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Background: Differences have often been reported in the outcomes of bladder cancer (BC) patients according to gender., Objective: This study aims to provide data on patients undergoing radical cystectomy (RC) in a high-volume tertiary urologic center and to assess whether gender discrepancies do exist in terms of surgical options and clinical outcomes., Materials and Methods: Consecutive BC patients treated between 2016 and 2020 at a single center (Careggi University Hospital, Florence, Italy) were included in the study. The impact of gender on disease stage at diagnosis, overall survival (OS), and type of surgery was analyzed., Results: The study series comprised 447 patients (85 females and 362 males). At a median follow-up of 28.3 months (IQR: 33.5), OS was 52.6% and cancer-specific survival was 67.6%. Significant differences in OS emerged for age, acute myocardial infarction (AMI), Charlson Comorbidity Index (CCI), pT, and pN. OS rates were higher in patients undergoing robot-assisted surgery and in those receiving open orthotopic neobladder (ONB) (p = 0.0001). No statistically significant differences were found between male and female patients regarding surgical offer in any age group, surgical time, early postoperative complications, pathologic stage, and OS., Conclusions: After adjustment for pathologic tumor stage and treatment modalities, female and male patients showed similar oncologic outcomes. Further studies should be undertaken to evaluate functional results in women subjected to RC., Competing Interests: Declaration of competing interest All authors declare that there's no financial/personal interest or belief that could affect their objectivity. They also declare that there's no potential competing interests., (© 2023 Published by Elsevier Ltd.)

Background: Robot-assisted kidney transplantation (RAKT) is increasingly performed at selected referral institutions worldwide. However, simulation and proficiency-based progression training frameworks for RAKT are still lacking, making acquisition of the RAKT-specific skill set a critical unmet need for future RAKT surgeons., Objective: To develop and test the RAKT Box, the first entirely 3D-printed, perfused, hyperaccuracy simulator for vascular anastomoses during RAKT., Design Setting and Participants: The project was developed in a stepwise fashion by a multidisciplinary team including urologists and bioengineers via an iterative process over a 3-yr period (November 2019-November 2022) using an established methodology. The essential and time-sensitive steps of RAKT were selected by a team of RAKT experts and simulated using the RAKT Box according to the principles of the Vattituki-Medanta technique. The RAKT Box was tested in the operating theatre by an expert RAKT surgeon and independently by four trainees with heterogeneous expertise in robotic surgery and kidney transplantation., Surgical Procedure: Simulation of RAKT., Measurements: Video recordings of the trainees' performance of vascular anastomoses using the RAKT Box were evaluated blind by a senior surgeon according to the Global Evaluative Assessment of Robotic Skills (GEARS) and Assessment of Robotic Console Skills (ARCS) tools., Results and Limitations: All participants successfully completed the training session, confirming the technical reliability of the RAKT Box simulator. Tangible differences were observed among the trainees in both anastomosis time and performance metrics. Key limitations of the RAKT Box include lack of simulation of the ureterovesical anastomosis and the need for a robotic platform, specific training instruments, and disposable 3D-printed vessels., Conclusions: The RAKT Box is a reliable educational tool to train novice surgeons in the key steps of RAKT and may represent the first step toward the definition of a structured surgical curriculum in RAKT., Patient Summary: We describe the first entirely 3D-printed simulator that allows surgeons to test the key steps of robot-assisted kidney transplantation (RAKT) in a training environment before performing the procedure in patients. The simulator, called the RAKT Box, has been successfully tested by an expert surgeon and four trainees. The results confirm its reliability and potential as an educational tool for training of future RAKT surgeons., (© 2023 The Author(s).)

Background: The use of kidneys from "expanded criteria" donors after brain death (ECD) and uncontrolled donors after circulatory death (uDCD) has been warranted to increase the pool of donors for kidney transplantation (KT). However, there is lack of evidence on the feasibility and safety of KT from such donors in the Italian setting., Methods: We queried our prospectively KT database to select patients undergoing KT from deceased donors (uDCDs, ECDs, and standard-criteria donors [SCD] after brain death) from January 2017 to December 2020, comparing the perioperative and mid-term functional outcomes., Results: Overall, 172 KTs were included. The donor's profile was different among the study groups, while recipients' characteristics were similar expect for median age. Grafts from uDCDs and ECDs had longer median cold ischemia times as compared to grafts from SCDs. The proportion of patients experiencing DGF, the median hospitalization, as well as the overall and major complications rate, were significantly higher among recipients from uDCDs. The proportion of patients needing dialysis at last follow-up was significantly higher among recipients from uDCDs (33.3% vs. 8.5% vs. 5.4%, P<0.001). However, the median eGFR at the last follow-up was lower for recipients from ECDs compared to those from uDCDs and SCDs, respectively (P<0.001)., Conclusions: While "marginal" donors represent a relevant source of organs, KTs from uDCDs carry higher risks of major surgical complications, DGF, and worse graft survival as compared to KT from both ECDs and SCDs. As such, the use of grafts from uDCDs should be carefully assessed balancing the potential benefits with the risk of primary no function and the subsequent immunological sensitization.

Background: The aim of our study is to evaluate the prevalence and predictive factors of short- (30 d) and mid-term continence in a contemporary cohort of patients treated with robotic-assisted laparoscopic prostatectomy (RALP) without any posterior or anterior reconstruction at our referral academic center., Methods: Data from patients undergoing RALP between January 2017 and March 2021 were prospectively collected. RALP was performed by three highly experienced surgeons following the principles of the Montsouris technique, with a bladder-neck-sparing intent and maximal preservation of the membranous urethra (if oncologically safe) without any anterior/posterior reconstruction. (Self-assessed urinary incontinence (UI) was defined as the need of one or more pads per die (excluding the need for a safety pad/die. Univariable and multivariable logistic regression analysis was used to assess the independent predictors of early incontinence among routinely collected patient- and tumor-related variables)., Results: A total of 925 patients were included; of these, 353 underwent RALP (38.2%) without nerve-sparing intent. The median patient age and BMI were 68 years (IQR 63-72) and 26 (IQR 24.0-28.0), respectively. Overall, 159 patients (17.2%) reported early (30 d) incontinence. In multivariable analysis adjusting for patient- and tumor-related features, a non-nerve-sparing procedure (OR: 1.57 [95% CI: 1.03-2.59], p = 0.035) was independently associated with the risk of urinary incontinence in the short-term period, while the absence of cardiovascular diseases before surgery (OR: 0.46 [95% CI: 0.320.67], p ≤ 0.01) was a protective factor for this outcome. At a median follow-up of 17 months (IQR 10-24), 94.5% of patients reported to be continent., Conclusions: In experienced hands, most patients fully recover urinary continence after RALP at mid-term follow-up. On the contrary, the proportion of patients who reported early incontinence in our series was modest but not negligible. The implementation of surgical techniques advocating anterior and/or posterior fascial reconstruction might improve the early continence rate in candidates for RALP.

Kidney transplantation (KT) is the treatment of choice for patients with end-stage renal disease, providing a better survival rate and quality of life compared to dialysis. Despite the progress in the medical management of KT patients, from a purely surgical standpoint, KT has resisted innovations during the last 50 years. Recently, robot-assisted KT (RAKT) has been proposed as an alternative approach to open surgery, especially due to its potential benefits for fragile and immunocompromised recipients. It was not until 2014 that the role of RAKT has found value thanks to the pioneering Vattikuti Urology Institute-Medanta collaboration that conceptualized and developed a new surgical technique for RAKT following the Idea, Development, Exploration, Assessment, Long-term follow-up recommendations for introducing surgical innovations into real-life practice. During the last years, mirroring the Vattikuti-Medanta technique, several centers developed RAKT program worldwide, providing strong evidence about the safety and the feasibility of this procedure. However, the majority of RAKT are still performed in the living donor setting, as an "eligible" procedure, while only a few centers have realized KT through a robotic approach in the challenging scenario of cadaver donation. In addition, despite the spread of minimally-invasive (predominantly robotic) surgery worldwide, many KTs are still performed in an open fashion. Regardless of the type of incision employed by surgeons, open KT may lead to non-negligible risks of wound complications, especially among obese patients. Particularly, the assessment for KT should consider not only the added surgical technical challenges but also the higher risk of postoperative complications. In this context, robotic surgery could offer several benefits, including providing a better exposure of the surgical field and better instrument maneuverability, as well as the possibility to integrate other technological nuances, such as the use of intraoperative fluorescence vascular imaging with indocyanine green to assess the ureteral vascularization before the uretero-vesical anastomosis. Therefore, our review aims to report the more significant experiences regarding RAKT, focusing on the results and future perspectives., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Objective: To report the outcomes of surgery for a contemporary series of patients with locally advanced non-metastatic renal cell carcinoma (RCC) treated at a referral academic centre, focusing on technical nuances and on the value of a multidisciplinary team., Methods: We queried our prospective institutional database to identify patients undergoing surgical treatment for locally advanced (cT3-T4 N0-1 M0) renal masses suspected of RCC at our centre between January 2017 and December 2020., Results: Overall, 32 patients were included in the analytic cohort. Of these, 12 (37.5%) tumours were staged as cT3a, 8 (25.0%) as cT3b, 5 (15.6%) as cT3c, and 7 (21.9%) as cT4; 6 (18.8%) patients had preoperative evidence of lymph node involvement. Nine (28.1%) patients underwent nephron-sparing surgery while 23 (71.9%) received radical nephrectomy. A template-based lymphadenectomy was performed in 12 cases, with evidence of disease in 3 (25.0%) at definitive histopathological analysis. Four cases of RCC with level IV inferior vena cava thrombosis were successfully treated using liver transplant techniques without the need for extracorporeal circulation. While intraoperative complications were recorded in 3 (9.4%) patients, no postoperative major complications (Clavien-Dindo ≥3) were observed. At histopathological analysis, 2 (6.2%) patients who underwent partial nephrectomy harboured oncocytoma, while the most common malignant histotype was clear cell RCC (62.5%), with a median Leibovich score of 6 (interquartile range 5-7)., Conclusion: Locally advanced RCC is a complex and heterogenous disease posing several challenges to surgical teams. Our experience confirms that provided careful patient selection, surgery in experienced hands can achieve favourable perioperative, oncological, and functional outcomes., Competing Interests: The authors declare no conflict of interest., (© 2022 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V.)

Background: While robot-assisted kidney transplantation (RAKT) from living donors has been shown to achieve favourable outcomes, there is a lack of evidence on the safety and efficacy of RAKT as compared with the gold standard open kidney transplantation (OKT) in the setting of deceased donors, who represent the source of most grafts worldwide., Objective: To compare the intraoperative, perioperative, and midterm outcomes of RAKT versus OKT from donors after brain death (DBDs)., Design Setting and Participants: Data from consecutive patients undergoing RAKT or OKT from DBDs at a single academic centre between October 2017 and December 2020 were prospectively collected., Intervention: RAKT or OKT., Outcome Measurements and Statistical Analysis: The primary outcomes were intraoperative adverse events, postoperative surgical complications, delayed graft function (DGF), and midterm functional outcomes. A multivariable logistic regression analysis assessed the independent predictors of DGF, trifecta, and suboptimal graft function (estimated glomerular filtration rate [eGFR] <45 ml/min/1.73 m 2 ) at the last follow-up., Results and Limitations: Overall, 138 patients were included (117 [84.7%] OKTs and 21 [15.3%] RAKTs). The yearly proportion of RAKT ranged between 10% and 18% during the study period. The OKT and RAKT cohorts were comparable regarding all graft-related characteristics, while they differed regarding a few donor- and recipient-related factors. The median second warm ischaemic time, ureterovesical anastomosis time, postoperative complication rate, and eGFR trajectories did not differ significantly between the groups. A higher proportion of patients undergoing OKT experienced DGF; yet, at a median follow-up of 31 mo (interquartile range 19-44), there was no difference between the groups regarding the dialysis-free and overall survival. At the multivariable analysis, donor- and/or recipient-related factors, but not the surgical approach, were independent predictors of DGF, trifecta, and suboptimal graft function at the last follow-up. The study is limited by its nonrandomised nature and the small sample size., Conclusions: Our study provides preliminary evidence supporting the noninferiority of RAKT from DBDs as compared with the gold standard OKT in carefully selected recipients., Patient Summary: Kidney transplantation using kidneys from deceased donors is still being performed with an open surgical approach in most transplant centres worldwide. In fact, no study has compared the outcomes of open and minimally invasive (robotic) kidney transplantation from deceased donors. In this study, we evaluated whether robotic kidney transplantation using grafts from deceased donors was not inferior to open kidney transplantation regarding the intraoperative, postoperative, and midterm functional outcomes. We found that, in experienced hands and provided that there was a time-efficient organisation of the transplantation pathway, robotic kidney transplantation from deceased donors was feasible and achieved noninferior outcomes as compared with open kidney transplantation., (© 2022 The Author(s).)

Background: The aim of the present study was to describe our totally intracorporeal robotic ileal ureter replacement technique, reporting perioperative and mid-term results and compare it with previous similar experiences, specifically focusing on technical considerations., Methods: Three patients were submitted to robotic ileal ureter substitution for long ureteral defects in our institution during 2019. The procedures were carried out fully intracorporeally. Two patients received a complete replacement of the urinary tract using an ileal segment, while in one patient the lower ureteral stump was maintained, and an ileal-ureter anastomosis was performed distally. Patients' baseline characteristics, as well as perioperative and mid-term results were collected. A detailed description of the technique is reported and compared with prior similar experiences., Results: Median operative time was 270 (range 240-300) min. No Clavien-Dindo complication >2 was collected. All patients experienced a fast return to oral intake and canalization. Antegrade pyelography, performed a 1-month follow-up, revealed full passage of the medium contrast in those patients submitted to complete ileal ureter replacement while, in the third one, stenosis at the level of ileal-ureter anastomoses was found., Conclusions: Robotic ileal ureter replacement can be performed completely intracorporeal with optimal results and limited complication rate, in selected cases. According to our considerations, specific surgical steps are needed to reduce the risks related to this procedure, including avoiding partial ileal substitution.

Objectives: The incidence of prostate cancer in renal transplant recipients (RTRs) is increasing, but few data are available in the literature. In this study, we reviewed the 25-year experience in the management of prostate cancer after kidney transplantation at the Florence Transplant Centre. Methods: We retrospectively reviewed the data from 617 RTR male patients who underwent renal transplantation at our institute between July 1996 and September 2016. Data regarding demographics, renal transplantation, prostate cancer and immunosuppressive treatment were analyzed. The probability of death was estimated by using the Kaplan-Meier method and differences between patients' groups were assessed by the log-rank test. Results: From July 1991 to September 2016, 617 kidney transplantations of male patients were performed at our institute. Among these, 20 patients were subsequently diagnosed with prostate cancer accounting for a cumulative incidence of 3.24%. After a median follow-up of 59 months, 10 patients underwent radical prostatectomy whereas 10 patients underwent primary radiotherapy. A biochemical recurrence was identified in five (25%) patients while a fatal event occurred in 11 (55%) patients. Univariate Cox regression showed that the basal value of PSA >10 ng/ml was the only significant factor negatively affecting the survival of patients. Conclusions: Standard treatments can be proposed to RTR with satisfactory results on both post-operative and oncological outcomes. Further studies are needed to address the issue of prostate cancer screening based on PSA levels and the optimal management of prostate cancer in RTRs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer JGR declared a past co-authorship with the authors FS and SS to the handling editor., (Copyright © 2021 Spatafora, Sessa, Caroassai Grisanti, Bisegna, Saieva, Roviello, Polverino, Rivetti, Verdelli, Zanazzi, Beatrice, Vignolini, Nesi, Nicita, Serni and Villari.)

Background: Recording the entire sexual history of a patient from the very first sexual experiences to the current sexual habits is a challenging issue that physicians usually address with partial and non-standardized interviews., Objectives: To validate the SExual Chronicle REcording Table (SECRET ® ), a structured written interview, developed and copyrighted both in English and Italian languages., Materials and Methods: A multicenter national validation study was performed asking 300 male patients affected by uro-andrological diseases to complete SECRET ® . The structured interview is based on four sexual dimensions (masturbation, oral, vaginal and anal sex), declined in seven items (1.Have you ever performed/Do you perform; 2.At what age did you first experience; 3.How many times a month; 4.With how many partners; 5.How much did/do you enjoy; 6.How many times did/do you use a condom; 7.How many times did/do you use the pull-out method). Data were stratified according to four stages of life (<30; 30-45; 45-60; >60 years old). Validity and reliability were assessed by using standard statistical methods for SECRET ® validation., Results: Overall, 295 patients (98.4%) filled all the questions. SECRET ® showed a high level of internal coherence (Cronbach's alpha coefficient ranged from 0.85 to 0.97) and reproducibility (paired sample t-test at Test-Retest: p > .10)., Conclusions: SECRET ® represents a novel, simple instrument to record a patient's sexual history in daily clinical practice and clinical research. SECRET ® has shown a good validity, internal consistence and reliability in different clusters of patients with uro-andrological diseases., (© 2020 American Society of Andrology and European Academy of Andrology.)

Purpose: The main objective was to compare minor (Clavien I-II) and major (Clavien ≥ III) intra- and postoperative complications of living donor robotic assisted kidney transplantation (RAKT) in obese (≥ 30 kg/m 2 BMI), overweight (< 30/ ≥ 25 kg/m 2 BMI) and non-overweight recipients (< 25 kg/m 2 BMI)., Methods: For the present retrospective study, we reviewed the multi-institutional ERUS-RAKT database to select consecutive living donor RAKT recipients. Functional outcomes, intra- and postoperative complications were compared between obese, overweight and non-overweight recipients., Results: 169 living donor RAKTs were performed, by 10 surgeons, from July 2015 to September 2018 in the 8 European centers. 32 (18.9%) recipients were obese, 66 (39.1%) were overweight and 71 (42.0%) were non-overweight. Mean follow-up was 1.2 years. There were no major intra-operative complications in either study group. Conversion to open surgery occurred in 1 obese recipient, in 2 overweight recipients and no conversion occurred in non-overweight recipients (p = 0.3). Minor and major postoperative complications rates were similar in the 3 groups. At one-year of follow-up, median eGFR was similar in all groups [54 (45-60) versus 57 (46-70) versus 63 (49-78) ml/min/1.73 m 2 in obese, overweight and non-overweight recipient groups, respectively, p = 0.5]. Delayed graft function rate was similar in the 3 groups. Only the number of arteries was an independent predictive factor of suboptimal renal function at post-operative day 30 in the multivariate analysis., Conclusion: RAKT in obese recipients is safe, compared to non-overweight recipients and yields very good function, when it performed at high-volume referral centers by highly trained transplant teams.

Objective: To report the results of the robot-assisted kidney transplantation (RAKT) experience performed in 10 European centres by members of the European Robotic Urology Section (ERUS)-RAKT group., Patients and Methods: This is a multicentre prospective observational study of RAKT. Descriptive analysis of recipients and donor characteristics, surgical data, intraoperative outcomes, complications rate and functional results were collected and analysed., Results: Between July 2015 and September 2019, 291 living-donor RAKTs were performed. Recipients were mostly male (189 [65%]), the mean Standard deviation (sd) age was 45.2 (13.35) years, the mean (sd) body mass index was 27.13 (19.28) kg/m 2 , and RAKT was pre-emptive in 155 (53.8%) cases. Right and multiple arteries kidneys were used in 15.4%. The mean (sd) total surgical and re-warming time was 244 (70.5) min and 53.16 (15.27) min, respectively. In all, 17 patients presented with postoperative bleeding (5.7%). Five kidneys had delayed graft function; five (2%) were lost due to thrombosis and one due to acute rejection. Two patients had arterial stenosis, three had incisional hernias, six had ureteric stenosis, and nine had lymphoceles. Neither surgical nor re-warming times were correlated with postoperative serum creatinine levels (P > 0.05). Comparison of surgical data between the first 120 cases and the following 171 cases showed a significantly shorter total surgical time in the second group (265 vs 230 min, P = 0.005)., Conclusions: This is the largest European multicentre study of RAKT with good surgical and functional results competitive with open kidney transplant series, with a relatively short learning curve when performed in centres with a wide experience in open kidney transplantation and robotic surgery., (© 2020 The Authors BJU International © 2020 BJU International Published by John Wiley & Sons Ltd.)