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Background and objective: The role of cytoreductive nephrectomy (CN) in the treatment of metastatic renal cell carcinoma (mRCC) has been called into question on the basis of clinical trial data from the tyrosine kinase inhibitor (TKI) era. Comparative analyses of CN for patients treated with immuno-oncology (IO) versus TKI agents are sparse. Our objective was to compare CN timing and outcomes among patients who received TKI versus IO therapy. Methods: This was a multicenter retrospective analysis of patients who underwent CN using data from the REMARCC (Registry of Metastatic RCC) database. The cohort was divided into TKI versus IO first-line therapy groups. The primary outcome was all-cause mortality (ACM). Secondary outcomes included cancer-specific mortality (CSM). Multivariable analysis was used to identify factors predictive for ACM and CSM. The Kaplan-Meier method was used to analyze 5-yr overall survival (OS) and cancer-specific survival (CSS) with stratification by primary systemic therapy and timing in relation to CN. Key findings and limitations: We analyzed data for 189 patients (148 TKI + CN, 41 IO +CN; median follow-up 23.2 mo). Multivariable analysis revealed that a greater number of metastases (hazard ratio [HR] 1.06; p = 0.015), greater primary tumor size (HR 1.10; p = 0.043), TKI receipt (HR 2.36; p = 0.015), and initiation of systemic therapy after CN (HR 1.49; p = 0.039) were associated with worse ACM. A greater number of metastases at diagnosis (HR 1.07; p = 0.011), greater primary tumor size (HR 1.12; p = 0.018), TKI receipt (HR 5.43; p = 0.004), and initiation of systemic therapy after CN (HR 2.04; p

Abstract The study aimed to evaluate the impact of abdominal drain placement (vs. omission) on perioperative outcomes of robot-assisted partial nephrectomy (RAPN), focusing on complications, time to canalization, deambulation, and pain management. A prospectively-maintained institutional database was queried to get data of patients who underwent RAPN for renal masses between January 2018 and May 2023 at our Institution. Baseline, surgical, and postoperative data were collected. Retrieved patients were stratified based upon placement of abdominal drain (Y/N). Descriptive analyses comparing the two groups were conducted as appropriate. After adjusting for potential confounders, a logistic regression analysis was conducted to evaluate significant predictors of any grade and “major” complications. 342 patients were included: 192 patients in the “drain group” versus 150 patients in the “no-drain” group. Renal masses were larger (p

ABSTRACT Purpose: Ureteropelvic junction obstruction (UPJO) is a prevalent cause of hydronephrosis, especially in young patients. The treatment paradigm for this condition has shifted from open to minimally invasive pyeloplasty. In the present study we describe our initial single centre experience with single port (SP) robot-assisted pyeloplasty (RAP) via periumbilical incision. Material and methods: With the patient in a 60-degree left flank position, the SP system is docked with the Access port (Intuitive Surgical, Sunnyvale, CA, US) placed in a periumbilical 3 cm incision. Robotic instruments are deployed as follows: camera at 12 o'clock, bipolar grasper at 9 o'clock, scissors at 3 o'clock and Cadiere at 6 o'clock. After isolation and identification of the ureter and the ureteropelvic junction (UPJ), the ureter is transected at this level and then spatulated. Anastomosis is carried out by two hemicontinuous running sutures, over a JJ stent. Results: Between 2021 and 2023, a total of 8 SP RAP have been performed at our institution, with a median (interquartile range, IQR) of 23 years (20.5-36.5). Intraoperative outcomes showed a median (IQR) OT of 210.5 minutes (190-240.5) and a median (IQR) estimated blood loss (EBL) of 50 mL (22.5-50). No postoperative complications were encountered, with a median (IQR) length of stay (LOS) of 31 hours (28.5-34). Conclusion: In the present study we evaluated the feasibility and safety of SP RAP. The observed outcomes and potential benefits, combined with the adaptability of the SP platform, hold promising implications for the application of SP system in pyeloplasty treatment.

ABSTRACT Purpose: Minimally invasive radical nephrectomy is often preferred for larger renal tumours not suitable for partial nephrectomy (1). When performed with a multiport robot, the procedure is routinely performed with a transperitoneal approach, with recent studies highlighting important factors for surgical outcomes, including predictive factors (2), segmental artery unclamping techniques (3), and comparisons of robotic techniques (4). This video shows that SP Robot-Assisted Radical Nephrectomy (RARN) via a lower anterior approach is valuable in challenging cases. Materials and Methods: We performed SP-RARN on two complex patients using a retroperitoneal lower anterior approach. The first patient, a 54-year-old female with a BMI of 36.8 kg/m2, had a ventral hernia and bowel obstruction history, with a 9 cm right middle kidney mass. The second patient, a 58-year-old male with a BMI of 31.19 kg/m2, had ESRD and was on peritoneal dialysis for 8 years, with a 3.4x3.7 cm mass in the right superior pole, suspected to be RCC. The surgical technique is detailed in the video. Results: Both procedures were successful, with operative times of 173 and 203 minutes and blood loss of 150 mL. No complications occurred. Patients were discharged after 31 and 38 hours, respectively. Histopathology confirmed RCC. At the 3-month follow-up, no complications or readmissions were reported. Second patient continued peritoneal dialysis without issues. Conclusion: Retroperitoneal SP-RARN via the lower anterior approach avoids the peritoneal cavity, making it suitable for certain patients. In these patients, more so than in others, this procedure is feasible, safe, and less morbid than the standard multiport approach.

Single-port (SP) robotic surgery is a relatively new technology that is expected to become available on the European market within a year. We investigated the current expectations of robotic surgery experts and opinion leaders practicing in Europe. A 17-item online questionnaire was sent to 120 participants identified as “experts” on the basis of their general contributions to the field of robotic surgery. Overall, 90 responses were registered, with a response rate of 75%. Italy (30%), France (15%), and the UK (12%) provided the most participants, who worked mainly in academic—either public (60%) or private (20%)—hospitals. Most respondents (79%) had no previous experience with “single site” surgery, and attendance at scientific meetings (79%) and perusal of the literature (65%) were the sources of SP knowledge most frequently reported. The perceived advantages of SP robotic surgery included lower invasiveness (61%), easier access to the retroperitoneal or extraperitoneal space (53%), better cosmetic results (44%), and lower postoperative pain (44%). The most “appealing” SP procedures were retroperitoneal partial nephrectomy via an anterior approach (43%) and transvesical simple prostatectomy (43%). Within the limitations of this type of analysis, our findings suggest high interest and a positive attitude towards SP technology overall. Patient summary: Technology for single-port (SP) robotic surgery, in which just one skin incision is made in the abdomen to perform the operation, will soon be available in Europe. We conducted a survey on SP surgery among European experts in urological robotic surgery. The results show that there is high interest in and a positive attitude to SP surgery. The SP approach could result in better cosmetic results and lower postoperative pain for patients.

Objective: Prostate cancer (PCa) patients might experience lower urinary tract symptoms as those diagnosed with benign prostatic hyperplasia (BPH). Some of them might be treated for their lower urinary tract symptoms instead of PCa. We aimed to test the effect of PCa versus BPH on surgical outcomes after transurethral prostate surgery, namely complication and mortality rates. Methods: Within the American College of Surgeons National Surgical Quality Improvement Program database (2011–2016), we identified patients who underwent transurethral resection of the prostate, photoselective vaporization, or laser enucleation. Patients were stratified according to postoperative diagnosis (PCa vs. BPH). Univariable and multivariable logistic regression models evaluated the predictors of perioperative morbidity and mortality. A formal test of interaction between diagnosis and surgical technique used was performed. Results: Overall, 34 542 patients were included. Of all, 2008 (5.8%) had a diagnosis of PCa. The multivariable logistic regression model failed to show statistically significant higher rates of postoperative complications in PCa patients (odds ratio: 0.9, 95% confidence interval: 0.7–1.1; p=0.252). Moreover, similar rates of perioperative mortality (p=0.255), major acute cardiovascular events (p=0.581), transfusions (p=0.933), and length of stay of more than or equal to 30 days (p=0.174) were found. Additionally, all tests failed to show an interaction between post-operative diagnosis and surgical technique used. Conclusion: Patients diagnosed with PCa do not experience higher perioperative morbidity or mortality after transurethral prostate surgery when compared to their BPH counterparts. Moreover, the diagnosis seems to not influence surgical technique outcomes.

Background: Men with localized invasive penile cancer (PC) can be treated with organ-sparing treatments with different functional and aesthetical outcomes. Thus, the aim of this study is to investigate sexual outcomes in patients with PC confined to the glans that underwent wide local excision (WLE) vs. glansectomy with urethral glanduloplasty. Methods: Complete data from 60 patients with PC were analyzed at our institution from 2017 to 2022. Patients were asked for personal habits and clinical features. PC was assessed with a clinical visit and imaging techniques. At the outpatient follow-up visit or phone call, all patients compiled the Changes in Sexual Function Questionnaire (CSFQ) and the International Index of Erectile Function in its short 5-item form (IIEF-5). Erectile function (EF) impairment was categorized using Cappelleri’s criteria. Results: Overall, 34 patients with PC confined to the glans (c ≤ T2N0) were included. Of those, 12 underwent WLE and 22 underwent glansectomy with urethral glanduloplasty. Using multivariable logistic regression, glansectomy (OR: 3.49) and diabetes (OR: 2.33) were associated with erectile disfunction (IEEF < 22). Meanwhile, using multivariable linear regression analysis, younger patients (Coeff: −2.41) and those that underwent glansectomy (Coeff: −7.5) had a higher risk of sexual function impairment, according to the CSFQ. Conclusions: Patients with PC ≤ T2N0 that underwent WLE have better outcomes in terms of sexual functioning than the patients who underwent glansectomy and uretheral gladuloplasty. Further research is needed to clarify the outcomes of penile-sparing surgery, to inform patients in pre-surgical counseling more comprehensively, and to meet their post-operative expectations more effectively.

Objective: Robot-assisted partial nephrectomy (RAPN) has become widely used for treatment of renal cell carcinoma and it is expanding in the field of complex renal masses. The aim of this systematic review was to analyze outcomes of RAPN for completely endophytic renal masses, large tumors (cT2-T3), renal cell carcinoma in solitary kidney, recurrent tumors, completely endophytic and hilar masses, and simultaneous and multiple tumors. Methods: A comprehensive search in the PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases was performed in December 2022 for English language papers. The primary endpoint was to evaluate the role of RAPN in the setting of each category of complex renal masses considered. The secondary endpoint was to evaluate the surgical and functional outcomes. Results: After screening 1250 records, 43 full-text manuscripts were selected, comprising over 8500 patients. Twelve and thirteen studies reported data for endophytic and hilar renal masses, respectively. Five and three studies reported outcomes for cT2-T3 and solitary kidney patients, respectively. Four studies focused on redo-RAPN for recurrent tumors. Two studies investigated simultaneous bilateral renal masses and five reports focused on multiple tumor excision in ipsilateral kidney. Conclusion: Over the past decade, evidence supporting the use of RAPN for the most challenging nephron-sparing surgery indications has continuously grown. Although limitations remain including study design and lack of detailed long-term functional and oncological outcomes, the adoption of RAPN for the included advanced indications is associated with favorable surgical outcomes with good preservation of renal function without compromising the oncological result. Certainly, a higher likelihood of complication might be expected when facing extremely challenging cases. However, none of these indications should be considered per se an exclusion criterion for performing RAPN. Ultimately, a risk-adapted approach should be employed.

Premature ejaculation (PE) is a common male sexual dysfunction that can cause significant distress in the patient and partner. This study aimed to compare the current international guidelines on PE to highlight their similarities and differences. We examined the latest guidelines from the European Association of Urology (EAU), American Urological Association/Sexual Medicine Society of North America (AUA/SMSNA), and International Society of Sexual Medicine (ISSM) by comparing definitions, classifications, epidemiology, pathophysiology, and recommendations on diagnosis and therapy. The quality of guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) Global Rating Scale (GRS). We found significant variations in the definitions of PE and recommendations on management of patients. The EAU guidelines were the most recent, the AUA/SMSNA guidelines lacked detail in some areas, and the ISSM guidelines were the most complete but also the least updated. The search for a unified definition and the development of standardized diagnostic and therapeutic pathways remain concrete issues to improve the management of patients with PE worldwide.

ABSTRACT Purpose: Partial nephrectomies in the salvage setting after ablative or surgical therapy remain challenging cases that are underreported in the literature (1-5). The aim of this video is to demonstrate techniques for robotic salvage partial nephrectomy to manage recurrent renal cell carcinoma (RCC) after failed prior partial nephrectomy and primary cryotherapy. Materials and methods: A 55-year-old man after previous robotic-assisted right partial nephrectomy presented with a 2.5 cm locally recurrent renal mass abutting the collecting system. A 59-year-old man with right renal cell carcinoma initially treated with cryoablation presented local recurrence. CT imaging demonstrated 2.6 cm right renal mass consistent with tumor recurrence at previous treatment site. Results: Both procedures were completed in under 180 minutes. Clamp time was 22 minutes after the previous partial nephrectomy and 25 minutes after previous cryotherapy. There were no perioperative complications. Pathology in both cases demonstrated pT1a clear cell RCC with negative margins. Both patients have since no evidence of recurrent disease on follow-up imaging at 1 and 2 years, respectively. Conclusions: Salvage robotic partial nephrectomy should be considered as a feasible treatment option after failure of initial therapy—surgical or ablative. A salvage procedure is often more challenging than its standard therapy-naïve counterpart due to development of dense inflammation after previous interventions. Despite this, robotic partial nephrectomies in the salvage setting can be safely carried out with good surgical outcomes, particularly when utilizing intraoperative ultrasound to identify tumor margins and key anatomy.

Abstract Background Retained surgical sharps (RSS) is a “never event” that is preventable but may still occur despite of correct count and negative X-ray. This study assesses the feasibility of a novel device (“Melzi Sharps Finder®” or MSF) in effective detection of RSS. Methods The first study consisted of determination of the presence of RSS or identification of RSS in an ex-vivo model (a container with hay in a laparoscopic trainer box). The second study consisted of determining presence of RSS in an in-vivo model (laparoscopy in live adult Yorkshire pigs) with 3 groups: C-arm, C-arm with MSF and MSF. The third study used similar apparatus though with laparotomy and included 2 groups: manual search and MSF. Results In the first study, the MSF group had a higher rate of identification of a needle and decreased time to locate a needle versus control (98.1% vs. 22.0%, p

In 2018, the da Vinci Single Port (SP) robotic system was approved by the US Food and Drug Administration for urologic procedures. Available studies for the application of SP to prostate cancer surgery are limited. The aim of our study is to summarize the current evidence on the techniques and outcomes of SP robot-assisted radical prostatectomy (SP-RARLP) procedures. A narrative review of the literature was performed in January 2023. Preliminary results suggest that SP-RALP is safe and feasible, and it can offer comparable outcomes to the standard multiport RALP. Extraperitoneal and transvesical SP-RALP appear to be the two most promising approaches, as they offer decreased invasiveness, potentially shorter length of stay, and better pain control. Long-term, high-quality data are missing and further validation with prospective studies across different sites is required.

(1) Background: Prostate Cancer (PCa) may be incidentally diagnosed during the microscopic evaluation of resected tissue from BPH surgeries, characterizing the clinical condition known as incidental PCa (iPCa). This study aims to assess the prevalence of iPCa following BPH surgery to evaluate the associated surgical procedures and to scrutinize preoperative and postoperative management. (2) Methods: A retrospective analysis was conducted using the PearlDiver™ Mariner database, containing patient records compiled between 2011 and 2021. International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify the population and outcomes. Our primary objective was to assess the prevalence of iPCa, categorized by the type of procedures, and to evaluate the subsequent treatment strategies. The secondary aim was to assess the impact of prostate biopsy (PB) and prostate MRI on iPCa detection. (3) Results: The overall cohort, accounting for 231,626 patients who underwent BPH surgery, exhibited a 2.2% prevalence rate of iPCa. The highest rate was observed for TURP (2.32%), while the lowest was recorded for RASP (1.18%). Preoperative MRI and PB demonstrated opposing trends over the years. Of the 5090 patients identified with iPCa, nearly 68% did not receive active treatment. The most common treatments were RT and ADT; 34.6% underwent RT, 31.75% received ADT, and 21.75% were treated with RT+ADT. RP was administered to approximately 9% of patients undergoing endoscopic procedures. Multivariate logistic regression analysis revealed age and openSP as additional risk factors for iPCa. Conversely, PB and MRI before surgery were linked to a decreased risk. (4) Conclusions: The contemporary prevalence of iPCa after BPH surgery is

Purpose: To prospectively evaluate the albumin/globulin ratio (AGR), neutrophil/lymphocyte ratio (NLR), and platelet/lymphocyte ratio (PLR) diagnostic and prognostic predictive value in a stratified population of prostate cancer (PC) cases. Methods: Population was divided based on the clinical and histologic diagnosis in: Group A: benign prostatic hyperplasia (BPH) cases (494 cases); Group B: all PC cases (525 cases); Group B1: clinically significant PC (426 cases); Group B2: non-metastatic PC (416 cases); Group B3: metastatic PC (109 cases). NLR, PLR, and AGR were obtained at the time of the diagnosis, and only in cases with PC considered for radical prostatectomy, determinations were also repeated 90 days after surgery. For each ratio, cut-off values were determined by receiver operating characteristics curve (ROC) analysis and fixed at 2.5, 120.0, and 1.4, respectively, for NLR, PLR, and AGR. Results: Accuracy in predictive value for an initial diagnosis of clinically significant PC (csPC) was higher using PLR (0.718) when compared to NLR (0.220) and AGR (0.247), but, despite high sensitivity (0.849), very low specificity (0.256) was present. The risk of csPC significantly increased only according to PLR with an OR = 1.646. The percentage of cases with metastatic PC significantly increased according to high NLR and high PLR. Accuracy was 0.916 and 0.813, respectively, for NLR and PLR cut-off, with higher specificity than sensitivity. The risk of a metastatic disease increased 3.2 times for an NLR > 2.5 and 5.2 times for a PLR > 120 and at the multivariate analysis. Conclusion: PLR and NLR have a significant predictive value towards the development of metastatic disease but not in relation to variations in aggressiveness or T staging inside the non-metastatic PC. Our results suggest an unlikely introduction of these analyses into clinical practice in support of validated PC risk predictors.

Over the past 20 years, the field of robotic surgery has largely been dominated by the da Vinci robotic platform. Nevertheless, numerous novel multiport robotic surgical systems have been developed over the past decade, and some have recently been introduced into clinical practice. This nonsystematic review aims to describe novel surgical robotic systems, their individual designs, and their reported uses and clinical outcomes within the field of urologic surgery. Specifically, we performed a comprehensive review of the literature regarding the use of the Senhance robotic system, the CMR-Versius robotic system, and the Hugo RAS in urologic procedures. Systems with fewer published uses are also described, including the Avatera, Hintori, and Dexter. Notable features of each system are compared, with a particular emphasis on factors differentiating each system from the da Vinci robotic system.

Objective: In this study our objective was to develop a simulation platform for use cases in Laparoendoscopic Single Site (LESS) Surgery intended for patient-specific rehearsal prior to Robot-assisted Partial nephrectomy procedures. Patients and Surgical Procedure: This represents a simulation platform requiring no patients, although the fabrication process allows for the platform to be patient-specific. Tissue phantom 3D models were developed from de-identified CT imaging fulfilling the criteria of tumors located in the posterior lower pole of the kidney. Results: Respondents completed surveys on platform novelty and effectiveness. Agreement on simulator novelty was unanimously positive (100% agree or better). Performance evaluations reached a minimum of 80% agreement for all categories, with zero respondents Conclusions: We have developed a highly realistic simulation platform for use in single-port robot-assisted partial nephrectomy that can be produced in a patient specific manner, which we believe will be highly useful for trainees as well as experts attempting to transfer skills to the newer platform.

ABSTRACT Aim: Renal leiomyoma is a rare benign mesenchymal tumor arising from the smooth muscle cells of the kidney. Renal capsule is its most common location (1). Large tumor may require surgical excision which can be challenging in case of proximity to major vessels (2). Indications of robotic partial nephrectomy (RPN) have exponentially expanded over the past few years (3). We aim to report a case of large renal leiomyoma successfully managed with RPN. Methods: A 59-year-old female patient with BMI 51 presented with chief complaint of abdominal discomfort. The patient underwent a CT scan that revealed a massive circumscribed exophytic complex solid cystic mass of 4.5 × 7.7 × 6.2 cm, arising from the lower pole of right kidney and abutting the inferior vena cava. RENAL score was 11ah (high complexity). Past surgical history included mid-urethral sling, breast reduction, and hysterectomy with salpingectomy. Preoperative creatinine and eGFR were 0.9 (mg/dL) and 77 (mL/min), respectively. A robotic excision of this mass was successfully performed by using Da Vinci Xi platform. Main steps of the procedure are illustrated in the present video. Results: Dissection and isolation of the tumor were carefully performed after identifying key anatomical structures such as the ureter, the IVC and the renal hilum. Intraoperative ultrasound was used to confirm the margins of the mass. The renal artery was clamped and then the tumor was resected/enucleated. Renal parenchyma was re-approximated with a single layer of interrupted CT-1 Vicryl 0 with sliding clip technique. Warm ischemia time was 19 min. Estimated blood loss (EBL) was 250 ml. Operative time was 165 min. No intraoperative complications occurred. No drain was placed. Patient was discharged on postoperative day 2. Post-operative hypotension was managed with fluid bolus. Postoperative creatinine and eGFR were 1,0 (mg/dL) and 69 (mL/min/1.72m2), respectively. Pathology revealed a leiomyoma of genital stromal origin with hyalinization and calcification. Conclusions: To the best of our knowledge, this is the first description of RPN for the management of a large (about 8 cm) renal leiomyoma. Robotic assisted surgery allows to expand the indications of minimally invasive conservative renal surgery whose feasibility becomes even more clinically significant in case of benign masses which can be managed without sacrificing healthy renal parenchyma.

Context: Robot-assisted partial nephrectomy (RAPN) has gained increasing popularity as primary minimally invasive surgical treatment for localized renal tumors, and it has preferably been performed with a transperitoneal approach. However, the retroperitoneal approach represents an alternative approach given potential advantages. Objective: To provide an updated analysis of the comparative outcomes of retroperitoneal RAPN (R-RAPN) versus transperitoneal RAPN (T-RAPN). Evidence acquisition: A systematic review of the literature was performed up to September 2021 using MEDLINE, EMBASE, and Web of Science databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. A sensitivity analysis was performed considering only matched-pair studies. Evidence synthesis: Seventeen studies, which were published between 2013 and 2021, were retrieved. None of them was a randomized clinical trial. Among the 6,266 patients included in the meta-analysis, 2261 (36.1%) and 4,005 (63.9%) underwent R-RAPN and T-RAPN, respectively. No significant difference was found in terms of baseline features. The T-RAPN group presented a higher rate of male patients (odds ratio [OR]: 0.86, p = 0.03) and larger tumor size (weighted mean difference [WMD]: 0.2 cm; p = 0.003). The R-RAPN group reported more frequent posterior renal masses (OR: 0.23; p

Radiomics and artificial intelligence (AI) may increase the differentiation of benign from malignant kidney lesions, differentiation of angiomyolipoma (AML) from renal cell carcinoma (RCC), differentiation of oncocytoma from RCC, differentiation of different subtypes of RCC, to predict Fuhrman grade, to predict gene mutation through molecular biomarkers and to predict treatment response in metastatic RCC undergoing immunotherapy. Neural networks analyze imaging data. Statistical, geometrical, textural features derived are giving quantitative data of contour, internal heterogeneity and gray zone features of lesions. A comprehensive literature review was performed, until July 2022. Studies investigating the diagnostic value of radiomics in differentiation of renal lesions, grade prediction, gene alterations, molecular biomarkers and ongoing clinical trials have been analyzed. The application of AI and radiomics could lead to improved sensitivity, specificity, accuracy in detecting and differentiating between renal lesions. Standardization of scanner protocols will improve preoperative differentiation between benign, low-risk cancers and clinically significant renal cancers and holds the premises to enhance the diagnostic ability of imaging tools to characterize renal lesions.

PurposeWe hypothesized that two-tier re-classification of the “M” (metastasis) domain of the Tumor-Node-Metastasis (TNM) staging of Renal Cell Carcinoma (RCC) may improve staging accuracy than the current monolithic classification, as advancements in the understanding of tumor biology have led to increased recognition of the heterogeneous potential of metastatic RCC (mRCC).MethodsMulticenter retrospective analysis of patients from the REMARCC (REgistry of MetAstatic RCC) database. Patients were stratified by number of metastases into two groups, M1 (≤3, “Oligometastatic”) and M2 (>3, “Polymetastatic”). Primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS). Cox-regression and Kaplan-Meier (KMA) analysis were utilized for outcomes, and receiver operating characteristic analysis (ROC) was utilized to assess diagnostic accuracy compared to current “M” staging.Results429 patients were stratified into proposed M1 and M2 groups (M1 = 286/M2 = 143; median follow-up 19.2 months). Cox-regression revealed M2 classification as an independent risk factor for worsened all-cause mortality (HR=1.67, p=0.001) and cancer-specific mortality (HR=1.74, p

Urachal carcinoma is a rare urological disease. The shortage of data about diagnosis and surgical treatment in literature makes it hard for clinicians to make a decision. Indeed, urachal carcinoma is an aggressive disease that requires prompt staging and treatment to ensure the best outcome for patients. We reviewed the last evidence about the management of urachal carcinoma to provide an easy-to-use guide for clinical practice. Patient summary: Urachal carcinoma is a rare malignancy. The literature on this challenging disease remains limited. Herein, we provide a practical guide for its management from diagnosis to treatment, which in most cases requires surgical intervention or chemotherapy.

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.

Context: Benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) is diagnosed in up to 80% of men during their lifetime. Several novel ultra-minimally invasive surgical treatments (uMISTs) for BPH/benign prostatic obstruction (BPO) have become available over the past 5 yr. Objective: To evaluate the perioperative and functional outcomes of recently introduced uMISTs for BPH/BPO, including Urolift, Rezūm, temporary implantable nitinol device, prostatic artery embolization (PAE), and intraprostatic injection. Evidence acquisition: A systematic literature search was conducted in December 2020 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42021225014). The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Pooled and cumulative analyses were performed to compare perioperative and functional outcomes between study groups. A random-effects model using the DerSimonian and Laird method was used to evaluate heterogeneity. Stata version 15.0 software was used for all statistical analyses. Evidence synthesis: The initial electronic search identified 3978 papers, of which 48 ultimately met the inclusion criteria and were included in the analysis. Pooled analysis revealed a uMIST benefit in terms of International Prostate Symptom Score (IPSS; −9.81 points, 95% confidence interval [CI] −11.37 to −8.25 at 1 mo; −13.13 points, 95% CI −14.98 to −11.64 at 12 mo), maximum flow rate (from +3.66 ml/s, 95% CI 2.8–4.5 to +4.14 ml/s, 95% CI 0.72–7.56 at 12 mo), and postvoid residual volume (−10.10 ml, 95% CI −27.90 to 7.71 at 12 mo). No negative impact was observed on scores for the International Index of Erectile Function-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction bother and function scales (overall postintervention change in pooled median score of 1.88, 95% CI 1.34–2.42 at the start of follow-up; and 1.04, 95% CI 0.28–1.8 after 1 yr), or the IPSS-Quality of Life questionnaire. Conclusions: Novel uMISTs can yield fast and effective relief of LUTS without affecting patient quality of life. Only Rezūm, UroLift, and PAE had a minimal impact on patients’ sexual function with respect to baseline, especially regarding preservation of ejaculation. Patient summary: We reviewed outcomes for recently introduced ultra-minimally invasive surgical treatments for patients with lower urinary tract symptoms caused by benign prostate enlargement or obstruction. The evidence suggests that these novel techniques are beneficial in terms of controlling symptoms while preserving sexual function. Take Home Message: Novel ultra-minimally invasive treatments can yield fast and effective relief of lower urinary tract symptoms without affecting a patient’s quality of life.

Recently, researchers have proposed perilesional sampling during prostate biopsies to avoid systematic biopsies of patients at risk of prostate cancer. The aim of our study is to evaluate the role of perilesional sampling to avoid systematic biopsies of patients undergoing fusion biopsies. A prospective cohort of patients undergoing transrectal MRI transrectal fusion biopsies were consecutively enrolled. All the patients underwent systematic biopsies (SB), targeted biopsies (TB) and perilesional biopsies within 10 mm from the lesion (PB). The detection rates of different strategies were determined. A total of 262 patients were enrolled. The median age of those enrolled was 70 years. The mean BMI was 27 kg/m2, and the mean and prostate volume was 52 mL. A PIRADS score ≥ 4 was recorded in 163/262 (40%) patients. Overall, the detection rates of cancer were 43.5% (114/262) and 35% (92/262) for csPCa. The use of the target + peri-target strategy resulted in a detection of 32.8% (86/262) of cancer cases and of 29% (76/262) of csPCa cases (Grade Group > 2). Using the target plus peri-target approach resulted in us missing 18/262 (7%) of the csPCa cases, avoiding the diagnosis of 8/262 (3%) of nsPCa cases. A biopsy strategy including lesional and perilesional sampling could avoid unnecessary prostate biopsies. However, the risk of missing significant cancers is present. Future studies should assess the cost–benefit relationship of different strategies.

Abstract Background A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management. Methods Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical “sharps,” a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of “sharps”. Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview. Results Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery. Conclusion The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.

Prostate cancer (PCa) is the most common worldwide diagnosed malignancy in male population. The diagnosis, the identification of aggressive disease, and the post-treatment follow-up needs a more comprehensive and holistic approach. Radiomics is the extraction and interpretation of images phenotypes in a quantitative manner. Radiomics may give an advantage through advancements in imaging modalities and through the potential power of artificial intelligence techniques by translating those features into clinical outcome prediction. This article gives an overview on the current evidence of methodology and reviews the available literature on radiomics in PCa patients, highlighting its potential for personalized treatment and future applications.

Abstract Introduction A retained surgical sharp (RSS) is a never event and defined as a lost sharp (needle, blade, instrument, guidewire, metal fragment) that is not recovered prior to the patient leaving the operating room. A “near-miss” sharp (NMS) is an intraoperative event where there is a lost surgical sharp that is recovered prior to the patient leaving the operating room. With underreporting of such incidents, it is unrealistic to expect aggressive development of new prevention and detection strategies. Moreover, awareness about the issue of “near-miss” or retained surgical sharps remains limited. The aim of this large-scale national survey-based study was to estimate the incidence of these events and to identify the challenges surrounding the use of surgical sharps in daily practice. Methods We hypothesized that there was a larger number of RSS and NMS events than what was being reported. We survived the different OR team members to determine if there would be discordance in reported incidence between groups and to also evaluate for user bias. An electronic survey was distributed to OR staff between December 2019 and April 2020. Respondents included those practicing within the United States from both private and academic institutions. Participants were initially obtained by designating three points of contact who identified participants at their respective academic institutions and while attending specialty specific medical conferences. Together, these efforts totaled 197 responses. To increase the number of respondents, additional emails were sent to online member registries. Approximately 2650 emails were sent resulting in an additional 250 responses (9.4% response rate). No follow up reminders were sent. In total, there were 447 survey responses, in which 411 were used for further analysis. Thirty-six responses were removed due to incomplete respondent data. Those who did not meet the definition of one of the three categories of respondents were also excluded. The 411 were then categorized by group to include 94 (22.9%) from anesthesiologist, 132 (32.1%) from resident/fellow/attending surgeon and 185 (45%) from surgical nurse and technologist. Survey The survey was anonymous. Participants were asked to answer three demographic questions as well as eight questions related to their personal perception of NMS and RSS (Fig. 1). Demographic questions were asked with care to ensure no identifiable information was obtained and therefore unable to be traced back to a specific respondent or institution. Perception questions 4–6 and 11 were designed to understand the incidence of various sharp events (e.g. lost, retained, miscounted). Questions 7 and 10 were dedicated to understanding time spent managing sharps and questions 8 and 9 were dedicated to understanding the use x-ray and its effectiveness. Results Overall, most of each respondent group reported 1–5 lost sharp events over the last year. Roughly 20% of surgeons believed they never had a miscounted sharp over the last year, where only 5.3% of anesthesiologist reported the same (p = 0.002). Each group agreed that roughly 4 lost events occur every 1000 surgeries, but a significant difference was found between the three groups regarding the number of lost sharps not recovered per 10,000 surgeries with anesthesiologist, surgeon and nurse/technologist groups estimating 2.37, 2.56 and 2.94 respectively (p = 0.001). All groups noted x-ray to offer poor effectiveness at 26–50% with 31-40 min added for each time x-ray was used. More than half (56.8%) of surgeons reported using x-ray 100% of the time when managing a lost sharp whereas anesthesiologists and nurses/technologists believe it is closer to 1/3 of the time. An average of 21-30 min is spent managing each NMS, making a lost sharp event result in up to 70 min of added OR time. Conclusions “Near-miss” and RSS are more prevalent than what is reported in current literature. Surgeons perceive a higher rate of success in retrieving the RSS when compared to anesthesiologists and OR nurses/technologists. We recognize several challenges surrounding “near-miss” and never events as contributing factors to their underreported nature and the higher degree of surgeon recall bias associated with these events. Additionally, we highlight that current methods for prevention are costly in time and resources without improvement in patient safety. As NMS and RSS have significant health system implications, a strong understanding of these implications is important as we strive to improve patient safety.

Renal cell carcinoma (RCC) is the seventh most common cancer in men and the ninth most common cancer in women worldwide. There is plenty of evidence about the role of the immune system in surveillance against tumors. Thanks to a better understanding of immunosurveillance mechanisms, immunotherapy has been introduced as a promising cancer treatment in recent years. Renal cell carcinoma (RCC) has long been thought chemoresistant but highly immunogenic. Considering that up to 30% of the patients present metastatic disease at diagnosis, and around 20–30% of patients undergoing surgery will suffer recurrence, we need to identify novel therapeutic targets. The introduction of immune checkpoint inhibitors (ICIs) in the clinical management of RCC has revolutionized the therapeutic approach against this tumor. Several clinical trials have shown that therapy with ICIs in combination or ICIs and the tyrosine kinase inhibitor has a very good response rate. In this review article we summarize the mechanisms of immunity modulation and immune checkpoints in RCC and discuss the potential therapeutic strategies in renal cancer treatment.

To identify the characteristics of patients with sepsis or acute pyelonephritis (APN) combined with ureteral calculi and to analyze the risk factors in its causation. Methods: We included patients with sepsis or APN caused by ureteral calculi who received treatment in the United States from January 2003 to December 2017 using the Optum® deidentified Clinformatics® Datamart. Demographic factors and risk factors for the receipt of sepsis or APN were subsequently analyzed for statistical significance. Results: Of 467,502 urinary stone patients, age-matched multivariate analysis revealed that a history of urinary tract infection (OR 11.31, 95% CI 10.68–11.99, p < 0.0001) and female gender (OR 2.73, 95% CI 2.62–2.84, p < 0.0001) were significantly related to an increased risk of sepsis or APN. Conversely, a previous past medical history of urolithiasis (OR 0.91, 95% CI 0.87–0.95, p < 0.0001) and cancer (OR 0.91, 95% CI 0.87–0.95, p < 0.0001) were associated with a decreased risk of sepsis or APN. With regards to comorbidities, when more than one comorbidity was present, there was an additive effect with higher OR point estimates, rising to 11.31 (10.68–11.99) when three or more comorbidities present. History of urinary tract infection and female gender are risk factors for sepsis or APN in patients with ureteral calculi. Conclusions: This large national cohort reveals the characteristics of sepsis or APN combined with ureteral stone and provides an important baseline for the treatment of urolithiasis in the future.

Aim: To investigate the prognostic role of neutrophil percentage-to-albumin ratio (NPAR) in muscle-invasive bladder cancer (MIBC) patients treated with neoadjuvant chemotherapy (NAC) and radical cystectomy (RC). Patients & methods: 213 patients were included. Inclusion criteria: Nonmetastatic, MIBC (cT2-T4aN0M0), at least three cycles of NAC, undergone RC and with blood count within 30 days before NAC. Results: Five-years overall survival (OS) with NPAR >18 was 34.06% (95% CI: 18.3–50.5) and 65.37% (95% CI: 52.4–75.6) with NPAR 18 was 42.9% (95% CI: 23.9–60.7) and 74.5% (95% CI: 62.6–83.1) with NPAR

Radical cystectomy (RC) remains a highly morbid urologic procedure, and erectile dysfunction (ED) represents a significant burden for bladder cancer survivors. While inflatable penile prosthesis (IPP) offers a definitive treatment option for post-RC ED, the hostile postoperative anatomy of RC patients poses some technical challenges for IPP implantation. We report the case of a 54-year-old male with high grade bladder cancer who was managed with a robotic-assisted RC with Bricker ileal conduit urinary diversion and simultaneous implantation of a 3-piece IPP. Operative time was 310 min (230 min for the RC and ileal conduit portion, 80 min for IPP implantation). Estimated blood loss was 300 ml. Postoperative course was regular. The patient was discharged home on postoperative day 6. A robotic RC with concomitant IPP implantation can be offered as “one-step” solution to bladder cancer male patients. This approach can potentially offer the advantage of better outcome in terms of sexual function, while minimizing surgical risks, ultimately improving the quality of life of these patients.

Background: Transurethral resection of the prostate (TURP) is the gold-standard treatment for benign prostatic hyperplasia (BPH). However, laser surgery techniques (e.g., photoselective vaporization of the prostate (PVP), holmium laser, thulium laser enucleation of the prostate (HoLEP or ThuLEP)), and minimally invasive treatment options (e.g., UroLift) are increasingly replacing TURP. This study seeks to report the annual incidence, management trends, and costs of BPH procedures in the U.S. Methods: Data analyses of U.S. health insurance claims from 2004 to 2017, collected from the de-identified Optum Clinformatics Claims Database, were performed to determine the number of BPH patients and the treatment selected. Results: A total of 51,448 patients underwent BPH procedures from 2004 to 2017. There was a significant increase in the annual rate from 770 in 2004 to 6571 in 2017. The mean patient age (±SD) increased from 67.6 years old (±8.4) in 2004 to 73.4 years old (±8.4) in 2017. More than 60% of patients underwent cystourethroscopy and a post-void residual urine check for workup prior to surgical management. TURP was the most-common, and PVP was the second-most-common BPH procedure. Medical and total treatment costs increased, while the detection rate of prostate cancer after BPH surgery gradually decreased from 19.87% in 2004 to 5.78% in 2017. Conclusions: Our study demonstrates a recent trend in BPH management that replaces the traditional TURP technique with alternative methods. Due to rising costs, future studies should assess whether these newer methods are cost effective over the long term.

BackgroundThree or four cycles of cisplatin-based chemotherapy is the standard neoadjuvant treatment prior to cystectomy in patients with muscle-invasive bladder cancer. Although NCCN guidelines recommend 4 cycles of cisplatin-gemcitabine, three cycles are also commonly administered in clinical practice. In this multicenter retrospective study, we assessed a large and homogenous cohort of patients with urothelial bladder cancer (UBC) treated with three or four cycles of neoadjuvant cisplatin-gemcitabine followed by radical cystectomy, in order to explore whether three vs. four cycles were associated with different outcomes.MethodsPatients with histologically confirmed muscle-invasive UBC included in this retrospective study had to be treated with either 3 (cohort A) or 4 (cohort B) cycles of cisplatin-gemcitabine as neoadjuvant therapy before undergoing radical cystectomy with lymphadenectomy. Outcomes including pathologic downstaging to non-muscle invasive disease, pathologic complete response (defined as absence of disease -ypT0), overall- and cancer-specific- survival as well as time to recurrence were compared between cohorts A vs. B.ResultsA total of 219 patients treated at 14 different high-volume Institutions were included in this retrospective study. Patients who received 3 (cohort A) vs. 4 (cohort B) cycles of neoadjuvant cisplatin-gemcitabine were 160 (73,1%) vs. 59 (26,9%).At univariate analysis, the number of neoadjuvant cycles was not associated with either pathologic complete response, pathologic downstaging, time to recurrence, cancer specific, and overall survival. Of note, patients in cohort B vs. A showed a worse non-cancer specific overall survival at univariate analysis (HR= 2.53; 95 CI= 1.05 - 6.10; p=0.046), although this finding was not confirmed at multivariate analysis.ConclusionsOur findings suggest that 3 cycles of cisplatin-gemcitabine may be equally effective, with less long-term toxicity, compared to 4 cycles in the neoadjuvant setting.

Background: A systemic inflammatory marker, the modified Glasgow prognostic score (mGPS), could predict outcomes in non-muscle-invasive bladder cancer (NIMBC). We aimed to investigate the predictive power of mGPS in oncological outcomes in HG/G3 T1 NMIBC patients undergoing Bacillus Calmette–Guérin (BCG) therapy. Methods: We retrospectively reviewed patient’s medical data from multicenter institutions. A total of 1382 patients with HG/G3 T1 NMIBC have been administered adjuvant intravesical BCG therapy, every week for 3 weeks given at 3, 6, 12, 18, 24, 30 and 36 months. The analysis of mGPS for recurrence and progression was performed using multivariable and univariable Cox regression models. Results: During follow-up, 659 patients (47.68%) suffered recurrence, 441 (31.91%) suffered progression, 156 (11.28%) died of all causes, and 67 (4.84%) died of bladder cancer. At multivariable analysis, neutrophil to lymphocyte ratio [hazard ratio (HR): 7.471; p = 0.0001] and erythrocyte sedimentation rate (ESR) (HR: 0.706; p = 0.006 were significantly associated with recurrence. mGPS has no statistical significance for progression (p = 0.076). Kaplan–Meier survival analysis showed a significant difference in survival among patients from different mGPS subgroups. Five-year OS was 93% (CI 95% 92–94), in patients with mGPS 0, 82.2% (CI 95% 78.9–85.5) in patients with mGPS 1 and 78.1% (CI 95% 60.4–70) in mGPS 2 patients. Five-year CSS was 98% (CI 95% 97–99) in patients with mGPS 0, 90% (CI 95% 87–94) in patients with mGPS 1, and 100% in mGPS 2 patients. Limitations are applicable to a retrospective study. Conclusions: mGPS may have the potential to predict recurrence in HG/G3 T1 NMIBC patients, but more prospective, with large cohorts, studies are needed to study the influence of systemic inflammatory markers in prediction of outcomes in NMIBC for a definitive conclusion.

Re-staging transurethral resection, the so-called repeat TUR (Re-TUR), is mandatory in case of incomplete first transurethral resection of bladder tumor (TURBT). In completely resected high grade T1 tumors, Re-TUR is recommended but question remains whether it provides advantages in terms of recurrence-free survival (RFS), progression-free survival (PFS), and cancer specific survival (CSS). The present study aimed to determine whether Re-TUR improves such outcomes in patients with completely resected high-grade T1 bladder cancer (BC). We queried our prospectively maintained database to identify patients with completely resected high-grade T1 BC who underwent (Group A) or not (Group B) Re-TUR before starting intravesical instillations of Bacillus Calmette-Guerin (BCG). The impact of Re-TUR as well as of other tested variables on RFS, PFS, and CSS was tested by Kaplan-Meier method and Log-rank testing. A total of 118 patients underwent Re-TUR, which pointed out no BC in 61 (51.7%), NMIBC in 54 (45.8%) and pT2 disease in 3 (2.5%). The 3 patients with pT2 disease underwent cystectomy, whereas all others were offered BCG treatment. Forty-two patients refused BCG treatment while 2 did not complete it; therefore, Group A (Re-TUR before BCG treatment) consisted of 71 patients whereas Group B consisted of 40 patients who refused Re-TUR but completed BCG treatment. Mean follow-up was 60 months (range 12-142). Kaplan-Meier curves and Log-rank testing showed no difference in RFS, PFS and CSS between patients who had (Group A) or had not (Group B) Re-TUR before starting BCG treatment. Our findings suggest that a Re-TUR in patients with a completely resected high-grade T1 BC does not translate into a better oncological outcome. Given its impact on both patients and healthcare system, the need for Re-TUR in completely resected high grade T1 BC should be further investigated into the framework of a randomized study.

Over the past few years, the role of robotic-assisted partial nephrectomy (RPN) has exponentially grown. Multiple recognized factors contribute to postoperative renal function in patients undergoing RPN. The aim of this review is to identify these potential factors, and to evaluate strategies that may help optimize the goal of renal function preservation. A nonsystematic literature review was performed to retrieve the most recent evidence on factors contributing to renal function post-RPN. Analyzed elements include baseline factors (tumor complexity and patient characteristics), intraoperative (surgical) factors (control of the renal hilum and type of ischemia, resection technique, renorrhaphy technique), and pharmacotherapeutics. In conclusion, the advantages of robotic surgery in the setting of partial nephrectomy (PN) are becoming well established. Maximal preservation of renal function remains a priority goal of the procedure, and it is influenced by a plethora of factors. Adequate patient selection using radiomics, control of comorbidities, utilization of evidence-based intraoperative techniques/strategies, and postoperative care are key components of postoperative preservation of renal function. Further investigations regarding these factors and their effects on long-term renal function are necessary and will continue to aid in guiding appropriate patient care.

We aimed to review studies comparing the outcomes of the laparoendoscopic single site (LESS) pyeloplasty with those of conventional laparoscopic pyeloplasty (CLP). A systematic review of the literature was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analysis) criteria. The methodological quality of the studies was rated according validated scales. The level of evidence (LE) was reported as described by the Oxford criteria. Preoperative demographic parameters and perioperative outcomes between the two surgical techniques were assessed. A meta-analysis of the included studies was performed. A total of 5 studies were elected for the analysis, including 164 cases, 70 (42.6%) of them being LESS and 94 (57.4%) being CLP. Four studies were observational retrospective comparative studies (LE: 3a-4); one was a prospective randomized controlled trial (LE: 2b). There was no significant difference in age, body mass index, gender, side and presence of the crossing vessel, between the groups. There was no significant difference regarding the operative time (weight mean difference [WMD]: −7.02; 95% confidence interval [CI]: −71.82-57.79; P = 0.83) and length of hospital stay (WMD: 0.04; 95% CI: −0.11-0.20; P = 0.58), whereas the estimated blood loss was statistically lower for LESS (WMD: −16.83; 95% CI: −31.79-−1.87; P = 0.03). The postoperative use of analgesic favored the LESS group but without reaching statistical significance (WMD: −7.52; 95% CI: −17.56-2.53; P = 0.14). In conclusion, LESS pyeloplasty offers comparable surgical and functional outcomes to CLP while providing the potential advantages of less blood loss and lower analgesic requirement. Thus, despite being more technically challenging, LESS pyeloplasty can be regarded as a minimally invasive approach for patients seeking fewer incisional scars.

Purpose To investigate risk factors for urine leak in patients undergoing minimally invasive partial nephrectomy (MIPN) and to determine the role of intraoperative ureteral catheterization in preventing this postoperative complication. Materials and Methods MIPN procedures done from September 1999 to July 2012 at our Center were reviewed from our IRB-approved database. Patient and tumor characteristics, operative techniques and outcomes were analyzed. Patients with evidence of urine leak were identified. Outcomes were compared between patients with preoperative ureteral catheterization (C-group) and those without (NC-group). Univariable and multivariable analyses were performed to identify factors predicting postoperative urine leak. Results A total of 1,019 cases were included (452 robotic partial nephrectomy cases and 567 laparoscopic partial nephrectomy cases). Five hundred twenty eight patients (51.8%) were in the C-group, whereas 491 of them (48.2%) in the NC-group. Urine leak occurred in 31(3%) cases, 4.6% in the C-group and 1.4% in the NC-group (p

The continued effort of improving cosmesis and reducing morbidity in urologic surgery has given rise to novel alternatives to traditional minimally invasive techniques: Laparoendoscopic Single-site Surgery (LESS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES). Despite the development of specialized access devices and instruments, the performance of complex procedures using LESS has been challenging due to loss of triangulation and instrument clashing. A robotic interface may represent the key factor in overcoming the critical restrictions related to NOTES and LESS. Although encouraging, current clinical evidence related to R-LESS remains limited as the current da Vinci® robotic platform has not been specifically designed for LESS. Robotic innovations are imminent and are likely to govern major changes to the current landscape of scarless surgery.

Most ureteral stones can be observed with reasonable expectation of uneventful stone passage. When an active ureteral stone treatment is warranted, the best procedure to choose is dependent on several factors, besides stone size and location, including operators′ experience, patients′ preference, available equipment and related costs. Placement of double-J stent or nephrostomy tube represents the classical procedures performed in a renal colic due to acute ureteral obstruction when the conservative drug therapy does not resolve the symptoms. These maneuvers are usually followed by ureteroscopy or extracorporeal shockwave lithotripsy, which currently represent the mainstay of treatment for ureteral stones. In this review paper a literature search was performed to identify reports dealing with emergency management of renal colic due to ureteral stones. The main aspects related to this debated issue are analyzed and the advantages and disadvantages of each treatment option are carefully discussed.

Encrustation constitutes a serious complication of ureteral stent use and can result in difficult stent removal. We report the case of a patient with a retained ureteral stent for 3 years following a radical cystectomy.

Introduction A duplicated renal collecting system is a relatively common congenital anomaly rarely presenting in adults. Aim In this video we demonstrate our step-by-step technique of Robotic heminephrectomy in a patient with non-functioning upper pole moiety. Materials and Methods Following cystoscopy and ureteral catheter insertion the patient was placed in 600 modified flank position with the ipsilateral arm positioned at the side of the patient. A straight-line, three arm robotic port configuration was employed. The robot was docked at a 90-degree angle, perpendicular to the patient. Following mobilization the colon and identifying both ureters of the duplicated system, the ureters were followed cephalically toward, hilar vessels where the hilar anatomy was identified. The nonfunctioning pole vasculature was ligated using hem-o-lok clips. The ureter was sharply divided and the proximal ureteral stump was passed posterior the renal hilum. Ureteral stump was used as for retraction and heminephrectomy is completed along the line demarcating the upper and lower pole moieties. Renorrhaphy was performed using 0-Vicryl suture with a CT-1 needle. The nonfunctioning pole ureter was then dissected caudally toward the bladder hiatus, ligated using clips, and transected. Results The operating time was 240 minutes and blood loss was 100 cc. There was no complication post-operatively. Conclusions Wrist articulation and degree of freedom offered by robotic platform facilitates successful performance of minimally invasive heminephrectomy in the setting of an atrophic and symptomatic renal segment.