RADS v2 threshold score ≥4, sensitivity was slightly lower, and FDR nearly halved for both readers. On the per-patient analysis, sensitivity for csPCa at the PI-RADS v2 threshold score ≥3 was 0.85 for Reader 1, and 0.78 for Reader 2. At the PI-RADS v2 threshold score ≥4, sensitivity was slightly lower for both readers. Inter-reader agreement was substantial (k 0.72 and 0.65 for PI-RADS v2 threshold score ≥3 and ≥4, respectively). Conclusion In our prospective study with pathology after RP as standard of reference, PI-RADS v2 showed good sensitivity in detecting csPCa on mpMRI with substantial agreement between 2 experienced readers. Threshold score ≥4 had lower FDR.

Ureteroileal anastomotic stricture (UAS) after ileal conduit diversion occurs in a non-negligible proportion of patients undergoing radical cystectomy (RC). Surgical techniques aimed at preventing this potential complication are sought.To describe our surgical technique of retrosigmoid ileal conduit, and to assess perioperative outcomes and postoperative complications with a focus on UAS rate.A prospective single-centre, single-surgeon cohort of 67 consecutive patients undergoing open RC with ileal conduit urinary diversion between July 2013 and April 2017 was analysed. A study group of 30 patients receiving retrosigmoid ileal conduit was compared with a control group of 37 patients receiving standard Wallace ileal conduit.Retrosigmoid versus Wallace ileal conduit diversion after open RC.Operative room (OR) time, estimated blood loss (EBL), transfusion rate, and 90-d postoperative complications were recorded and compared between the two groups. In particular, rate of UAS, defined as upper collecting system dilatation requiring endourological or surgical management, was assessed and compared.The two groups were comparable with regard to all demographic, clinical, and pathological variables. No differences were observed in terms of OR time (p=0.35), EBL (p=0.12), and transfusion rate (p=0.81). Ninety-day postoperative complications were observed in 11 (36.7%) patients who underwent a retrosigmoid ileal conduit and 20 (54.1%) patients who received a traditional ileal conduit (p=0.32). Major complications (grade 3-4) were observed in three (10%) cases in the former group and in 12 (32.4%) cases in the latter group (p=0.08). Mean (standard deviation) follow-up time was 10.8±4.0 mo in the study group and 27.5±9.5 mo in the control group (p0.001). No single case of UAS was observed in the study group, whereas six (16.2%) cases of UAS occurred in the control group (p=0.02). The main limitation is a nonrandomised comparison of a relatively small cohort with short-term follow-up.In our study, we observed a significantly reduced rate of UAS and no increase in postoperative complications with the retrosigmoid ileal conduit diversion compared with standard Wallace ileal conduit diversion after open RC.We describe our surgical technique of retrosigmoid ileal conduit as urinary diversion after open radical cystectomy. Compared with traditional techniques, our technique for ileal conduit was found to be safe and reduce the risk of ureteric strictures.

There is a lack of protocols, formal guidance, and procedural training regarding open conversions from robot-assisted radical prostatectomy (RARP) to open radical prostatectomy (ORP). An open conversion places complex demands on the healthcare team and has recently been shown to be associated with adverse perioperative outcomes.To perform a root cause analysis of open conversion simulations from RARP to ORP to identify errors that may contribute to adverse events.From May 2013 to December 2013, with a team of two surgeons, an anesthesiologist, and three nurses, we simulated 20 emergencies during RARP that require open conversion. A human simulation model was intubated and prepared in the Trendelenburg position; a robot da Vinci SI was locked to it. All simulations were timed, transcribed, and filmed to identify errors and areas for improvement. An institutional conversion protocol was developed at the end of the conversion training.The average conversion time was 130.9 (interquartile range [IQR] 90-201) seconds. Frequencies of the observed errors were as follows: lack of task sequence (70%), errors in robot movements (50%), loss of sterility (50%), space conflict (40%), communication errors (25%), lack of leadership (25%), and accidental fall of surgical devices (25%). Four main strategies were implemented to reduce errors: improving leadership, clearly defining roles, improving knowledge base, and surgical room reorganization. By the last simulation, conversions were performed without errors and using 55.2% less time compared with initial simulations.In this preliminary study, repeated simulations, increased leadership, improved role delineation, and surgical room reorganization enabled faster and less flawed conversions. Further studies are needed to identify if such protocols may translate to actual safety improvement during open conversions.

Objective To evaluate the impact of standardized training and institutional checklists on improving teamwork during complications requiring open conversion from robotic-assisted partial nephrectomy (RAPN). Materials and Methods Participants to a surgical team safety training program were randomly divided into 2 groups. A total of 20 emergencies were simulated: group 1 performed simulations followed by a 4-hour theoretical training; group 2 underwent 4-hour training first and then performed simulations. All simulations were recorded and scored by 2 independent physicians. Time to conversion (TC) and procedural errors were analyzed and compared between the 2 groups. A correlation analysis between the number of previous conversion simulations, total errors number, and TC was performed for each group. Results Group 1 showed a higher TC than group 2 (116.5 vs 86.5 seconds, P = .0.53). As the number of simulation increased, the numbers of errors declined in both groups. The 2 groups tend to converge toward 0 errors after 9 simulations; however, the linear correlation was more pronounced in group 1 (R 2 = 0.75). TC shows a progressive decline for both groups as the number of simulations increases (group 1, R 2 = 0.7 and group 2, R 2 = 0.61), but it remains higher for group 1. Lack of task sequence and accidental falls or loss of sterility were higher in group 1. Conclusion OC is a rare but potentially dramatic event in the setting of RAPN, and every robotic team should be prepared to manage intraoperative emergencies. Training protocols can effectively improve teamwork and facilitate timely conversions to open surgery in the event of intraoperative emergencies during RAPN. Further studies are needed to confirm if such protocols may translate into an actual safety improvement in clinical settings.

Background: Fibroepithelial polyps (FEPs) are a rare cause of ureteropelvic junction (UPJ) obstruction. Radiologists and urologists are not always confident with this disease because of its rarity, complex diagnosis, and heterogeneity of the available treatment options. Case Presentation: We present the endourologic diagnosis and the robotic management of a ureteral polyp close to the left UPJ. A 16-year-old woman with a 12 years history of left lumbar pain was referred to our Center. A computed tomography scan detected a left hydronephrosis with no signs of obstructions at MAG-3 scintigraphy. The endourologic evaluation revealed a giant FEP of the left ureter, which was removed surgically with a videolaparoscopic robot-assisted approach. Conclusion: Considering that conventional radiologic imaging techniques can hardly detect a ureteral FEP, an endourologic study of the urinary tract is mandatory to directly observe the polyp. The mini-invasive treatment of ureteral FEPs is feasible and safe, and should be considered as first option in young patients.

A 74-year-old male came to our clinic for rectal tenesmus, lower urinary tract symptoms and a previous episode of acute retention of urine. Computed tomography (CT) and magnetic resonance imaging (MRI) scan of abdomen showed a multiloculated, cystic formation of 12 cm in the pelvic cavity to the left, with compression of the prostate, bladder, sigmoid and rectum, and its extension imprinted the back of the pubis and back bladder. Saturation prostate biopsy was negative for carcinoma. The histology of transurethral resection of bladder formation revealed flogistic tissue. Cistoprostatectomy and ureteroileal pouch with Wallace anastomosis, removal of the rectum and colostomy with Hartmann pouch were performed. The histopatology showed a ductal carcinoma of the prostate.

Study Type – Therapy (multi-centre cohort) Level of Evidence 3b What's known on the subject? and What does the study add? In RCC about 5% of the patients presented multifocal disease. Prevalence of tumour multifocality was associated with a higher percentage of symptomatic RCC, higher pathological TNM stages, higher tumour grade and higher prevalence of tumour necrosis. Although in univariable analysis multifocal tumours had lower probability of CSS, tumour multifocality did not retain an independent predictive role in multivariable analysis. Patient age at surgery, gender, mode of presentation, pathological N stage and presence of metastases were independent predictors of CSS in multivariable analyses. OBJECTIVE • To evaluate the prevalence and the prognostic role of multifocality in a large multi-institutional series of patients who underwent radical or partial nephrectomy for renal cell carcinoma (RCC). METHODS • We retrospectively collected the data of 5378 patients who were surgically treated for RCC in 16 academic centres involved in the Surveillance and Treatment Update Renal Neoplasms (SATURN) project. • Univariable and multivariable Cox regression models addressed time to cancer-specific survival (CSS) after surgery. RESULTS • Tumour multifocality was identified in 249 patients (5%). The median follow-up of the whole cohort was 42 months. At last follow-up, 786 (14.6%) were dead of cancer and 336 (6.2%) had experienced non-cancer-related death. • The 5- and 10-year CSS estimates were 84.1% and 77.3%, respectively, in patients with monofocal RCC, compared with 71.1% and 63.6%, respectively, in patients with multifocal disease (P < 0.001). • In univariable Cox regression analysis, tumour multifocality was significantly associated with CSS (hazard ratio [HR]= 1.83; P < 0.001). • On multivariate Cox regression analysis adjusted for the effects of other covariates, tumour multifocality did not retain an independent predictive value (HR = 1.24; P= 0.291). CONCLUSIONS • In the present multi-institutional collaboration, about 5% of the patients presented multifocal RCC. • The presence of multifocal cancer was associated with some unfavourable clinical and pathological features. • Although in univariable analysis multifocal tumours had lower CSS probabilities, tumour multifocality did not retain an independent predictive role in multivariable analysis, once adjusted for the effect of the other clinical and pathological covariates.

Port placement and docking of the da Vinci(®) Surgical System is fundamental in robotic-assisted laparoscopic radical prostatectomy (RALP). The aim of our study was to investigate learning curves for port placement and docking of robots (PPDR) in RALP. This manuscript is a retrospective review of prospectively collected data looking at PPDR in 526 patients who underwent RALP in our institute from April 2005 to May 2010. Data included patient-factor features such as body mass index (BMI), and pre-, intra- and post-operative data. Intra-operative information included operation time, subdivided into anesthesia, PPDR and console times. 526 patients underwent RALP, but only those in whom PPDR was performed by the same surgeon without laparoscopic and robotic experience (F.D.M.) were studied, totalling 257 cases. The PPDR phase revealed an evident learning curve, comparable with other robotic phases. Efficiency improved until approximately the 60th case (P 0.001), due more to effective port placement than to docking of robotic arms. In our experience, conversion to open surgery is so rare that statistical evaluation is not significant. Conversion due to robotic device failure is also very rare. This study on da Vinci procedures in RALP revealed a learning curve during PPDR and throughout the robotic-assisted procedure, reaching a plateau after 60 cases.

Objectives:To compare the effects of CO2 insufflation on hemodynamics and oxygen levels and on acid-base level during Robot-Assisted Radical Prostatectomy (RARP) with transperitoneal (TP) versus extra-peritoneal (EP) accesses.Materials and Methods:Sixty-two patients were randomly assigned to TP (32) and EP (30) to RARP. Pre-operation data were collected for all patients. Hemodynamic, respiratory and blood acid-base parameters were measured at the moment of induction of anesthesia (T0), after starting CO2 insuffation (T1), and at 60 (T2) and 120 minutes (T3) after insufflation. In all cases, the abdominal pressure was set at 15 mmHg. Complications were reported according to the Clavien-Dindo classification. Student's two–t-test, with a significance level set at pResults:The demographic characteristics of the patients in both groups were statistically comparable. Analysis of intra-operative anesthesiologic parameters showed that partial CO2 pressure during EP was significantly higher than during TP, with a consequent decrease in arterial pH. Other parameters analysed were similar in the two groups. Postoperative complications were comparable between groups. The most important limitations of this study were the small size of the patient groups and the impossibility of maintaining standard abdominal pressure throughout the operational phases, despite attempts to regulate it.Conclusions:This prospective randomized study demonstrates that, from the anesthesiologic viewpoint, during RARP the TP approach is preferable to EP, because of lower CO2 reabsorption and risk of acidosis.

To determine whether a novel intraoperative technique of COmplete Reconstruction of the Posterior Urethral Support (CORPUS) improves early urinary continence after robotic-assisted radical prostatectomy (RARP). In this prospective study, between November 2012 and June 2013, 36 consecutive patients suitable for non-nerve-sparing RARP were alternatively assigned to either CORPUS surgery or Rocco's standard reconstruction.In the CORPUS group, fibers of the bilateral portions of the puborectalis muscle were used to create a sort of posterior hammock for the urethra. The International Consultation on Incontinence Questionnaire, Short Form Questionnaire (ICIQ-SF) and International Prostate Symptom Score were collected for all patients preoperatively and then ICIQ-SF at 1 day and both tests at 30 days after catheter removal after RARP. Intraoperative and/or postoperative complications were evaluated. Pearson chi-square test compared urinary continence according to ICIQ-SF at 1 and 30 days. Statistical significance was set at P .05.Fifty percent of CORPUS patients were continent immediately after catheter removal and 83% after 30 days. In controls, the respective percentages were 16% and 61%. The differences were statistically significant in both cases. The International Prostate Symptom Score at 30 days did not show obstructive symptoms in either group. One limitation of this study is the low number of cases, "superselected" to evaluate the true effect of CORPUS reconstruction. The very early continence rate of the CORPUS patients was significantly improved compared with that of patients undergoing Rocco's standard technique. Further studies extending the inclusion criteria are needed to confirm the impact of the new CORPUS technique in a more heterogeneous group.