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ABSTRACT Purpose: Salvage robotic-assisted radical prostatectomy (S-RARP) has gained prominence in recent years for treating patients with cancer recurrence following non-surgical treatments of Prostate Cancer. We conducted a systematic literature review to evaluate the role and outcomes of S-RARP over the past decade. Materials and Methods: A systematic review was conducted, encompassing articles published between January 1st, 2013, and June 1st, 2023, on S-RARP outcomes. Articles were screened according to PRISMA guidelines, resulting in 33 selected studies. Data were extracted, including patient demographics, operative times, complications, functional outcomes, and oncological outcomes. Results: Among 1,630 patients from 33 studies, radiotherapy was the most common primary treatment (42%). Operative times ranged from 110 to 303 minutes, with estimated blood loss between 50 to 745 mL. Intraoperative complications occurred in 0 to 9% of cases, while postoperative complications ranged from 0 to 90% (Clavien 1-5). Continence rates varied (from 0 to 100%), and potency rates ranged from 0 to 66.7%. Positive surgical margins were reported up to 65.6%, and biochemical recurrence ranged from 0 to 57%. Conclusion: Salvage robotic-assisted radical prostatectomy in patients with cancer recurrence after previous prostate cancer treatment is safe and feasible. The literature is based on retrospective studies with inherent limitations describing low rates of intraoperative complications and small blood loss. However, potency and continence rates are largely reduced compared to the primary RARP series, despite the type of the primary treatment. Better-designed studies to assess the long-term outcomes and individually specify each primary therapy impact on the salvage treatment are still needed. Future articles should be more specific and provide more details regarding the previous therapies and S-RARP surgical techniques.

Objective: To present the surgical technique and outcomes of robotic ureteral reimplantation in ileal conduit (IC) and neobladder (NB) in patients with prior minimally-invasive radical cystectomy and intracorporeal urinary diversion, who developed benign uretero-ileal anastomotic strictures. Patients and surgical procedure: We report on a multiinstitutional cohort of 10 patients (7 IC, 3 NB) who had 12 uretero-ileal strictures (8 unilateral, 2 bilateral) causing hydronephrosis and renal function deterioration, who underwent robotic uretero-ileal reimplantation in referral centers for robotic surgery between 2016 and 2022. Median age was 67.5 years (Interquartile range [IQR]: 66–69). The stricture was diagnosed at a median of 6 months (IQR 5–10) from the initial surgery. All unilateral strictures were on the left side. Two patients received unsuccessful endoscopic dilatation before the reconstructive surgery. All patients underwent nephrostomy placement prior to the reconstructive procedure. Robotic uretero-ileal reanastomosis started with adhesiolysis, followed by the identification of the ureters and urinary diversion, facilitated by the use of intracavitary saline or ICG. When dissecting the ureters, a „no touch” technique was used, in order to minimize devascularization and ischemia. Localization of the ureteral stricture was critical. The excision of the entire ischemic segment was performed until signs indicative of adequate tissue trophism were found. At the same time, consideration was given to spare sufficient length of the ureteral stumps to allow for a tension-free anastomosis. Direct anastomosis using monofilament resorbable suture, with insertion of mono J or double J stent was performed with both ileal conduit and neobladder. Bricker technique was used in case of unilateral stricture. Results: The median operative time for robotic uretero-ileal reanastomosis was 152 min (IQR 120–180) and the median blood loss was 50 ml (IQR 40–70). No intraoperative complications occurred according to the ICARUS criteria. Median length of hospital stay was 4.5 days (IQR 3–6). Two Clavien-DIndo II (20 %) postoperative complications were registered (urinary tract infection and acute kidney injury). No patients required readmission or reoperation. The mean length of ureteral catheterization for reimplantation in IC was 20.7 days (± 4.29). For patients with NB, the mean ureteral and urethral catheterization times were 54.3 days (± 22.8) and 19.3 days (± 11.08), respectively. The ureteral stents were removed in all patients. At a median of 16 months follow-up (range 6–36 months), 2 patients (one IC and one NB, respectively) had persistent hydronephrosis. Conclusion: In patients requiring surgery for benign ureteral strictures following cystectomy, robotic surgery allows for safe and efficient ureteral reimplantation in urinary diversion.

Background: The role of redo partial nephrectomy (PN) for recurrent renal cell carcinoma (RCC) is still overlooked. Objective: To report our experience of salvage PN for local recurrence after previous nephron-sparing surgery (NSS). Design, setting, and participants: We prospectively gathered data from patients treated with robotic redo PN for locally recurrent RCC after previous NSS from January 2017 to January 2023. The type of surgical resection technique was assigned to the pathologic specimen according to the surface-intermediate-base (SIB) score. Surgical procedure: Redo PN was performed by using the Si Da Vinci robotic platform. Measurements: Operative time, warm ischemia time, and intra- and postoperative complications were recorded. The severity of postoperative complications and tumor stage were evaluated. Results and limitations: Overall, 26 patients entered the study. The median clinical diameter was 3.5 (interquartile range [IQR] 2.2–4.9) cm and the median Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score was 8 (IQR 7–9). In 14 (53.8%) cases, recurrence was at the level of previous tumor resection bed. The median operative time was 177 (IQR 148–200) min, and hilar clamping was performed in 14 (53.8%) cases with a median warm ischemia time of 16 (14.5–22) min. Pure enucleation (SIB score 0–1), hybrid enucleation (SIB score 2), and pure enucleoresection (SIB score 3) were recorded in 13 (50%), eight (30.8%), and five (19.2%) cases, respectively. The totality of recurrent RCC far from previous tumor resection bed received a SIB score of 0–1, while in 57.1% and 35.8% of recurrent RCC on previous tumor resection a hybrid enucleation and a pure enucleoresection were performed, respectively. At a median follow-up of 37 (IQR 16–45) mo, five (19%) patients experienced disease recurrence, being local and systemic in three (11.5%) and two (7.7%) patients, respectively. Conclusions: Our study highlights the feasibility and safety of redo PN for the treatment of locally recurrent RCCs after NSS, either on previous tumor resection bed or elsewhere in the kidney. Patient summary: Robotic redo partial nephrectomy is a challenging procedure. The surgeon needs to tailor the surgical strategy and tumor resection technique case by case, given the heterogeneity of clinical scenarios and the need to achieve maximal functional preservation while ensuring oncologic efficacy.

ABSTRACT Introduction: The aim of the study was to investigate clinical and surgical factors associated with early catheter replacement in patients treated with Holmium Laser Enucleation of the Prostate (HoLEP). Materials and Methods: Data of patients treated with HoLEP at our Institution by a single surgeon from March 2017 to January 2021 were collected. Preoperative variables, including non-invasive uroflowmetry and abdominal ultrasonography (US), were recorded. Bladder wall modifications (BWM) at preoperative US were defined as the presence of single or multiple bladder diverticula or bladder wall thickening ≥5 mm. Clinical symptoms were assessed using validated questionnaires. Only events occurred within the first week after catheter removal were considered. Results: Overall, 305 patients were included, of which 46 (15.1%) experienced early catheter replacement. Maintenance of anticoagulants/antiplatelets (AC/AP) therapy at surgery (p=0.001), indwelling urinary catheter (p=0.02) and the presence of BWM (p=0.001) were more frequently reported in patients needing postoperative re-catheterization. Intraoperative complications (p=0.02) and median lasing time (p=0.02) were significantly higher in this group. At univariate analysis, indwelling urinary catheter (p=0.02), BWM (p=0.01), ongoing AC/AP therapy (p=0.01) and intraoperative complications (p=0.01) were significantly associated with early catheter replacement. At multivariate analysis, indwelling urinary catheter (OR: 1.28; p=0.02), BWM (OR: 2.87; p=0.001), and AC/AP therapy (OR: 2.21; p=0.01) were confirmed as independent predictors of catheter replacement. Conclusions: In our experience the presence of indwelling urinary catheter before surgery, BWM and the maintenance of AC/AP therapy were shown to be independent predictors of early catheter replacement after HoLEP.

Background: Chronic Prostatitis/Chronic Pelvic Pain syndrome NIH-class III is a widespread condition affecting men universally, with existing treatments showing limited success. This study evaluated the efficacy and safety of a natural supplement, composed of Serenoa repens, Solanum lycopersicum, lycopene, and bromelain, in managing symptoms of this condition among a substantial patient group. Methods: In this prospective study, 245 patients diagnosed with Chronic Prostatitis/Chronic Pelvic Pain syndrome NIH-class III were treated with the aforementioned supplement, alongside lifestyle alterations, such as refraining from spicy foods, alcohol, caffeine, and cycling, for a duration of three months. Patients’ progress was assessed at one and three months using the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), the International Prostate Symptom Index (IPSS), quality of life (QoL) scores, and changes in total prostate-specific antigen (PSA) levels. Results: The supplement was well received with no serious adverse events reported. Significant improvements were observed in NIH-CPSI scores, IPSS, QoL scores, and a substantial decrease in total PSA levels at three months compared to baseline, with a positive trend noted from one-month to three-month evaluations. This was consistent in either patients with predominantly voiding or storage urinary symptoms. Conclusions: Our results suggest that this natural supplement in conjunction with lifestyle changes could offer a safe and effective alternative treatment for patients suffering from Chronic Prostatitis/Chronic Pelvic Pain syndrome NIH-class III. However, these findings require validation through further large-scale randomized controlled trials.

Purpose: The present study sought to provide reproducible and patient-oriented metrics to assess the rate of “successful” outcomes (Trifecta) following holmium laser enucleation of the prostate (HoLEP). Clinical and surgical predictors of failure to achieve Trifecta were investigated. Materials and Methods: We queried our prospectively collected database of all patients treated with HoLEP between March 2017 and January 2021. Trifecta was defined as the contemporary presence of: (1) no postoperative complication within 3 months; (2) no urinary incontinence at 3-months follow-up; and (3) 3-month postoperative max flow-rate >15 mL/s. Cases were grouped according to Trifecta achievement. All surgical procedures were carried out by a single surgeon. Surgical experience was divided into two different eras according to the number of procedures conducted (surgical era). Multivariate logistic regression analysis was performed to assess predictors of Trifecta failure. Results: Overall 305 patients were included. Of these, 192 patients (63.0%) achieved Trifecta. Preoperative patient-related features were comparable between the two groups, except for a higher post-void residual (PVR) in non-Trifecta patients (median 180 vs. 130 mL, p=0.003). A significant proportion of Trifecta patients (88.5%) were treated in the second surgical era and in 126 (65.6%) cases an en-bloc enucleation was performed. Multivariate analysis confirmed PVR ≥250 mL, first surgical era and standard three-lobes enucleation technique as independent predictors of Trifecta failure. Conclusions: In our experience the rate of “successful” HoLEP, defined according to our newly introduced Trifecta metric, was 63.0%. We demonstrated that surgical strategy together with rising experience and baseline PVR are key elements to forecast the outcomes.

ABSTRACT Introduction We assessed the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) in patients with high comorbidity burden. Materials and methods Data from patients treated with HoLEP at our academic referral center from March 2017 to January 2021 were prospectively collected. Patients were divided according to their CCI (Charlson Comorbidity Index). Perioperative surgical data and 3-month functional outcomes were collected. Results Out of 305 patients included, 107 (35.1%) and 198 (64.9%) were classified as CCI ≥ 3 and < 3, respectively. The groups were comparable in terms of baseline prostate size, symptoms severity, post-void residue and Qmax. The amount of energy delivered during HoLEP (141.3 vs. 118.0 KJ, p=0.01) and lasing time (38 vs 31 minutes, p=0.01) were significantly higher in patients with CCI ≥ 3. However, median enucleation, morcellation and overall surgical time were comparable between the two groups (all p>0.05). Intraoperative complications rate (9.3% vs. 9.5%, p=0.77), median time to catheter removal and hospital stay were comparable between the two cohorts. Similarly, early (30 days) and delayed (>30 days) surgical complications rates were not significantly different between the two groups. At 3-month follow up, functional outcomes using validated questionnaires did not differ between the two groups (all p>0.05). Conclusions HoLEP represents a safe and effective treatment option for BPH also in patients with high comorbidity burden.

Background: Current literature does not provide large-scale data regarding clinical outcomes of robot-assisted (RAPN) versus open (OPN) partial nephrectomy. Moreover, data assessing predictors of long-term oncologic outcomes after RAPN are scarce. Objective: To compare perioperative, functional, and oncologic outcomes of RAPN versus OPN, and to investigate the predictors of oncologic outcomes after RAPN. Design, setting, and participants: This study included 3467 patients treated with OPN (n = 1063) or RAPN (n = 2404) for a single cT1–2N0M0 renal mass from 2004 to 2018 at nine high-volume European, North American, and Asian institutions. Outcome measurements and statistical analysis: The study outcomes were short-term postoperative, functional, and oncologic outcomes. Regression models investigated the effect of surgical approach (open vs Robot assisted) on study outcomes, and interaction tests were used for subgroup analyses. Propensity score matching for demographic and tumor characteristics was used in sensitivity analyses. Multivariable Cox-regression analyses identified predictors of oncologic outcomes after RAPN. Results and limitations: Baseline characteristics were similar between patients receiving RAPN and OPN, with only few differences. After adjusting for confounding, RAPN was associated with lower odds of intraoperative (odds ratio [OR]: 0.39, 95% confidence interval [CI]: 0.22, 0.68) and Clavien-Dindo ≥2 postoperative (OR: 0.29, 95% CI: 0.16, 0.50) complications (both p 0.05 on interaction tests). On multivariable analyses, we found no differences between the two techniques with respect to functional and oncologic outcomes (all p > 0.05). Overall, there were 63 and 92 local recurrences and systemic progressions, respectively, with a median follow-up after surgery of 32 mo (interquartile range: 18, 60). Among patients receiving RAPN, we assessed predictors of local recurrence and systemic progression with discrimination accuracy (ie, C-index) that ranged from 0.73 to 0.81. Conclusions: While cancer control and long-term renal function did not differ between RAPN and OPN, we found that the intra- and postoperative morbidity—especially in terms of complications—was lower after RAPN than after OPN. Our predictive models allow surgeons to estimate the risk of adverse oncologic outcomes after RAPN, with relevant implications for preoperative counseling and follow-up after surgery. Patient summary: In this comparative study on robotic versus open partial nephrectomy, functional and oncologic outcomes were similar between the two techniques, with lower morbidity—especially in terms of complications—for robot-assisted surgery. The assessment of prognosticators for patients receiving robot-assisted partial nephrectomy may help in preoperative counseling and provides relevant data to tailor postoperative follow-up.

Objective:. To compare binary metrics and Global Evaluative Assessment of Robotic Skills (GEARS) evaluations of training outcome assessments for reliability, sensitivity, and specificity. Background:. GEARS–Likert-scale skills assessment are a widely accepted tool for robotic surgical training outcome evaluations. Proficiency-based progression (PBP) training is another methodology but uses binary performance metrics for evaluations. Methods:. In a prospective, randomized, and blinded study, we compared conventional with PBP training for a robotic suturing, knot-tying anastomosis task. Thirty-six surgical residents from 16 Belgium residency programs were randomized. In the skills laboratory, the PBP group trained until they demonstrated a quantitatively defined proficiency benchmark. The conventional group were yoked to the same training time but without the proficiency requirement. The final trial was video recorded and assessed with binary metrics and GEARS by robotic surgeons blinded to individual, group, and residency program. Sensitivity and specificity of the two assessment methods were evaluated with area under the curve (AUC) and receiver operating characteristics (ROC) curves. Results:. The PBP group made 42% fewer objectively assessed performance errors than the conventional group (P < 0.001) and scored 15% better on the GEARS assessment (P = 0.033). The mean interrater reliability for binary metrics and GEARS was 0.87 and 0.38, respectively. Binary total error metrics AUC was 97% and for GEARS 85%. With a sensitivity threshold of 0.8, false positives rates were 3% and 25% for, respectively, the binary and GEARS assessments. Conclusions:. Binary metrics for scoring a robotic VUA task demonstrated better psychometric properties than the GEARS assessment.

Partial nephrectomy (PN) may be recommended for selected patients with advanced-stage (>cT2) renal cell carcinoma (RCC) with the aim of avoiding dialysis and chronic kidney disease–related comorbidities. The spread of robotic surgery has led to expansion of PN indications to more challenging scenarios and even frontier surgeries, including advanced-stage RCC. Here we describe the management of a patient with a solitary kidney diagnosed with multiple cT3a (renal vein thrombus) RCC who was treated using a conservative robotic approach. The most crucial surgical considerations for this procedure were: (1) tailored planning of the surgical approach using three-dimensional reconstruction software; (2) accurate boundary delineation for the tumors and thrombus; (3) avoiding unnecessary warm ischemia time; (4) performing an anatomical excision to follow eventual tumor bulging; and (5) en bloc removal of the main lesion and its thrombus. No perioperative complications were recorded. Histopathology revealed clear cell RCC for all four lesions with nucleolar grade 3 and negative surgical margins. At 12-mo follow-up the patient was disease-free. When performed by an experienced surgeon, PN plus venous thrombus excision for imperative cases with cT3 RCC may represent a valid treatment option with valuable oncological and functional outcomes. Patient summary: We describe the case of patient who had a single kidney with multiple kidney tumors and tumor extension into a blood vessel. The patient was treated with robot-assisted removal of the tumors, sparing as much kidney tissue as possible. This technique was found to be safe and effective, with no complications and good intermediate-term results.

Background: There might be differential sensitivity to neoadjuvant chemotherapy (NAC) in patients with primary muscle-invasive bladder cancer (MIBC) in comparison to patients with secondary MIBC after a history of non–muscle-invasive disease. Objective: To investigate pathologic response rates and survival associated with primary versus secondary MIBC among patients treated with cisplatin-based NAC for cT2–4N0M0 MIBC. Design, setting, and participants: Oncologic outcomes were compared for 350 patients with primary MIBC and 64 with secondary MIBC treated with NAC and radical cystectomy between 1992 and 2021 at 11 academic centers. Genomic analyses were performed for 476 patients from the Memorial Sloan Kettering/The Cancer Genome Atlas cohort. Outcome measurements and statistical analysis: The outcome measures were pathologic objective response (pOR; ≤ypT1 N0), pathologic complete response (pCR; ypT0 N0), overall mortality, and cancer-specific mortality. Results and limitations: The primary MIBC group had higher pOR (51% vs 34%; p = 0.02) and pCR (33% vs 17%; p = 0.01) rates in comparison to the secondary MIBC group. On multivariable logistic regression analysis, primary MIBC was independently associated with both pOR (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.26–0.87; p = 0.02) and pCR (OR 0.41, 95% CI 0.19–0.82; p = 0.02). However, on multivariable Cox regression analysis, primary MIBC was not associated with overall mortality (hazard ratio 1.70, 95% CI 0.84–3.44; p = 0.14) or cancer-specific mortality (hazard ratio 1.50, 95% CI 0.66–3.40; p = 0.3). Genomic analyses revealed a significantly higher ERCC2 mutation rate in primary MIBC than in secondary MIBC (12.4% vs 1.3%; p

Background: Long-term renal function after partial nephrectomy (PN) is difficult to predict as it is influenced by several modifiable and nonmodifiable variables, often intertwined in complex relations. Objective: To identify variables influencing long-term renal function after PN and to assess their relative weight. Design, setting, and participants: A total of 457 patients who underwent either robotic (n = 412) or laparoscopic PN (n = 45) were identified from a multicenter international database. Outcome measurements and statistical analysis: The 1-yr estimated glomerular filtration rate (eGFR) percentage loss (1YPL), defined as the eGFR percentage change from baseline at 1 yr after surgery, was the outcome endpoint. Predictors evaluated included demographic data, tumor features, and operative and postoperative variables. Bayesian multimodel analysis of covariance was used to build all possible models and compare the fit of each model to the data via model Bayes factors. Bayesian model averaging was used to quantify the support for each predictor via the inclusion Bayes factor (BFincl). High-dimensional undirected graph estimation was used for network analysis of conditional independence between predictors. Results and limitations: Several models were found to be plausible for estimation of 1YPL. The best model, comprising postoperative eGFR percentage loss (PPL), sex, ischemia technique, and preoperative eGFR, was 207 times more likely than all the other models regarding relative predictive performance. Its components were part of the top 44 models and were the predictors with the highest BFincl. The role of cold ischemia, solitary kidney status, surgeon experience, and type of renorraphy was not assessed. Conclusions: Preoperative eGFR, sex, ischemia technique, and PPL are the best predictors of eGFR percentage loss at 1 yr after minimally invasive PN. Other predictors seem to be irrelevant, as their influence is insignificant or already nested in the effect of these four parameters. Patient summary: Kidney function at 1 year after partial removal of a kidney depends on sex, the technique used to halt blood flow to the kidney during surgery, and kidney function at baseline and in the early postoperative period.

Abstract Background Periprosthetic femoral fractures are challenging complications of hip arthroplasty. They are supposed to be a rare complication, but their incidence is rapidly increasing. Surgical treatment aims to achieve early mobilization and avoid the complications of prolonged bed rest. Aim of this study is to evaluate the clinical outcomes of surgical treatment comparing two surgical approaches: revision arthroplasty (RA) versus open reduction and internal fixation (ORIF). Methods Authors retrospectively reviewed a series of 117 patients with total hip arthroplasty treated for periprosthetic femur fractures in the period between January 2013 and March 2018 at a single tertiary referral center. Of these, 70 patients satisfied strict inclusion criteria. Patients were classified according to the Unified Classification System (UCS) and distributed in two groups according to surgical treatment. Clinical outcomes were assessed using the Oxford Hip recorded preoperatively and post operatively, Barthel Score, CIRS score (Cumulative illness rating scale), type of fracture and post-operative complications with a minimum follow up of 1 year. Results Nominal univariate statistical analysis revealed significant differences between the post and pre-operative Oxford Hip Score (Δ Oxford) and the surgical treatment (p = 0.008) and CIRS score (p = 0.048). Moreover, we observed a significant relationship between type of treatment and type of fracture (p = 0.0001). Multivariate analyses revealed that CIRS score was independently associated with Oxford Score improvement after surgery (p = 0.024). Conclusions Data from this case series confirmed that surgical treatment was correlated to type of fracture, according to UCS classification. Patients treated by RA had a better functional outcome than patients treated with ORIF, but these results are strongly influenced from the patients’ age, Barthel index and CIRS score. Also, authors found a correlation between functional outcome and comorbidities evaluated by CIRS score. Based on these data we suggest a multimodal approach to these patients, like those used for proximal femoral fractures.

Background: Phytotherapeutic agents aroused an increasing interest either as alternative or in addition to conventional therapy in the management of BPH. The aim of the article was to evaluate the clinical and functional changes after add-on treatment with Serenoa repens associated with Solanum lycopersicum, lycopene and bromelain in patients with BPH presenting with mild to moderate LUTS and previously treated only with Alfuzosin over a 6–12 months period. Materials and methods: Between January and July 2019, patients with symptomatic BPH already on treatment with Alfuzosin (Al) 10 mg for at least 6–12-month were enrolled at three academic referral centres, included in a prospective treatment group, and managed with a combination treatment of Al and 6-month daily oral single-tablet supplementation of Serenoa repens and Solanum lycopersicum + lycopene + bromelain (SeR + SL + Ly + Br). A retrospective control group with comparable baseline characteristics was obtained by performing a propensity score matching from a database of 434 patients managed with Alfuzosin 10 mg/day only over a 6–12 months period between March 2015 and December 2018. IPSS, QoL questionnaires, voiding diary assessment, postvoid residual volume (PVR), maximal (Qmax) and average (Qave) urinary flow rates were evaluated at baseline in the treatment group at the moment of patient accrual, in the control group after 6-month of treatment with alfuzosin, and thereafter at 3 and 6 months in both groups. Results: Overall, 250 patients entered the study (n = 125 treatment group; n = 125 control group). Total IPSS score significantly decreased at 6-month assessment from baseline in the treatment vs control group (17 [IQR: 12–20] vs 12 [IQR: 9–14], p = 0.02) with a significative storage symptoms improvement detected both at 3- (p = 0.03) and 6-month evaluation (p = 0.001). PVR significantly improved at each follow-up visit with the most relevant reduction at 6-month assessment (125 cc vs. 102 cc; p = 0.02). Moreover, a significative improvement in LUTS-related quality of life (QoL) was recorded at 3- and 6-month assessment with a median decrease of −1 and −2 (p = 0.05 and p = 0.001 respectively) from baseline. Conclusions: Combination treatment with AB and SeR + SL + Ly + Br led to meaningful improvements in LUTS severity compared to AB as monotherapy, after a 6-month treatment period in men with mild to moderate LUTS/BPH.

Peyronie’s disease (PD), a fibrotic disorder of the tunica albuginea fully described in 1793 by French physician Francois de la Peyronie, is characterized by pain, plaque formation, penile deformity, and ultimately sexual function decline. The epidemio-logical data on PD vary considerably across previous studies, with recent evidence reporting a prevalence of up to 9%. PD is generally divided into two different phases: active or acute and stable or chronic. Plaque formation generally occurs during the acute phase, while during chronic phase pain usually tends to complete resolution and penile deformity stabilizes. PD’s pathophysiology is still subject of great discussion. Tunical mechanical stress and microvascular trauma are major contribu-tory factors. However, better understanding of the molecular pathophysiology of this condition remains paramount towards an in-depth comprehension of the disorder and the development of newer and more effective disease-targeted interventions. In this review we provide a detailed overview of natural history of PD, specifically focusing on clinical manifestations and the underlying molecular regulation patterns.

Background: Radiation-induced cystitis is a common side effect of radiotherapy (RT) to the pelvic area. Hyaluronic acid (HA) and chondroitin sulfate (CS) are components of the urothelial mucosa and positive results have been obtained for intravesical HA/CS instillations for the treatment of urinary tract infections and bladder pain syndrome. HA/CS may also have a protective effect against RT bladder toxicity. Objective: To investigate whether HA and CS protect the urothelium during RT, alleviate lower urinary tract symptoms, and improve quality of life. Design, setting, and participants: This multicentre randomised controlled trial was conducted across seven centres in four countries. Male patients aged ≥18 yr scheduled to undergo primary intensity-modulated radiotherapy for localised prostate cancer were enrolled. Intervention: Patients were randomised to intravesical HA/CS plus an oral formulation of curcumin, quercetin, HA, and CS (group A) or no treatment (group B). Outcome measurements and statistical analysis: The primary endpoint was absolute changes from baseline to follow-up in urinary domain scores for the Expanded Prostate Cancer Index Composite (EPIC), the International Consultation on Incontinence Questionnaire-Male Lower Urinary Tract Symptoms (ICIQ-MLUTS), and the EuroQol Group EQ-5D-5L questionnaire. Data analysis for efficacy and safety outcomes was performed using an intention-to-treat (ITT) approach; the ITT population was defined as all randomised patients. Results and limitations: Of 57 patients screened, 49 were enrolled and randomly assigned to either active treatment (group A, n = 25) or the control (group B, n = 24). Three patients in the control group withdrew after randomisation. Changes from baseline to 12 mo were worse in the control group for subtotal scores for urinary symptoms and impact of symptoms on quality of life and for the total score (p = 0.05, p = 0.003, and p = 0.008, respectively). There was a significant time × group interaction in favour of active treatment for the incontinence symptom score (p = 0.011) and bother score (p = 0.017). The absence of a sham procedure and/or placebo is the main limitation. Conclusions: Our results suggest that intravesical HA/CS in combination with an oral formulation may reduce urinary symptoms and improve QoL at short-term (1 yr) follow-up. Patient summary: We investigated whether hyaluronic acid (HA) and chondroitin sulfate (CS) have a protective effect against the bladder toxicity of radiotherapy for prostate cancer. HA/CS used for weekly bladder irrigation for 6 wk and given orally with curcumin and quercetin for 12 wk reduced urinary incontinence symptoms and bother measured at 1-year follow-up. This may hold promise as a preventive treatment if the results are confirmed in further trials.

Purpose: To compare the efficacy and safety of intralesional hyaluronic acid (HA) as compared with verapamil injection in patients with Peyronie’s disease (PD). Materials and Methods: Between January 2015 and December 2018, men in PD acute phase were prospectively recruited. This open-label, prospective study included 2 different protocols. Group A: 8-week cycle of weekly intraplaque injections with HA; Group B: 8-week cycle of weekly intraplaque injections with verapamil. Penile curvature, plaque size, International Index of Erectile Function (IIEF)-15 score and visual analogue scale (VAS) were assessed at baseline and after 3 months. Results: Two-hundred forty-four patients were enrolled. Of these, 125 received intralesional HA (Group A), 119 received intralesional verapamil (Group B). At enrollment, median age was 56.0 years (interquartile range [IQR]=47.0–63.0 years), median curvature 35.0° (IQR=25.0°–45.0°), median IIEF-15 score 19.0 (IQR=16.0–23.0), median VAS 4.0 (IQR=4.0–5.0). Median difference for IIEF-15 was 1.0 (95% confidence interval [CI]=1.12–1.94) in Group A and 0.0 (95% CI=-0.04–0.14) in Group B (p

Abstract Background Bladder cancer is the ninth most common type of cancer worldwide. In the past, radical cystectomy via open surgery has been considered the gold-standard treatment for muscle invasive bladder cancer. However, in recent years there has been a progressive increase in the use of robot-assisted laparoscopic radical cystectomy. The aim of the current project is to investigate the surgical, oncological, and functional outcomes of patients with bladder cancer who undergo radical cystectomy comparing three different surgical techniques (robotic-assisted, laparoscopic, and open surgery). Pre-, peri- and post-operative factors will be examined, and participants will be followed for a period of up to 24 months to identify risks of mortality, oncological outcomes, hospital readmission, sexual performance, and continence. Methods We describe a protocol for an observational, prospective, multicenter, cohort study to assess patients affected by bladder neoplasms undergoing radical cystectomy and urinary diversion. The Italian Radical Cystectomy Registry is an electronic registry to prospectively collect the data of patients undergoing radical cystectomy conducted with any technique (open, laparoscopic, robotic-assisted). Twenty-eight urology departments across Italy will provide data for the study, with the recruitment phase between 1st January 2017-31st October 2020. Information is collected from the patients at the moment of surgical intervention and during follow-up (3, 6, 12, and 24 months after radical cystectomy). Peri-operative variables include surgery time, type of urinary diversion, conversion to open surgery, bleeding, nerve sparing and lymphadenectomy. Follow-up data collection includes histological information (e.g., post-op staging, grading, and tumor histology), short- and long-term outcomes (e.g., mortality, post-op complications, hospital readmission, sexual potency, continence etc). Discussion The current protocol aims to contribute additional data to the field concerning the short- and long-term outcomes of three different radical cystectomy surgical techniques for patients with bladder cancer, including open, laparoscopic, and robot-assisted. This is a comparative-effectiveness trial that takes into account a complex range of factors and decision making by both physicians and patients that affect their choice of surgical technique. Trial registration ClinicalTrials.gov , NCT04228198 . Registered 14th January 2020- Retrospectively registered.

Abstract In the present study we aimed to investigate the surgical outcomes of patients with persistent penile curvature (PC) after Collagenase Clostridium histolyticum (CCH) intraplaque injections. Data from 90 patients with persistent PC after CCH in a multicentre study from 6 andrological centres were retrospectively reviewed. Three standardized surgical techniques were performed. Group 1: plaque incision grafting (PIG) with penile prosthesis implant (PPI); Group 2: PIG without PPI; Group 3: Nesbit technique. Hospital stay, operative time, postoperative complications and PC persistency/recurrence (> 20°) were evaluated. Overall satisfaction and functional outcomes were assessed through International Index of Erectile Function-Erectile Function (IIEF-EF), Peyronie’s Disease Questionnaire (PDQ), Female Sexual Function Index (FSFI) administered pre and 3 months postoperatively. Of all, 25 (27.8%) patients received grafting procedure + PPI (Group 1), 18 (20.0%) patients belonged to Group 2, and 47 (52.2%) to Group 3. Bovine pericardium graft and collagen fleece have been used in in 22 (51.2%) and 21 (48.8%) patients, respectively. Median penile length after surgery was 13.0 cm (IQR 12.0–15.0). After surgery, Group 1 showed higher increase in penile length after surgery and better improvements in terms of PDQ-PS. In contrast, both IIEF-EF and FSFI scores did not differ among groups. Overall, 86 (95.6%) did not report any complication. 4 (4.4%) patients had PC recurrence; of those, 2 (8.0%), 1 (5.6%) and 1 (2.1%) cases were observed in Group 1, Group 2 and Group 3, respectively. In case of persistent PC after CCH, surgical correction by grafting with or without concomitant PPI or Nesbit technique emerged as a technically feasible, effective and safe procedure, with no significant postoperative complications.

ABSTRACT Purpose: Robot-assisted partial nephrectomy (RAPN) is rapidly increasing its role in the nephron-sparing surgery setting (1). The recent introduction of technological advancements is leading more experienced surgeons to approach complex renal mass with a conservative intent (2, 3). In particular, three-dimensional reconstruction and the use of intraoperative ultrasonography are gaining attention as crucial tools to safely and effectively approach complex cases (4, 5). We aimed to video-report the management of highly complex renal mass treated with RAPN, focusing on preoperative surgical planning and intraoperative technical nuances. Materials and methods: A 73-year-old male patient was referred to our institution for an incidental detection of a 70 mm diameter, completely endophytic, hilar renal mass (PADUA score 13, RENAL score 11a). Contrast-enhanced CT scan images were processed by M3DICS (Turin, Italy) and used to obtain a 3D virtual model. RAPN was performed by a highly experienced surgeon using Da Vinci Si robotic platform with a three-arm configuration. Results: The overall operative time was 114 min, with a warm ischemia time of 16 min. No intraoperative or postoperative complications were recorded. According to the SIB score, the pure enucleation excision strategy was performed. Histopathological analysis revealed a pT3a low-grade oncocytic kidney tumor with negative surgical margins. with negative surgical margins. At 24-months follow up, no local or systemic recurrence was detected. Conclusions: Conservative management of complex renal masses is challenging with a highly nuanced decision-making process. In this regard, preoperative 3D models and intraoperative ultrasound (US) guidance play a pivotal role to develop a tailored surgical strategy according to patient’ and tumor's characteristics.

IntroductionThe Italian Radical Cystectomy Registry (RIC) is an observational prospective study aiming to understand clinical variables and patient characteristics associated with short- and long-term outcomes among bladder cancer (BC) patients undergoing radical cystectomy (RC). Moreover, it compares the effectiveness of three RC techniques - open, robotic, and laparoscopic.MethodsFrom 2017 to 2020, 1400 patients were enrolled at one of the 28 centers across Italy. Patient characteristics, as well as preoperative, postoperative, and follow-up (3, 6, 12, and 24 months) clinical variables and outcomes were collected.ResultsPreoperatively, it was found that patients undergoing robotic procedures were younger (p

Background: Robotic sacrocolpopexy (RSCP) is an established option for the treatment of apical, anterior, and proximal posterior compartment pelvic organ prolapses (POP). However, there is lack of evidence investigating how lower bowel tract symptoms (LBTS) may change after RSCP. Methods: Data from consecutive patients treated with RSCP for stage 3 or higher POP from 2012 to 2019 at a single tertiary referral center with at least 1 year of follow-up were prospectively collected and retrospectively analyzed. RSCP was performed following a standardized technique which always employed both anterior and posterior hand-shaped meshes. Outcomes were collected at follow-up and analyzed. LBTS were evaluated through the Wexner questionnaire. Results: Overall, 114 women underwent RSCP. Eleven were excluded for missing data, whereas 12 had insufficient follow-up. Thus, 91 (79.8%) patients were included in this cohort. Median follow-up was 42 [interquartile range (IQR), 19–62] months. Mean age was 65 ± 10 years. In our series, RSCP was mainly performed for anterior and apical/medium stage 3 POP (in 95.6% of patients). Anatomic success rate of RSCP was 97.8%, with 89 patients with POP stage 0–1 at 12-month follow-up. Two patients (2.2%) experienced POP recurrence and were treated with redo-SCP. No patient experienced clinically significant posterior vaginal wall prolapse after RSCP. When analyzing LBTS, there was no significant change in postoperative total Wexner’s score as compared to the preoperative value ( p > 0.05). However, the manual assistance subscore was statistically significantly lower within the first-year follow-up ( p = 0.04), but it spontaneously improved during the follow-up ( p = 0.12). Conclusion: RSCP with simultaneous placement of both anterior and posterior mesh is safe and successful to treat high-stage POP in carefully selected patients. Of note, LBTS appear unaffected by posterior mesh placement, supporting its routine use to prevent posterior POP recurrence. Larger prospective studies are needed to confirm our results.

Objective: To report our technique for robotic surgical treatment of left-side renal cell carcinoma (RCC) with level III inferior vena cava (IVC) thrombus. Patients and surgical procedure: A 47-year old man was diagnosed with a 9 × 8 × 6 cm left-side RCC with level III IVC tumor thrombus and para-aortic lymphadenopathies. The whole procedure was split up into three different steps: 1) Isolation of the left kidney and para-aortic lymphadenopathies, section of the renal artery and adrenal vessel, isolation of the left renal vein; 2) entire mobilization of the liver to allow supra-hepatic and sub-diaphragmatic control of the IVC with subsequent isolation and section of the hepatic veins; 3) isolation of the IVC until the origin of the right renal vein, isolation of the right adrenal vein, section of the left renal vein using the Endo-GIA and IVC thrombectomy. Results: Overall operative time was 600 min. IVC clamping time was 15 min. No intra- or post-operative complications occurred. Patient was discharged in 6th postoperative day. Histopathologic examination revealed a pT3cN1 clear cell RCC with rhabdoid differentiation. Conclusions: Robotic radical nephrectomy with IVC thrombectomy for level III tumor thrombus is a feasible and safe procedure in experienced hands and selected candidates. Specific technical skills and multidisciplinary approach are essential to fulfill the surgical success.

Objective: To report our technique of robotic enucleation for the management of renal masses focusing of preoperative considerations and intraoperative nuances. Patients and surgical procedure: In our center, all patients with suspicious renal mass amenable to partial nephrectomy and presenting an identifiable tumor pseudocapsule are submitted to robotic pure enucleation. Several steps have to be followed to perform a successful tumor enucleation. In particular, 1) preoperative evaluation of the tumor and renal anatomical complexity; 2) accurate intraoperative identification of the tumor margins; 3) reaching the tumor pseudocapsule through an anatomic resection strategy; 4) adapting the ischemia management in order to maintain a bloodless surgical field; 5) enucleative resection technique 6)minimizing tumor tensions; 7) anatomical renorraphy. Results: Pure enucleation is effectively performed. Conclusions: Tumor enucleation represents the most anatomical technique for partial nephrectomy since it maximizes the amount of healthy renal parenchyma spared. Evidence supports the adoption un pure enucleation whenever feasible.

Purpose: The aim of this study was to evaluate the efficacy of collagenase Clostridium histolyticum (CCH) in patients with Peyronie’s disease (PD) suffering from atypical deformities. Materials and Methods: We retrospectively collected data of patients with atypical penile curvature (PC) secondary to PD. All patients underwent a modified treatment protocol, consisting of 3 intralesional injections of 0.9 mg of CCH performed at 4-week intervals at the point of maximum PC. Patients were instructed to follow a strict routine, involving daily modeling of erect penis and stretching at the urinary toilette time, two minutes each. Success was defined as a decrease in PC of ≥20° from baseline. Results: Sixty-five patients were included in the analysis. Median age was 59.0 years (interquartile range [IQR], 53.0 to 63.0 years), median curvature 40.0° (IQR, 30.0° to 45.0°) median duration of the disease 12.0 years (IQR, 6.5 to 24.0 years). Fiftythree patients (81.54%) had ventral PC, 7 (10.77%) hourglass PC, and 5 (7.69%) shortening PC. Median changes of PC were -20.0 (IQR, -20.0 to -10.0; p

Objective: A prospective longitudinal cohort study on the impact of anthropometric measures on the sexual function and continence recovery in patients treated with laparoscopic radical prostatectomy (LRP) is presented. Material and methods: Anthropometric measures, International Index of Erectile Function (IIEF-5) and International Prostatic Symptoms Score questionnaires, were collected before surgery and at the end of follow-up period. All patients were assigned into the following groups: A) non-obese; B) non-obese with central adiposity; C) obese without central adiposity; D) obese with central adiposity. Urinary and sexual functions were the outcome measures. Results: At the end of follow-up, in 29 patients with visceral adiposity (VA) the median IIEF-5 was 14 (IQR 7-18) while in 49 non-VA patients (62.8%) was 22 (IQR 17-24) (p < 0.001). Twenty-three patients (79.3%) with VA reported complete continence, while 6 (20.7%) used ≥ 2 pads per day. Forty-eight patients (97.9%) without VA reported complete continence. VA was confirmed as a strong independent predictor for worse continence (HR 3.67; 2.75-4.51 CI95% p = 0.003) and sexual function recovery (HR: 4.51; 3.09-5.63 CI95% p < 0.001). Conclusion: We truly believe obese with visceral adiposity patients with prostate cancer should receive detailed preoperative counseling before surgery, including higher risk of suboptimal functional outcomes.

The possible role of JC virus in determining urinary tract involvement has only recently been recognized. The case of a man with laboratory-confirmed JC virus replication in the urine after a maintenance schedule of rituximab administered for a lymphoproliferative disorder is reported herein. The patient developed severe renal and urinary tract impairment, characterized by the onset of nephropathy, bilateral ureteral strictures, and a serious reduction in vesical compliance, ultimately requiring an ileal neobladder configuration. The renal and urinary tract involvement was finally attributed to JC virus reactivation. This observation suggests that renal and urinary tract diseases related to JC virus might be associated with long-term rituximab treatment.

ABSTRACT Purpose: The expansion of technology is leading to a paradigm shift in several urological fields (1, 2). In particular, the adoption of lasers within the surgical treatment of patients with benign prostatic hyperplasia (BPH) is considered one of the most relevant innovations (3-5). In this video, we aimed to report our experience with holmium laser for the ablation of the prostate (HoLAP) in patients with obstructive lower urinary tract symptoms (LUTS) due to BPH. Materials and Methods: From 2018 to 2020, 10 patients with obstructive LUTS secondary to BPH were treated at our Institution with HoLAP (120W Holmium laser Lumenis® with Moses® technology). Main inclusion criteria were: 1) International Prostate Symptom Score ≥12; 2) prostate volume ≤65mL, 3) maximal flow rate (Qmax) ≤15ml/s at preoperative non-invasive uroflowmetry. Results: Mean patient age was 65 (range: 59-72) years. Preoperative mean prostate volume was 50 (range: 35-65) mL. Mean operative time was 66 (range: 45-85) minutes with a mean laser time/operative time ratio of 0.51 (range: 0.44-0.60). Voiding symptoms, Qmax and post voiding residual were significantly improved after 3 and 12 months (all p

ItalyPurpose: In this study, we aimed to determine the role of extracorporeal shockwave therapy (ESWT) in the management of Peyronie’s disease (PD). Materials and Methods: A total of 325 patients suffering from PD were enrolled in this single-arm clinical study. All patients were received ESWT using a schedule of 1 treatment/wk. Penile curvature was measured by a goniometer after intracavernosal drug-induced erection using Alprostadil. Plaque size was measured with a ruler and sexual function assessed by the international index of erectile function (IIEF)-15 score. Severity of erectile dysfunction was classified as severe (IIEF-15 ≤10), moderate (IIEF-15 between 11 and 16), or mild (IIEF-15 between 17 and 25). Results were evaluated at baseline and 3 months after the treatment.Results: All the patients completed the study protocol. Median age was 59.0 years (55.0–64.0 years). After treatment, the median (interquartile range, IQR) plaque size reduced from 1.78 cm2 (1.43–2.17 cm2) to 1.53 cm2 (1.31–1.96 cm2) (p

ABSTRACT Purpose: Three-dimensional (3D) virtual models have recently gained consideration in the partial nephrectomy (PN) field as useful tools since they may potentially improve preoperative surgical planning and thus contributing to maximizing postoperative outcomes (1-5). The aim of the present study was to describe our first experience with 3D virtual models as preoperative guidance for robot-assisted PN. Materials and methods: Data of patients with renal mass amenable to robotic PN were prospectively collected at our Institution from January to April 2020. Using a dedicated web-based platform, abdominal CT-scan images were processed by M3DICS (Turin, Italy) and used to obtain 3D virtual models. 2D CT images and 3D models were separately assessed by two different highly experienced urologists to assess the PADUA score and risk category and to forecast the surgical strategy of the single cases, accordingly. Results: Overall, 30 patients were included in the study. Median tumor size was 4.3cm (range 1.3-11). Interestingly, 8 (26.4%) cases had their PADUA score downgraded when switching from 2D CT-scan to 3D virtual model assessment and 4 (13.4%) cases had also lowered their PADUA risk category. Moreover, preoperative off-clamp, selective clamping strategy and enucleation resection strategy increased from CT-scan to 3D evaluation. Conclusion: 3D virtual models are promising tools as they showed to offer a reliable assessment of surgical planning. However, the advantages offered by the 3D reconstruction appeared to be more evident as the complexity of the mass raises. These tools may ultimately increase tumor's selection for PN, particularly in highly complex renal masses. Disclosure of potential conflicts of interest: The authors declare they do not have conflict of interests. Informed consent: Informed consent was obtained from all individual participants included in the study. All the procedures were in accordance with the ethical standards of the institutional and national research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Background: A marker of urothelial damage could be helpful for early detection and monitoring of local toxicity due to intravesical therapy for non-muscle invasive bladder cancer (NMIBC). The aim of the study was to investigate the correlation between fibronectin (FN) gene expression in bladder washings and local toxicity secondary to adjuvant intravesical therapy. Materials and methods: Patients undergoing adjuvant intravesical therapy for NMIBC and age-matched healthy patients were enrolled. Real time polymerase chain reaction was performed to analyze FN expression in bladder washings. Local toxicity was classified as: 0–1 mild (no medical therapy), 2 moderate (medical therapy and/or instillation postponed), 3 severe (discontinuation of therapy). Results: Seventy-two patients and 21 controls entered the study. A useful pellet was obtained in 58 patients and 18 controls. Intravesical Bacillus Calmette–Guerin (BCG), Epirubicin and Mitomycin C was offered to 69%, 13.8% and 17.2% of patients respectively. Compared with healthy controls (FN = 1.0 fold), overall median FN expression before adjuvant intravesical therapy was 1.73 fold [interquartile range (IQR) 0.8–2.3], while during therapy median FN expression increased to 3.41 (IQR: 1.6–6.1) fold. Considering 40 intermediate and high-risk patients undergoing intravesical BCG, median FN expression before adjuvant treatment was 1.92 [(IQR: 1.0–2.7) fold, increasing up to 4.1 (IQR: 1.9–6.6) during therapy. In more detail, FN increased during BCG therapy, showing a median expression of 4.22 (IQR: 2.2–5.5) and 6.16 (IQR: 2.6–8.7) fold in presence of grade 2 and 3 toxicity respectively, while remaining more or less stable in asymptomatic patients. After receiver operating characteristic curve analysis, FN value of 3.6 fold resulted, corresponding to 75% sensitivity and 69% specificity to predict grade 2–3 toxicity events (area under the curve 0.74, 95% confidence interval 0.63–0.85, p = 0.001). Conclusion: Our study validated the correlation between FN expression and urothelial damage. BCG seems to induce a urothelial activation with FN overexpression during adjuvant intravesical therapy. Grade of toxicity was related to FN expression.

Objective: To evaluate the efficacy of a phytotherapic combination of L-Methionine associated with Hibiscus sabdariffa and Boswellia serrata for treatment of acute episodes of uncomplicated urinary tract infections (UTI) in women affected by recurrent UTIs. Materials and methods: In this randomized phase III clinical trial, adult females with uncomplicated UTI were enrolled into one of the following treatment groups: Group A: phytotherapic combination 1 tablet in the morning and 1 tablet in the evening for 7 days; Group B: Short term antibiotic treatment according to international guidelines recommendations. At baseline, all patients were evaluated by a urologist and quality of life (QoL) questionnaires and mid-stream urine culture. Same clinical and laboratory investigations were repeated at each follow-up visit. Results: Forty-six patients were enrolled in Group A and 47 in Group B. At the first follow-up (30 days), both groups showed a statistically significant improvement in quality of life scores as compared with baseline assessment [Group A: (QoL 94.3 VS 98.5 p < 0.001); Group B: (QoL 94.5 VS 98.7 p < 0.001)]. An improvement from baseline was also seen at the second followup evaluation after 3 months [Group A: (QoL 94.3 VS 99.1 p < 0.001); Group B: (QoL 94.5 VS 98.1 p < 0.001)]. At the second follow-up visit, a statistically significant difference in QoL was reported between the two groups (99.1 VS 98.1; p < 0.003) and a transition from UTI to asymptomatic bacteriuria (ABU) was observed 12 of 46 (26%) patients in Group A, while no patients in Group B demonstrated ABU (p = 0.007). Conclusions: Here, we demonstrated that this phytotherapic combination is able, in comparison to antibiotic treatment, to improve patients quality of life, reducing symptoms in acute setting and preventing the recurrences. Interestingly, a significantly higher proportion of patients in the phytotherapy group had ABU after three months. Our findings are of great interest in an antibiotic stewardship perspective.

Context: The correlation between aggressive prostate cancer and obesity mainly based on body mass index (BMI) and pathology after surgery remains controversial. Aims: The aim of the study was to correlate BMI, visceral adiposity index (VAI), and the plasmatic levels of leptin, adiponectin, and matrix metalloproteinase-3 (MMP-3), and biomarkers of adipose tissue function, with the detection of Gleason patterns 4 and 5 at biopsy. Subjects and Methods: Consecutive patients with prostate cancer at 12-core transrectal biopsy were enrolled. BMI, waist circumference (WC), blood samples to evaluate the plasmatic levels of triglycerides (TG) and high-density lipoproteins (HDL), adiponectin, leptin, and MMP-3 were obtained immediately before biopsy. The VAI was calculated according to the formula: WC/(39.68 + [1.88 × BMI]) × TG/1.03 × 1.31/HDL. Results: One hundred and forty-nine patients were entered. The median PSA, BMI, and VAI were 10.0 ng/ml, 27.6 kg/m2, and 4.6, respectively. Gleason patterns 4 or 5 were detected in 68 (45.6%) patients; in 15 (41.7%), 31 (44.9%), and 22 (50.0%) among normal weight, overweight, and obese patients, respectively (P = 0.55). The statistical analysis did not show any significant correlation between BMI, VAI, the plasmatic levels of leptin, adiponectin, MMP-3, and the detection of Gleason patterns 4 and 5 at biopsy. A statistically significant association emerged with older age (P = 0.017) and higher PSA values (P = 0.02). Conclusion: We did not find any association between BMI, VAI, the plasmatic levels of adiponectin, leptin, and MMP-3 and the detection of Gleason patterns 4 and 5 at prostate biopsy.

ABSTRACT Purpose: The conservative management of localized renal masses has been recently widened to cT2 tumors showing encouraging functional and oncological outcomes (1). This video aims to report the conservative management of a highly complex renal tumor treated with robotic pure enucleation in our center, specifically focusing on preoperative work-up, video-reported surgical steps and perioperative outcomes. Materials and Methods: A 63 year-old lady underwent CT scan revealing a single 75 x 68mm, mainly endophytic, right renal mass dislocating the vascular pedicle (cT3a). Two renal arteries and two veins were identified. PADUA, RENAL and simplified SPARE scores were 14a, 12a and 12 respectively. Since the contralateral kidney was hypotrophic, the indication for nephron-sparing approach was considered absolute. Preoperative surgical planning included the employment of 3D-virtual models (2). Results: Operative time was 150 minutes and warm ischemia time was 25 minutes. No major complication occurred. Histopathological analysis revealed a cromophobe renal cell carcinoma with extension to perirenal fat tissue (pT3a). Resection technique was classified as pure enucleation since Surface-Intermediate-Base (SIB) score was 0-0-0 (3, 4). At seven-months follow-up no signs of local or systemic recurrence were recorded. Postoperative CT-scan revealed optimal parenchymal volume preservation with last creatinine blood level of 1.16mg/dL. Conclusion: This video highlights how, in experienced hands, robotic partial nephrectomy represents a feasible, effective treatment option for surgical management of highly complex renal tumors. The employment of intraoperative ultrasonography and 3D-virtual models allowed to accurately tailor surgical approach, improving the perception of tumor anatomy and its vascularization and maximizing perioperative outcomes.

Objective: The purpose of this study was to provide a detailed analysis of surgical and functional outcomes after correction of acquired buried penis in the adult. Materials and Methods: From 2006 to 2016, we retrospectively reviewed 47 patients undergoing surgical treatment for the correction of buried penis. Functional and surgical outcomes, as well as patients’ satisfaction were the main endpoints. Results: The most common complains at presentation were recurrent uro-genital infections, sexual dysfunction, voiding dysfunction and Lichen Sclerosus (LS). Surgical management steps included: circumcision (27.66%), scrotoplasty (19.14%), V-Y skin plasty (4.25%), split thickness skin graft (STSG) 12.76%, full thickness skin graft (FTSG) 36.17%, suprapubic fat pad excision (57.44%), abdominoplasty (25.53%), division of the suspensory ligament (36.17%). Postoperative complications were recorded in 15% of patients. Vaginal penetration and erectile function ended up being more effective in 97.87% (46/47) and 42.55% (20/47) of patients. Improvement in penile erogenous sensation was in 6.38% (3/47). Aesthetic appearance of genitalia fully satisfied 36.17% of patients (17/47). Overall patients’ satisfaction rate resulted 76.59% (36/47). Conclusion: Management of adult acquired buried penis still remains a challenging task to achieve, however excellent cosmetic results can be obtained by surgical reconstruction.

Background: The role of lymph node dissection (LND) for renal cell carcinoma (RCC) is controversial. Notably, the conflicting evidence on the benefits and harms of LND is inherently linked to the lack of consensus on both anatomic templates and extent of lymphadenectomy. Herein, we provide a detailed overview of the most commonly dissected templates of LND for RCC, focusing on key anatomic landmarks and patterns of lymphatic drainage.Methods: A systematic review of the English-language literature was performed without time filters in July 2018 in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement recommendations. The primary endpoint was to summarize the most commonly dissected templates of LND according to the side of RCC.Results: Overall, 25 studies were selected for qualitative analysis. Of these, most were retrospective. The LND template was heterogeneous across studies. Indications and extent of LND were either not reported or not standardized in most series. The most commonly dissected template for right-sided tumors included hilar, paracaval, and precaval nodes, with few authors extending the dissection to the inter-aortocaval, retrocaval, common iliac or pre/paraaortic nodes. Similarly, the most commonly dissected template for left-sided tumors encompassed the renal hilar, preaortic and paraaortic nodes, with few authors reporting a systematic dissection of inter-aortocaval, retro-aortic, common iliac, or para-caval nodes.Conclusions: In light of the unpredictable renal lymphatic anatomy and the evidence from available prospective mapping studies, the extent of the most commonly dissected templates might be insufficient to catch the overall anatomic pattern of lymphatic drainage from RCC.

Systemic treatment of renal cancer (RCC) has undergone remarkable changes over the past 20 years with the introduction of immunotherapeutic agents targeting programmed cell death (PD-1)/programmed death-ligand 1 (PD-L1) axis, as a single-agent or combined with anti-CTLA-4 monoclonal antibodies (MoAbs) or a multi-target vascular endothelial growth factor-(VEGF) tyrosine kinase inhibitor (TKI). In this paper, we review the main evidence on the use of Immune Checkpoint Inhibitors (ICIs) for RCC treatment from the first demonstration of activity of a nivolumab single agent in a phase I trial to the novel combination strategies (anti-PD-1 plus anti-CTLA4 or anti-PD-1 plus TKI). In addition, we discuss the use of anti-PD-1/PD-L1 agents in patients with non-clear cells and rare histological subtype RCC. Then, we critically examine the current findings in biomarkers that have been proposed to be prognostic or predictive to the response of immunotherapy including immune gene expression signature, B7-H1 expression, PBRM1 loss of function, PD-L1 expression, frame shift indel count, mutations in bromodomain-containing genes in patients with MiT family translocation RCC (tRCC), high expression of the T-effector gene signature, and a high myeloid inflammation gene expression pattern. To date, a single biomarker as a predictor of response has not been established. Since the dynamic behavior of the immune response and the different impact of ICI treatment on patients with specific RCC subtypes, the integration of multiple biomarkers and further validation in clinical trials are needed.

We present an uncommon case of mucinous adenocarcinoma of the bladder (MAB) with signet-ring cells extensively infiltrating prostate gland and pelvic/retroperitoneal lymph node stations and not responsive to usual systemic chemotherapy regimens. This case highlights the important features of MAB including the pattern of tumor spread, the tendency for initial misdiagnosis, and the importance of immunohistochemical study in order to define its primary origin from the bladder and choose the most appropriate treatment since the beginning.