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Background: Evidence-practice gaps exist in urology. We previously surveyed European Association of Urology (EAU) guidelines for strong recommendations underpinned by high-certainty evidence that impact patient experience for which practice variations were suspected. The recommendation “Do not offer neoadjuvant androgen deprivation therapy (ADT) before surgery for patients with prostate cancer” was prioritised for further investigation. ADT before surgery is neither clinically effective nor cost effective and has serious side effects. The first step in improving implementation problems is to understand their extent. A clear picture of practice regarding ADT before surgery across Europe is not available. Objective: To assess current ADT use before prostate cancer surgery in Europe. Design, setting, and participants: This was an observational cross-sectional study. We retrospectively audited recent ADT practices in a multicentre international setting. We used nonprobability purposive sampling, aiming for breadth in terms of low- versus high-volume, academic, versus community and public versus private centres. Outcome measurements and statistical analysis: Our primary outcome was adherence to the ADT recommendation. Descriptive statistics and a multilevel model were used to investigate differences between countries across different factors (volume, centre type, and funding type). Subgroup analyses were performed for patients with low, intermediate, and high risk, and for those with locally advanced prostate cancer. We also collected reasons for nonadherence. Results and limitations: We included 6598 patients with prostate cancer from 187 hospitals in 31 countries from January 1, 2017 to May 1, 2020. Overall, nonadherence was 2%, (range 0–32%). Most of the variability was found in the high-risk subgroup, for which nonadherence was 4% (range 0–43%). Reasons for nonadherence included attempts to improve oncological outcomes or preoperative tumour parameters; attempts to control the cancer because of long waiting lists; and patient preference (changing one's mind from radiotherapy to surgery after neoadjuvant ADT had commenced or feeling that the side effects were intolerable). Although we purposively sampled for variety within countries (public/private, academic/community, high/low-volume), a selection bias toward centres with awareness of guidelines is possible, so adherence rates may be overestimated. Conclusions: EAU guidelines recommend against ADT use before prostate cancer surgery, yet some guideline-discordant ADT use remains at the cost of patient experience and an additional payer and provider burden. Strategies towards discontinuation of inappropriate preoperative ADT use should be pursued. Patient summary: Androgen deprivation therapy (ADT) is sometimes used in men with prostate cancer who will not benefit from it. ADT causes side effects such as weight gain and emotional changes and increases the risk of cardiovascular disease, diabetes, and osteoporosis. Guidelines strongly recommend that men opting for surgery should not receive ADT, but it is unclear how well the guidance is followed. We asked urologists across Europe how patients in their institutions were treated over the past few years. Most do not use ADT before surgery, but this still happens in some places. More research is needed to help doctors to stop using ADT in patients who will not benefit from it.

Background Few studies examined the role of prostate MRI in patients with abnormal digital rectal examination (DRE) and/or PSA > 10 ng/ml. In a cohort of non-screened patients with abnormal DRE, we investigated the rate of avoidable prostate biopsies and potentially missed clinically significant prostate cancer (csPCa) with negative MRI, and the concordance between targeted biopsy (TBx) and systematic biopsy (SBx) in detecting csPCa with positive MRI.Methods We retrospectively examined 199 biopsy-naïve patients with abnormal DRE who underwent prostate MRI before transperineal biopsy. Prostate Imaging - Reporting And Data System (PI-RADS) v2.1 ≥ 3 category of the index lesion defined a positive MRI. Combined TBx/SBx and SBX alone was performed for positive and negative MRI, respectively. An International Society of Urogenital Pathology Grade Group ≥2 defined csPCa. We calculated csPCa detection rate of TBx, SBx and combined TBx/SBx. The Cohen kappa statistic was used to measure the concordance between TBx and SBx.Results Ninety-one (45.7%) csPCa cases were detected. MRI was positive in 153 (76.9%) patients. In the 46 patients with negative MRI, SBx detected 5 (10.9%) csPCa cases. Prostate biopsy could, thus, be avoided in 41/199 (20.6%) patients at the cost of missing 5/91 (5.5%) csPCa cases. The concordance between TBx and SBx in detecting csPCa with positive mpMRI was substantial (k 0.70). Specifically, 6/86 (6.9%) csPCa cases were detected with TBx, and 17/86 (19.7%) with SBx alone. Concordance was almost perfect (k 0.82) in patients with PSA > 10 ng/ml. Only 4/38 (10.5%) csPCa cases were missed by TBx, and only 1 (2.6%) csPCa case was identified by TBx alone.Conclusion MRI in patients with abnormal DRE could avoid roughly 21% of unnecessary biopsies at the cost of missing approximately 6% of csPCa cases. Moreover, MRI and TBx complemented SBx in detecting csPCa in the subgroup with PSA > 10 ng/ml.

Androgen independency is associated with poor prostate cancer (PCa) survival. Here we report that silencing of transglutaminase-2 (TG2) expression by CRISPR-Cas9 is associated with upregulation of androgen receptor (AR) transcription in prostate cancer cell lines. Knockout of TG2 reversed the migratory potential and anchorage independency of PC3 and DU145 cells and revealed a reduced level of MUC1 RNA transcript through unbiased multi-omics profiling, which was restored by selective add back of the truncated TG2 isoform (TGM2_v2). Silencing of AR resulted into increased MUC1 in TG2KO PC3 cells showing that TG2 affects transcriptional regulation of MUC1 via repressing AR expression. Treatment of PC3 WT cell line with TG2 inhibitor ZDON led to a significant increase in AR expression and decrease in MUC1. ZDON also blocked the formation of MUC1-multimers labelled with TG amine-donor substrates in reducing conditions, revealing for the first time a role for TG2, which we show to be externalised via extracellular vesicles, in MUC1 stabilisation via calcium-dependent transamidation. A specific antibody towards TGM2_v2 revealed its restricted nuclear location compared to the canonical long form of TG2 (TGM2_v1), which is predominantly cytosolic, suggesting that this form contributes to the previously suggested TG2-mediated NF-κB activation and AR transcriptional repression. As TGM2_v2 transcription was increased in biopsies of early-stage prostate cancer patients compared to subjects presenting inflammatory prostatitis, the role of TG2 truncated form as a prostate malignancy marker is suggested. In conclusion, this investigation has provided the first unbiased discovery of a novel pathway mediated by an aberrant form of TG2 via MUC1, which is shown to contribute to androgen insensitivity and malignancy of PCa cells and be upregulated in prostate cancer biopsies, with potential relevance to cancer immune evasion.

Retzius-sparing robot-assisted radical prostatectomy (RARP) is not yet universally accepted due to still limited functional data and some concerns on oncological safety compared to the standard one. We assessed perioperative, pathological and early functional outcomes in patients with clinically localised prostate cancer treated with Retzius-sparing versus standard RARP.A single-surgeon cohort of 207 consecutive patients undergoing RARP was analysed. A later study group of 102 patients receiving the Retzius-sparing approach was compared with an earlier control group of 105 patients receiving the standard one. Urinary continence recovery 1 week after catheter removal was the primary study outcome. Urinary continence recovery 1, 2, 3 and 6 months after catheter removal, potency recovery 6 months postoperatively, rate of perioperative complications and positive surgical margins were secondary study outcomes.Patients in the study group reported significantly higher urinary continence recovery rates 1 week (91.2% vs. 54.3%, p 0.001), 1 month (92.2% vs. 66.7%, p 0.001), 2 months (95.1% vs. 74.3%, p 0.001), 3 months (96.1% vs. 83.8%, p = 0.01), but not 6 months (97% vs 90.5%, p = 0.09) after catheter removal compared to controls. Potency recovery rates 6 months after catheter removal were significantly higher in the study than the control group (68.2% vs 51.6%, p = 0.03). On multivariable analyses, the Retzius-sparing approach was an independent predictor of 1-week urinary continence recovery, but not of 6-month potency recovery. There were significant differences neither in perioperative complication rate (9.8% in the study vs. 14.3% in the control group, p = 0.28) nor in positive surgical margin rate (9.8% in the study vs. 8.6% in the control group, p = 0.75).In a comparative study, we observed a significant improvement in immediate urinary continence, but not in early potency recovery, using the Retzius-sparing compared to the standard approach for RARP, with no increase in perioperative complication and positive surgical margin rate.

Background Urinary continence recovery after radical prostatectomy is a major issue even in the robotic era. Surgical techniques aimed at improving earlier return to continence are continuously sought. Objective To describe our novel surgical technique of urethral fixation during robot-assisted radical prostatectomy (RARP) and to assess early urinary continence recovery and perioperative complications. Design, setting, and participants A prospective, single-center, single-surgeon cohort of 70 consecutive patients undergoing RARP between January and December 2019 was analyzed. A study group of 35 patients operated on with the urethral fixation technique was compared with a control group of 35 patients receiving standard vesicourethral anastomosis. Surgical procedure Urethral fixation versus standard vesicourethral anastomosis during RARP was evaluated. In the study group, the urethral stump was fixed to the dorsal median raphe posteriorly and to the medial portion of the levator ani muscle posterolaterally. The same posterior musculofascial reconstruction incorporating the vesicourethral anastomosis was performed in both groups. Measurements Urinary continence recovery, perioperative complications, operating room time, and estimated blood loss were recorded and compared between the two groups. Results and limitations The two groups were comparable with regard to all demographic, clinical, and pathological variables. Recovery of urinary continence at 3 mo after catheter removal was reported by 34 (97.1%) patients in the study and 28 (80%) patients in the control group (p = 0.02). Patients in the study group reported significantly higher rates of urinary continence even at 1 wk and 1 mo after catheter removal compared with the control group (68.6% vs 45.7%, p = 0.04, and 80% vs 54.3%, p = 0.04, respectively). No differences were observed in operating room time (p = 0.7) or estimated blood loss (p = 0.65). Ninety-day postoperative complications were observed in one (2.9%) patient in the study and in four (11.4%) in the control group (p = 0.3). The main limitation is the nonrandomized comparison of relatively small cohorts. Conclusions In our study, we observed a significant improvement in early urinary continence recovery, with no increase in operating room time or perioperative complications, using the novel urethral fixation technique compared with the standard vesicourethral anastomosis during RARP. Patient summary We describe our novel surgical technique of urethral fixation during robot-assisted radical prostatectomy. Compared with the standard technique, utilization of our technique was found to be associated with an improved early recovery of urinary continence, with no increase in operating room time or perioperative complications.

Objectives: To assess whether bladder neck angle and position on cystogram predict early urinary continence in patients scheduled for early catheter removal after radical prostatectomy (RP). Methods: A total of 103 patients undergoing open or robot-assisted RP by one expert surgeon between January and December 2019 were retrospectively analyzed. A cystogram was performed on postoperative day 3 or 4 to evaluate anastomotic leakage, and, if none or minimal, the catheter was removed. Urinary continence was evaluated with a validated questionnaire at 1 week, 1 month, and 3 months after RP. Four investigators of different experience assigned bladder neck angle and relative position of bladder neck to pubic symphysis on archived cystogram images. Association between these two parameters and urinary continence rates at different follow-up times was assessed with logistic regression analysis adjusting for patient and tumor characteristics, and surgical technique. Interobserver agreement in assigning the two parameters was measured with k statistic. Results: Catheter was removed immediately after cystogram in 101 (98%) patients. On multivariable analysis, only relative position of bladder neck to pubic symphysis was an independent predictor of 1-week (odds ratio [OR] 30. 95% confidence intervals [CIs] 6-138, p Conclusions: Relative position of bladder neck to pubic symphysis on cystogram is a strong and reproducible predictor of early urinary continence after RP.

INTRODUCTION AND OBJECTIVE:We have previously proposed a novel technique based on the concept of fixing the urethral stump laterally and posteriorly instead of supporting it, and have shown that ur...

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.

The aim of this study was to identify and standardize computed tomography (CT) features having a potential role in predicting aggressiveness of malignant parenchymal renal tumors suitable for partial nephrectomy (PN). We performed a non-systematic review of the recent literature to evaluate the potential impact of CT variables proposed by the Society of Abdominal Radiology Disease-Focused Panel on Renal Cell Carcinoma in predicting aggressiveness of newly diagnosed malignant parenchymal renal tumors. The analyzed variables were clinical tumor size, tumor growth rate, enhancement characteristics, amount of cystic component, polar and capsular location, tumor margins and distance between tumor and renal sinus. Unfavorable behavior was defined as: 1) renal cell carcinoma (RCC) with stage ≥pT3; 2) nuclear grade 3 or 4; 3) presence of sarcomatoid de-differentiation; or 4) non-clear cell subtypes with unfavorable prognosis (type 2 papillary RCC, collecting duct or renal medullary carcinoma, unclassified RCC). Beyond clinical tumor size, tumor growth rate, enhancement characteristics, amount of cystic component, tumor margins and distance between tumor and renal sinus are highly relevant features predicting an unfavorable behavior. Moreover, several studies supported the role of necrosis as preoperative predictor of tumor aggressiveness. Peritumoral and intratumoral vasculature as well as capsule status are emerging variables that need to be further evaluated. Tumor size, enhancement characteristics, tumor margins and distance to the renal sinus are highly relevant CT features predicting biological aggressiveness of malignant parenchymal renal tumors. Combination of these parameters might be useful to generate tools to predict the unfavorable behavior of renal tumors suitable for PN.

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.

Objective: We performed an update of previous reviews of the literature to provide an overview on incidence, predictive factors, management and prognosis of positive surgical margins (PSMs) after partial nephrectomy (PN) including recent surgical series and studies comparing different approaches and techniques. Material and methods: A literature search was performed from January 2013 to January 2018 using the Medline database. The search strategy included a free-text protocol using the term “nephron-sparing surgery” OR “partial nephrectomy” AND “positive surgical margins” across the title and abstract fields of the records. From each selected study, we extracted the following data: number of analyzed patients, study design, approach and surgical technique used, PSMs rate, pathological features, type of PSMs treatment, mean (median) follow-up duration and final patient status. Meta-analysis was conducted using Review Manager software v. 5.2 (Cochrane Collaboration, Oxford, UK). Results: We selected a total of 36 (48%) studies. All studies were retrospective and the best statistical method used for comparison was the matched-pair analysis (level 4). Overall, 45,786 patients treated with PN were included in the selected studies. PSMs were reported in a total of 3,093 (6.7%) patients. The mean estimated PSMs rate was 7%, 5% and 4.3% in patients who underwent robot-assisted PN (RAPN), laparoscopic PN (LPN) and open PN (OPN), respectively. Comparative studies showed a significant advantage in favor of OPN compared with minimally invasive approach, while RAPN showed more favourable PSMs risk compared with LPN (odds ratio 3.02, 95% confidence intervals 2.05–4.45). No differences were detected stratifying data according to other surgical or tumor-related factors. Tumor size, nuclear grading and pT3a stage represent the most important predictors of PSMs. In 6,809 patients, follow-up data were available. Only 101 (1.4%) local recurrences and 88 (1.3%) distant recurrences were observed both in PSMs and negative surgical margins subgroups. PSMs were associated with a significant increased risk of local recurrence with a significant impact on local recurrence-free survival and metastasis-free survival. However, a significant impact on cancer-specific and overall survival could not be demonstrated. Conclusions: Studies published in the last 5 years confirmed that PSMs after PN are a rare condition. Although PSMs increase the risk of local and distant recurrence, their influence on cancer-specific and overall survival seems to be limited. Close surveillance should be strongly recommended as initial treatment of patients with PSMs after PN.

To establish the current standard for open radical cystectomy (ORC) in England, as data entry by surgeons performing RC to the British Association of Urological Surgeons (BAUS) database was mandated in 2013 and combining this with Hospital Episodes Statistics (HES) data has allowed comprehensive outcome analysis for the first time.All patients were included in this analysis if they were uploaded to the BAUS data registry and reported to have been performed in the 2 years between 1 January 2014 and 31 December 2015 in England (from mandate onwards) and had been documented as being performed in an open fashion (not laparoscopic, robot assisted or the technique field left blank). The HES data were accessed via the HES website. Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures version 4 (OPCS-4) Code M34 was searched during the same 2-year time frame (not including M34.4 for simple cystectomy or with additional minimal access codes Y75.1-9 documenting a laparoscopic or robotic approach was used) to assess data capture.A total of 2 537 ORCs were recorded in the BAUS registry and 3 043 in the HES data. This indicates a capture rate of 83.4% of all cases. The median operative time was 5 h, harvesting a median of 11-20 lymph nodes, with a median blood loss of 500-1 000 mL, and a transfusion rate of 21.8%. The median length of stay was 11 days, with a 30-day mortality rate of 1.58%.This is the largest, contemporary cohort of ORCs in England, encompassing80% of all performed operations. We now know the current standard for ORC in England. This provides the basis for individual surgeons and units to compare their outcomes and a standard with which future techniques and modifications can be compared.

Background: Arteriovenous fistula is a relatively frequent complication after partial nephrectomy. The timing of this complication is generally limited to the perioperative period. In this study, we describe a case of arteriovenous fistula after imperative right partial nephrectomy occurred 2 years after surgery. Case Presentation: A 69 year-old man previously treated with left partial nephrectomy and concomitant right partial nephrectomy for synchronous bilateral renal cell carcinoma developed a right 5 cm arteriovenous fistula 2 years after the procedure. An arteriographic study of right renal vessel with concomitant embolization of the tributary artery branch was performed with the resolution of the fistula and preservation of renal function. Conclusion: Late arteriovenous fistula is a rare complication after partial nephrectomy that may occur in bleeding and affects renal function especially in solitary kidney. Radiological approach for its treatment is feasible in expert hands.

Background and objectives A detailed understanding of surgical anatomy is an essential requisite to maximize perioperative and functional outcomes of partial nephrectomy. The objectives of this study were 1) to validate the Graves classification and 2) to verify the real absence of collateral arterial blood-supply between different renal segments. Material and methods The study was performed on 15 normal kidneys sampled from 8 un-embalmed cadavers. Kidneys with the surrounding perirenal fat tissue were removed en bloc with the abdominal segment of the aorta. The renal artery was injected with acrylic and radiopaque resins with the specimen suspended in water. A computed tomography examination of the injected kidneys was performed in order to analyse the branches located deeply. After the imaging acquisition, the specimens were treated with sodium hydroxide for removal of the parenchyma to obtain the vascular casts. Results Ten casts (66.6%) showed the classical subdivision of the main artery in a single posterior and anterior branch. Concerning the distribution of the segmental or second order arteries, only 2 (13%) casts showed a pattern similar to that described by Graves characterized by 4 segmental (second order) branches coming from the anterior renal artery (apical, superior, middle and inferior). In the remaining 13 kidneys (87%) a different arterial vascular network was detected. In 10 (80%) casts a single renal segment resulted vascularised by two or more different branches coming from an artery destined to another segment (multiple vascularisation). In details, multiple vascularisation was observed in 3 (20%) apical segments, in 5 (33%) superior segments, in 6 (40%) middle segments, in 7 (47%) inferior segments, and in 2 (13%) posterior segments. Conclusions This study demonstrates that in the human kidneys the arterial vasculature is frequently different from the classical Graves description. Moreover, in a significant percentage of cases, a single renal segment receives two or more branches coming from an artery destined to another segment. This article is protected by copyright. All rights reserved.

Eosinophilic cystitis is a rare disease that presents with either urinary frequency, hematuria, suprapubic pain or urinary retention. Although benign, this entity may progress to diffuse bladder involvement with the need for surgical treatment. We report on 2 cases of advanced disease that required cystectomy with very complex lower urinary tract reconstruction, and review the literature of surgically treated cases.

Conversion to radical nephrectomy (RN) in patients scheduled for partial nephrectomy (PN) is an important outcome that should be strongly considered during the decision-making process and adequately discussed with patients during their preoperative counseling. This unplanned event could be due to severe intraoperative complications or oncologic reasons. Intraoperative suspicion of hilar and/or perirenal fat tissue involvement, peritumoral venous involvement, tumor multifocality and/or iatrogenic rupture of the tumor are the most common conditions threatening the oncological safety of the procedure.

Male lower urinary tract symptoms are frequently due to benign prostatic enlargement. Medical therapy is strongly recommended in patients with moderate to severe symptoms. Lower urinary tract symptoms may require a different medical approach using drugs with different mechanisms of action. Alpha-1 blockers, muscarinic receptor antagonists and phosphodiesterase type 5 inhibitors are the most frequently used drugs. 5-Alpha reductase inhibitors are commonly prescribed to reduce prostate volume and to prevent benign prostatic hyperplasia progression. Currently, medical treatment of lower urinary tract symptoms suggestive of benign prostatic enlargement can be tailored according to different symptom characteristics and severity, and to different patient comorbidities and preferences. For this reason, the decision-making process should be based on an accurate patient counselling with detailed clarification of potential benefits and, above all, potential side effects of different drugs. This non-systematic review of the literature presents an update of the current options for medical treatment of lower urinary tract symptoms suggestive of benign prostatic enlargement, helping urologists in the decision-making and counselling process.

INTRODUCTION Among the measures taken in the recent years to reduce the morbidity and improve functional recovery after radical cystectomy (RC), the optimization of perioperative care pathways is gaining a prominent role. The aim of this systematic review of the literature with meta-analysis is to assess the impact of enhanced recovery after surgery (ERAS) protocols vs. standard of care on perioperative outcomes of patients undergoing RC. EVIDENCE ACQUISITION A systematic review with meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. MEDLINE, SCOPUS and Web of Science databases were searched. Only comparative studies evaluating the impact of ERAS protocols vs. standard of care on intraoperative and postoperative outcomes of patients undergoing RC were included. Cumulative analysis was conducted using Review Manager v.5.3 software. Statistical heterogeneity was tested using the χ2 Test, and a P value

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.

About 30% of patients treated with partial or radical nephrectomy for localized renal cell carcinoma (RCC) develop nodal or distant metastases during the follow-up (1). According to the time of recurrence, relapses are classified into early or late if occurring before or after 5 years from surgery (2). Early recurrences seem to be associated with a worse prognosis in comparison with late ones (3,4). Indeed, risk stratification according to the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) currently represents the most relevant prognosticator for patients with metastatic renal cell carcinoma (mRCC) (5).

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.

Elderly men are likely to be diagnosed with clinically localized prostate cancer, however only few studies have assessed the appropriate treatment in such patients. Radical prostatectomy is one valid alternative. Perioperative outcomes, functional outcomes and oncological outcomes have to be carefully discussed in patient counselling. Fewer perioperative complications, lower perioperative mortality, and shorter hospitalization times have been reported for patients undergoing radical prostatectomy by high-volume surgeons at high-volume centers. Although elderly patients are more likely to be preoperatively incontinent, and increasing age impacts negatively on continence recovery, long-term urinary continence rates have been reported to be satisfactorily high also in older patients. Potency should not be considered as a relevant outcome, since many elderly patients already suffer from longstanding erectile dysfunction and advanced age itself is associated with low chances of recovery. Although some inter-study variability exists in different oncological outcomes measured, most studies are consistent in showing no different cancer-specific survival rates between younger and older patients, thus implying that even elderly patients may benefit from radical treatment. Biological rather than chronological age should be used to base the decision as to whether a patient will profit from definitive treatment. Therefore, elderly men should undergo a health assessment using validated tools before any treatment decision. Only fit and motivated individuals with a reasonable life expectancy and, above all, high-risk disease should be offered radical prostatectomy. In these patients, high-volume surgeons and minimally invasive approaches should be preferable to minimize perioperative complications.

To assess whether an Enhanced Recovery After Surgery pathway was associated with a faster bowel function recovery and no increase in morbidity compared with standard perioperative care in a contemporary series of patients undergoing radical cystectomy.A prospective single-center single-surgeon cohort of 114 consecutive patients treated with open radical cystectomy between July 2013 and June 2016 was analyzed. A study group of 74 patients with Enhanced Recovery After Surgery pathway was compared with a control group of 40 patients with standard perioperative care. Primary outcome was recovery of bowel function, measured by resumption of bowel sounds, passage of flatus, and passage of stool. Secondary outcome was rate of overall and major 90-day postoperative complications.Bowel function recovery was significantly faster in the study group. Resumption of bowel sounds on postoperative day 1 was recorded in 43 (58%) vs 4 (10%) patients, passage of flatus within postoperative day 2 in 41 (55%) vs 11 (28%) patients, and passage of stool within postoperative day 3 in 37 (50%) vs no patients in the study vs control group, respectively (P .01 for all). Overall and major 90-day complications were observed in 35 (47.3%) and 13 (17.6%) patients in the study group, and in 25 (62.5%) and 9 (22.5%) patients in the control group (P = .14 and 0.38, respectively).In patients undergoing open radical cystectomy, an Enhanced Recovery After Surgery pathway allowed a significantly faster bowel function recovery with no increase in 90-day postoperative complications compared with standard perioperative care.

From its first developments, robot-assisted surgery had a rapid and wide diffusion into the field of urology and its indications have been expanded to several urological procedures and, as experience increased in the last years, even to challenging and complex cases with an acceptably low complication rate in the hands of high-volume surgeons. Robot-assisted radical prostatectomy (RARP) is currently the most common treatment modality for surgical management of clinically localized prostate cancer in the US. The consequence of the widespread adoption of RARP was the use of the robotic platform to treat other urological malignancies as well as benign conditions.

Retroperitoneal lymph node dissection (RPLND) is a fundamental surgical step in the treatment of testicular cancer. Nowadays, primary RPLND has partially lost its role in favour of active surveillance (for low risk stage I disease) and short cycle chemotherapy in non-seminomatous germ cell tumor (NSGCT). Conversely, post-chemotherapy RPLND (PC-RPLND) remains the standard treatment for residual masses after chemotherapy. In consideration of curability rate of testicular cancer and the life expectancy of testicular cancer survivors the identification and the prevention of andrological complications became fundamental. Erectile dysfunction (ED) is generally transitory and interests about 25% of patients, conversely retrograde ejaculation (RE) is definitive. Antegrade ejaculation is guaranteed by the sparing of at least one paravertebral sympathetic trunks and the postganglionic sympathetic fibers, which travel dorsal to the inferior vena cava and cross ventrally to the aorta. The maintenance of antegrade ejaculation can be obtained by a bilateral sparing of these fibers or by the modification of templates. In primary RPLND setting RE ranged between 2-6.7% and 1.2-61% in the major open and laparoscopic series respectively. In PC-RPLND series it ranged between 21-36% and 4-7.1% for open and laparoscopic approach respectively with the limitation of the restrictive indications of laparoscopic approach. The setting of this surgery and the importance of the oncological and functional outcomes that are pursued reinforced following the evidence that RPLND is a highly technical demanding procedure, whose best performances are achieved only when delivered in referral, high-volume centers.

Objectives: To describe step-by-step an original urethrovesical anastomosis technique (urethral fixation) in patients undergoing retropubic radical prostatectomy (RRP), to compare their early urinary continence recovery with those in a control group receiving a standard anastomosis technique and to identify the predictors of early urinary continence recovery. Patients and methods: We compared 70 patients who underwent RRP with the urethral-fixation technique with a contemporary control group of 51 patients who received RRP with a standard urethrovesical anastomosis. In the urethral-fixation group, the urethrovesical anastomosis was made using eight single sutures. Specifically, to avoid retraction and/or deviations, we fixed the urethral stump laterally to the medial portion of levator ani muscle. Also, to maintain the normal position in the context of the pelvic floor, we fixed the urethral sphincter deeper to the medial dorsal raphe using a 3-0 polydioxanone suture at the 6 o'clock position before completing the incision of the urethral wall. Urinary continence recovery was evaluated at 1, 4, 8 and 12 weeks after catheter removal. Patients self-reporting no urine leak were considered continent. Uni- and multivariable analyses were used to identify predictors of urinary incontinence at the different follow-up time-points. Results: The evaluated groups had comparable preoperative variables. At 1 week after catheter removal, 32 (45.7%) patients in the urethral-fixation group and 10 (19.6%) in the control group were continent (P = 0.01). At 4 weeks after catheter removal, 46 (65.7%) patients in the urethral-fixation group and 16 (31.4%) in the control group were continent (P = 0.001). At 8 weeks after catheter removal, 59 (84.3%) patients in the urethral-fixation group and 21 (41.2%) in the control group were continent (P < 0.001). Finally, at 12 weeks after catheter removal, 63 (90%) patients in the urethral-fixation group and 32 (62.7%) in the control group were continent (P = 0.001). The urethral-fixation technique was an independent predictor of urinary continence recovery at 1 week [odds ratio (OR) 4.305; P = 0.002); 4 weeks (OR 4.784; P < 0.001); 8 weeks (OR 7.678; P < 0.001) and 12 weeks (OR 5.152; P = 0.001) after catheter removal. Conclusions: The urethral-fixation technique significantly improves early urinary continence recovery in comparison with the standard technique. Moreover, our study confirmed that this surgical technique is an independent predictor of urinary continence recovery at 1, 4, 8 and 12 weeks after catheter removal.