The Impact of COVID-19 Pandemic on Urological Emergencies: A Multicenter Experience on over 3,000 Patients.

OBJECTIVE: COVID-19 pandemic represents a dramatic challenge for healthcare systems worldwide, and it also affects daily urological practice. After China and Italy, Tessin (Switzerland) has been hit the hardest, due to its close proximity to Lombardy and the high number of frontier workers in the area. Our objective was to share with the scientific community how, during the COVID-19 period, there has been a huge modification in urological emergencies throughout all hospitals included in the Ente Ospedaliero Cantonale (EOC). METHODS: We retrospectively reviewed urgent urological consultations requested by the emergency department (ED) of the 4 public hospitals located in Tessin belonging to EOC in the 3-month period between February 15 and May 15, 2020, and compared them to the 2 previous years cases within the same time frame (February 15 to May 15, 2018 and 2019). The number of daily consultations, urgent invasive procedures performed, and admissions were evaluated. RESULTS: The final sample resulted in 594 consultations performed in 2020, 974 in 2018, and 974 in 2019. A higher number of daily consultations were performed during 2018 and 2019. The number of daily admissions dropped consistently during the COVID-19 pandemic (737 vs. 392). CONCLUSIONS: Our multicenter study aimed to quantify changes in urgent urological care in Tessin in the midst of the COVID-19 pandemic. Urgent urology practice was dramatically affected with a remarkable reduction in urgent urological consultations, whereas a higher risk of admissions was observed in 2020, due to the severity of the patients.

A novel tool for predicting extracapsular extension during graded partial nerve sparing in radical prostatectomy.

OBJECTIVES: To create a statistical tool for the estimation of extracapsular extension (ECE) level of prostate cancer and determine the nerve-sparing (NS) approach that can be safely performed during radical prostatectomy (RP). PATIENTS AND METHODS: A total of 11 794 lobes, from 6 360 patients who underwent robot-assisted RP between 2008 and 2016 were evaluated. Clinicopathological features were included in a statistical algorithm for the prediction of the maximum ECE width. Five multivariable logistic models were estimated for: presence of ECE and ECE width of >1, >2, >3, and >4 mm. A five-zone decision rule based on a lower and upper threshold is proposed. Using a graphical interface, surgeons can view patient's pre-treatment characteristics and a curve showing the estimated probabilities for ECE amount together with the areas identified by the decision rule. RESULTS: Of the 6 360 patients, 1 803 (28.4%) were affected by non-organ-confined disease. ECE was present in 1 351 lobes (11.4%) and extended beyond the capsule for >1, >2, >3, and >4 mm in 498 (4.2%), 261 (2.2%), 148 (1.3%), 99 (0.8%) cases, respectively. ECE width was up to 15 mm (interquartile range 1.00-2.00). The five logistic models showed good predictive performance, the area under the receiver operating characteristic curve was: 0.81 for ECE, and 0.84, 0.85, 0.88, and 0.90 for ECE width of >1, >2, >3, and >4 mm, respectively. CONCLUSION: This novel tool predicts with good accuracy the presence and amount of ECE. Furthermore, the graphical interface available at www.prece.it can support surgeons in patient counselling and preoperative planning.

Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta-analysis.

To evaluate the influence of posterior musculofascial plate reconstruction (PR) on early return of continence after radical prostatectomy (RP); an updated systematic review of the literature. A systematic review of the literature was performed in June 2015, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and searching Medline, Embase, Scopus and Web of Science databases. We searched the terms posterior reconstruction prostatectomy, double layer anastomosis prostatectomy across the 'Title' and 'Abstract' fields of the records, with the following limits: humans, gender (male), and language (English). The authors reviewed the records to identify studies comparing cohorts of patients who underwent RP with or without restoration of the posterior aspect of the rhabdosphincter. A meta-analysis of the risk ratios estimated using data from the selected studies was performed. In all, 21 studies were identified, including three randomised controlled trials. The overall analysis of comparative studies showed that PR improved early continence recovery at 3-7, 30, and 90 days after catheter removal, while the continence rate at 180 days was statistically but not clinically affected. Statistically significantly lower anastomotic leakage rates were described after PR. There were no significant differences for positive surgical margins rates or for complications such as acute urinary retention and bladder neck stricture. The analysis confirms the benefits at 30 days after catheter removal already discussed in the review published in 2012, but also shows a significant advantage in terms of urinary continence recovery in the first 90 days. A multicentre prospective randomised controlled trial is currently being conducted in several institutions around the world to better assess the effectiveness of PR in facilitating an earlier recovery of postoperative urinary continence.

Efficacy of spermatic vein ligation in patients affected by high grade left varicocele.

PURPOSE: To study the effect of high grade varicocele treatment in infertile patients. MATERIALS AND METHODS: Seventy-five patients were selected by the following criteria: infertility persisting for more than 1 year; abnormal semen parameters; no other infertility-related disease; no obvious causes of infertility in the subject's partner; basal eco-color Doppler ultrasound demonstrating continuous reflux in the spermatic vein. All patients considered for the study had at least a six months period from the diagnosis to the surgery due to waiting list, choice of the patient or time needed to complete diagnostic evaluation of the couple. The surgical procedure was performed through an inguinal approach. All enrolled patients were counseled to have unprotected intercourse during the ovulation period in order to maximize the probability of pregnancy within the 6-month preoperative period. The achievement of pregnancy and semen parameters were recorded during the preoperative and postoperative period. RESULTS: Two of the seventy-five patients were excluded because of persistent varicocele after surgery. The preoperative pregnancy rate was 1.3% (1 couple). The postoperative pregnancy rate was 42.5%. The stratification of pregnancies by semester showed a significantly higher rate in the first postoperative period (p = 0.0012). Mean time to conception was 13.5 months. Mean preoperative sperm count was 17.6x10(6)/mL compared to 19.7x10(6)/mL in the postoperative period (p < 0.0001). Mean percentage of progressive sperm motility was 13.7%, compared to 17.6% in the postoperative period (p < 0.0001). Mean percentage of normal sperm morphology was 7.6%, compared to 15.2% postoperatively (p < 0.0001). CONCLUSION: Surgical treatment of high grade varicocele proved to effectively treat associa¬ted infertility by improving seminal parameters and pregnancy rate in our patient cohort.

Radio guided radical prostatectomy: evaluation of feasibility, safety and clinical outcomes.

BACKGROUND: The standard surgical treatment of PCa consists of radical prostatectomy (RP). Lymphadenectomy with removal of the sentinel lymph node (SLN) is now evolving towards the concept of radio guided surgery as an instrument for the removal of the lymph nodes of primary drainage. METHODS: From October 2012 to September 2013 laparotomic SLN dissection was performed in 43 patients during standard open radical prostatectomy. Twenty hours before surgery, 240 MBq of 99mTc nanocolloid were injected into the prostate gland under transrectal ultrasound guidance. A planar scintigraphy and a SPET/CT scan were performed 1-2 hours after the injection. Intraoperatively, all LNs detected by gamma-probe with an activity significantly higher than background were removed and classified as SLNs. We evaluated operative time, complications, postoperative outcomes and costs of the procedures of patients who underwent radio guided surgery. We measured radioactive exposure rates. RESULTS: The intraoperative detection of SLNs occurred in all 43 patients, while the scintigraphic localization was observed in 42/43 patients. A total of 77 SLNs were found, at histopathological analysis 7/77 SLNs resulted positive for metastases (4/43 patients): 3 were in the obturator fossa while the remaining SLNs were in the internal iliac chain (1), common iliac chain (1), external iliac chain (2). Global radiation exposure was not significant. CONCLUSION: Our preliminary data confirm the feasibility and the safety of SLN biopsy in nodal staging of PCa. The intraoperatively SLN detection rate resulted 100%. In 3 patients (7%) a micrometastases was found outside of obturator fossa in a not routinely sampled site.

Predicting length of stay after robotic partial nephrectomy.

INTRODUCTION: To investigate factors predictive of length of stay (LOS) after robotic partial nephrectomy (RPN) in an effort to identify patients suitable for RPN with overnight stay at outpatient surgical facilities. MATERIALS AND METHODS: Retrospective chart review of patients who underwent RPN at Memorial Sloan Kettering Cancer Center from January 2007 to July 2012 was conducted. Univariate and multivariate analyses were performed to identify the main predictors of LOS. The discrimination of the multivariate model was measured using the area under the curve (AUC); tenfold cross-validation was performed to correct for over-fit. RESULTS: One hundred and eighty-six patients were included in the analysis; 84 (45 %) had LOS of ≤1 day (median LOS 2 day; interquartile range 1-2). On univariate analysis, preoperative variables associated with LOS > 1 included larger tumors (P < 0.0001), lower estimated glomerular filtration rate (P = 0.003), older age (P = 0.006), female gender (P = 0.035), and higher comorbidity score (P = 0.015); operative variables associated with LOS > 1 day included greater estimated blood loss (P < 0.0001) and longer operative (P < 0.0001) and ischemia (P < 0.0001) times. The AUC of the preoperative model was 0.61 (95 % CI 0.52-0.69) after tenfold cross-validation. CONCLUSIONS: LOS after RPN is influenced by age, gender, medical comorbidities, and tumor size. However, when analyzed retrospectively, these factors had limited ability to predict LOS after RPN with sufficient accuracy to develop a prediction tool.

Concordance between biopsy and radical prostatectomy specimen Gleason score in internal and external pathology facilities.

BACKGROUND: Biopsy Gleason score (bGS) is an important tool for staging and decision making in patients with prostate cancer. Therefore, the data from biopsy should be both reproducible across different pathologists and predictive of the true underlying tumour. We evaluated the agreement between bGS with prostatectomy Gleason score (pGS) comparing patients who underwent prostate biopsy at our hospital with those who did it at an outside facility. MATERIALS AND METHODS: We retrospectively analyzed patients who underwent robot-assisted radical prostatectomy at our Hospital in 2011 and 2012. Patients were divided depending on the site of prostate biopsy. We calculated a weighted κ statistic to evaluate the concordance from bGS and pGS in the two groups and to evaluate the Gleason score (GS) concordance comparing the proportion of positive cores at biopsy. RESULTS: A total of 124 patients with completed data were identified (70 patients performed biopsy at our institution and 54 at an outside facility). The weighted κ score for GS agreement was 0.40 for our Institution and 0.27 for other facilities. The weighted κ score stratified by biopsy hospital for patients with at least 30% of positive cores was 0.46 for our hospital and 0.42 for other facilities. CONCLUSION: Internal prostate biopsy predicted better pGS than outside facility biopsy reports. When the percentage of biopsy-positive cores increases, the agreement between bGS and pGS is similar between the two groups. For certain cases in which an outside laboratory biopsy results in equivocal clinical decision, biopsy re-evaluation by internal pathologists can help reveal the true underlying tumor architecture and extension.

[BPH: state of the art in the surgical treatment]. / IPB: stato dell'arte sul trattamento chirurgico.

TURP has been considered the gold standard for surgical treatment of BPH for many years. Symptoms relief, improvement in maximum flow rate and reduction of post void residual urine have been reported in several experiences. Nevertheless, concerns have been reported in terms of safety outcomes: intracapsular perforation, TUR syndrome, bleeding. In the recent years the use of new forms of energy and devices such as bipolar resector, Ho: YAG and potassium-titanyl-phosphate laser are challenging the role of traditional TURP for BPH surgical treatment. In 1999 TURP represented 81% of surgical treatment for BPH versus 39% in 2005. We have analyzed guidelines and recent literature to evaluate the role of the most relevant new surgical approaches compared to TURP for the treatment of BPH.

Efficacy of spermatic vein ligation in patients affected by high grade left varicocele

Purpose: To study the effect of high grade varicocele treatment in infertile patients. Materials and Methods: Seventy-five patients were selected by the following criteria: infertility persisting for more than 1 year; abnormal semen parameters; no other infertility-related disease; no obvious causes of infertility in the subject’s partner; basal eco-color Doppler ultrasound demonstrating continuous reflux in the spermatic vein. All patients considered for the study had at least a six months period from the diagnosis to the surgery due to waiting list, choice of the patient or time needed to complete diagnostic evaluation of the couple. The surgical procedure was performed through an inguinal approach. All enrolled patients were counseled to have unprotected intercourse during the ovulation period in order to maximize the probability of pregnancy within the 6-month preoperative period. The achievement of pregnancy and semen parameters were recorded during the preoperative and postoperative period. Results: Two of the seventy-five patients were excluded because of persistent varicocele after surgery. The preoperative pregnancy rate was 1.3% (1 couple). The postoperative pregnancy rate was 42.5%. The stratification of pregnancies by semester showed a significantly higher rate in the first postoperative period (p = 0.0012). Mean time to conception was 13.5 months. Mean preoperative sperm count was 17.6x10 6 /mL compared to 19.7x10 6 /mL in the postoperative period (p < 0.0001). Mean percentage of progressive sperm motility was 13.7%, compared to 17.6% in the postoperative period (p < 0.0001). Mean percentage of normal sperm morphology was 7.6%, compared to 15.2% postoperatively (p < 0.0001). Conclusion: Surgical treatment of high grade varicocele proved to effectively treat associated infertility by improving seminal parameters and pregnancy rate in our patient cohort. .