A Velocity-Based Approach to Noninvasive Methodology for Urodynamic Analysis.

PURPOSE: To date, invasive urodynamic investigations have been used to define most terms and conditions relating to lower urinary tract symptoms. This invasiveness is almost totally due to the urethral catheter. In order to remove this source of discomfort for patients, the present study investigated a noninvasive methodology able to provide diagnostic information on bladder outlet obstruction or detrusor underactivity without any contact with the human body. METHODS: The proposed approach is based on simultaneous measurements of flow rate and jet exit velocity. In particular, the jet exit kinetic energy appears to be strongly related to bladder pressure, providing useful information on the lower urinary tract functionality. We developed a new experimental apparatus to simulate the male lower urinary tract, thus allowing extensive laboratory activities. A large amount of data was collected regarding different functional statuses. RESULTS: Experimental results were compared successfully with data in the literature in terms of peak flow rate and jet exit velocity. A new diagram based on the kinetic energy of the exit jet is proposed herein. Using the same notation as a Schäfer diagram, it is possible to perform noninvasive urodynamic studies. CONCLUSION: A new noninvasive approach based on the measurement of jet exit kinetic energy has been proposed to replace current invasive urodynamic studies. A preliminary assessment of this approach was carried out in healthy men, with a specificity of 91.5%. An additional comparison using a small sample of available pressure-flow studies also confirmed the validity of the proposed approach.

Prostate Cancer Characteristics in Renal Transplant Recipients: A 25-Year Experience From a Single Centre.

Objectives: The incidence of prostate cancer in renal transplant recipients (RTRs) is increasing, but few data are available in the literature. In this study, we reviewed the 25-year experience in the management of prostate cancer after kidney transplantation at the Florence Transplant Centre. Methods: We retrospectively reviewed the data from 617 RTR male patients who underwent renal transplantation at our institute between July 1996 and September 2016. Data regarding demographics, renal transplantation, prostate cancer and immunosuppressive treatment were analyzed. The probability of death was estimated by using the Kaplan-Meier method and differences between patients' groups were assessed by the log-rank test. Results: From July 1991 to September 2016, 617 kidney transplantations of male patients were performed at our institute. Among these, 20 patients were subsequently diagnosed with prostate cancer accounting for a cumulative incidence of 3.24%. After a median follow-up of 59 months, 10 patients underwent radical prostatectomy whereas 10 patients underwent primary radiotherapy. A biochemical recurrence was identified in five (25%) patients while a fatal event occurred in 11 (55%) patients. Univariate Cox regression showed that the basal value of PSA >10 ng/ml was the only significant factor negatively affecting the survival of patients. Conclusions: Standard treatments can be proposed to RTR with satisfactory results on both post-operative and oncological outcomes. Further studies are needed to address the issue of prostate cancer screening based on PSA levels and the optimal management of prostate cancer in RTRs.

Quantitative Polymerase Chain Reaction Detection of Microchimerism in Female Transplant Renal Recipients.

INTRODUCTION: Microchimerism (MC) is the presence of a small amount of foreign cells or DNA within a person's circulation or tissues. It has been identified also in recipients of solid organ transplants where it seems to be critical for the development and maintenance of immunological tolerance. Nevertheless, natural and/or iatrogenic MC can be acquired prior to transplantation, through pregnancy and/or blood transfusion. OBJECTIVE: The aim of this study was to detect the presence of MC in women after renal transplantation from male cadaveric donors and its relationship with graft outcomes. METHODS: We studied by qPCR the presence of the DYS14 gene sequence of the Y chromosome in 12 females who received a kidney graft from a male donor before transplantation (T0), after 15 days (T1) and 1 year of transplantation (T2). We found the sequence in all recipients after renal transplantation. RESULTS: All the women were negative for this sequence prior to transplantation (T0). Mean (SD) Y-related DNA quantity was 0.80 (0.69) ng/mL plasma and 0.15 (0.26) ng/mL plasma at T1 and T2, respectively. No acute rejection was observed, and mean (SD) estimated Cr clearance was 68.8 (16.9) mL/min within 1 year from transplantation. CONCLUSIONS: Presence of MC was associated with good kidney graft outcomes after 1 year of transplantation, but further studies will be needed to investigate the relationship between clinical outcomes and the development of MC in renal transplant recipient.

Sexual Rehabilitation After Nerve-Sparing Radical Prostatectomy: Free-of-Charge Phosphodiesterase Type 5 Inhibitor Administration Improves Compliance to Treatment.

BACKGROUND: In December 2006, the region of Tuscany (Italy) authorized the free-of-charge provision of phosphodiesterase type 5 inhibitors (PDE5I) for all patients with Tuscan citizenship who undergo nerve-sparing radical prostatectomy (NSRP). OBJECTIVE: To compare sexual rehabilitation outcomes in patients with low risk of erectile dysfunction and minimal comorbidities who received PDE5Is free of charge (PDE5I-F) with those who paid for PDE5Is (PDE5I-P) after bilateral NSRP. METHODS: We reviewed prospectively recorded clinical data of 2,368 patients with Tuscan (PDE5I-F) and non-Tuscan (PDE5I-P) citizenship treated with NSRP at 3 different institutions in Tuscany from 2008 to 2013. Inclusion criteria for the final analysis were open or robot-assisted bilateral NSRP; low risk of postoperative erectile dysfunction according to the Briganti risk stratification tool; no smoking and no drug and alcohol abuse; no cardiovascular risk factors; no major surgery before and after NSRP; no neoadjuvant or adjuvant treatment; and no biochemical relapse. Dropout was defined as an interruption longer than 40 days of the treatment protocol indicated in the inclusion criteria. Treatment compliance was defined as more than 90% consumption of the prescribed PDE5I. OUTCOMES: The Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) and the Italian version of the University of California-Los Angeles Prostate Cancer Index sexual function (UCLA-PCI-s) questionnaires were administered to assess patients' satisfaction with PDE5I treatment and sexual function. RESULTS: Overall, 648 patients in the PDE5I-F group and 182 in the PDE5I-P group met the inclusion criteria and were eligible for the study. Patients had comparable preoperative and surgical characteristics. The PDE5I-F group had a significantly higher early rehabilitation onset (P < .001), lower treatment dropout at 12, 24, and 36 months (P < .001 for all comparisons), and higher compliance to the treatment protocol at 6 and 12 months (P = .01 and P < .001, respectively). At multivariable analysis, the PDE5I-F protocol was an independent predictor of an EDITS score higher than 50 (hazard ratio = 1.54, P = .03) and a UCLA-PCI-s score higher than 50 (hazard ratio = 3.12, P = .01) after adjusting for the effects of several clinical features. CLINICAL IMPLICATIONS: The free-of-charge protocol has a significant impact on patients' satisfaction with PDE5I treatment. STRENGTHS AND LIMITATIONS: To our knowledge, this is the first study comparing free vs paid access to a sexual rehabilitation protocol. Major limitations are the observational nature of the study and the different population sizes of the 2 groups. CONCLUSIONS: In a selected cohort of patients after NSRP, free-of-charge access to a sexual rehabilitation protocol was significantly associated with higher early rehabilitation onset, major compliance to the protocol, minor treatment dropout, and higher satisfaction rate of patients. Siena G, Mari A, Canale A, et al. Sexual Rehabilitation After Nerve-Sparing Radical Prostatectomy: Free-of-Charge Phosphodiesterase Type 5 Inhibitor Administration Improves Compliance to Treatment. J Sex Med 2018;15:120-123.

Long-term experience with a novel uterine-sparing transvaginal mesh procedure for uterovaginal prolapse.

OBJECTIVES: To evaluate outcomes and quality of life in patients operated transvaginally with an original mesh shape for uterus-sparing prolapse surgery and to demonstrate the safety and efficacy of the technique. STUDY DESIGN: We prospectively evaluated 66 postmenopausal patients (POP-Q Stage III: 32, IV: 34) operated between May 2008 and December 2013. We used wide weave polypropylene monofilament mesh that functions as a hammock anchored posteriorly to sacrospinous ligaments, its anterior wings exit the pelvis through the obturatory membrane. Follow-up was scheduled at 3-, 12- months and in May 2016. Prolapse-Quality of Life Questionnaire (P-QoL) was administered preoperatively, at 12 months and in May 2016. The chi square and Wilcoxon test were used for statistical analysis. RESULTS: Mean follow-up was 5.6 (SD: 1.6, Range: 1.1-8.1) years. The overall success rate (POP-Q ≤ 2) was 92.5% at 12 months and 84.4% at May 2016, these data remained stable over time (p > 0.05). Early complications occurred in 2 (3%) patients, late in 5 (7.8%) of which mesh extrusion in 4 (6.3%). Data from P-QoL showed significant improvement between preoperative and postoperative data (P < 0.01 for all domains) and they remained stable with time (p > 0.05). De-novo dyspareunia was 17.6% at 12 months and 10.3% at May 2016. CONCLUSIONS: The low rate and grade of complications demonstrates the safety of the procedure, which offers stable anatomical correction with significant improvement in QoL.

Long-term complications arising from bowel interposition in the urinary tract.

After radical cystectomy or pathologies affecting the ureter(s), bowel segments can be employed to restore the natural urine flow or to create an external urinary diversion. Nevertheless, the interposition of bowel segments in the urinary tract is not devoid of complications. In fact, bowel's microstructure differs from the urothelium; specifically its mucosa is aimed at reabsorption, rather than storage. The aim of this paper is to revise the pathophysiology of complications related to bowel's mucosal properties. Those are: metabolic imbalance, malabsorption of vitamins, cholelitiasis, nephrolitiasis and infections. Their entity varies according to the segment used and to its length, which reflects the surface in contact with urine. Mostly, they occur on the long-term, but metabolic imbalances might occur soon after surgery as well.

A contemporary series of renal masses with emphasis on recently recognized entities and tumors of low malignant potential: A report based on 624 consecutive tumors from a single tertiary center.

INTRODUCTION: A number of new renal tumor entities have been recognized by the 2016 World Health Organization classification of urologic tumors. The classification includes tumors with different behavior and introduces one tumor with low malignant potential, the multilocular cystic clear cell renal cell neoplasm of low malignant potential (mcCCRCNLMP). However, some categories still labeled as "carcinoma", such as clear cell papillary renal cell carcinoma (CCPRCC), renal angioleiomyomatous tumor (RAT), and tubulocystic carcinoma (TCRCC), all with a particularly good prognosis when diagnosed as low stage, show no malignant behavior: in fact, no metastases have been reported in these categories when surgically excised. Current experience is limited to supporting these neoplasms as benign entities although, recent literature data is defining these entities as "low malignant potential tumors". MATERIAL AND METHODS: We conducted a search through our files on a consecutive series of 624 renal tumors diagnosed over a period of 2 years to address the incidence of this category of tumors. RESULTS: Applying strict histological criteria, the "low malignant potential" tumors, comprised 7% of renal masses that are less than 4cm in size and 3.8% of renal masses measuring 4-7cm in the series of 624 renal tumors. When benign tumors are taken into considerations, the benign and "low malignant potential tumors" represent about one third of renal masses <4cm and one sixth of renal masses between 4 and 7cm. All these cases have not shown recurrence or metastasis at follow-up, mean follow-up of 18 months (range 6-30 months). CONCLUSIONS: This information may assist urologists in developing guidelines for counseling and proper clinical management for patients with "low malignant potential" tumors or small renal masses.

Minimally Invasive Transanal Repair of Rectourethral Fistulas.

BACKGROUND: Rectourethral fistulas (RUFs) represent an uncommon complication of pelvic surgery, especially radical prostatectomy. To date there is no standardised treatment for managing RUFs. This represents a challenge for surgeons, mainly because of the potential recurrence risk. OBJECTIVE: To describe our minimally invasive transanal repair (MITAR) of RUFs and to assess its safety and outcomes. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively evaluated 12 patients who underwent MITAR of RUF at our centre from October 2008 to December 2014. Exclusion criteria were a fistula diameter greater than 1.5cm, sepsis, and/or faecaluria. SURGICAL PROCEDURE: After fistula identification through cystoscopy and 5F-catheter positioning within the fistula, MITAR is performed using laparoscopic instruments introduced through Parks' anal retractor. The fibrotic margins of the fistula are carefully dissected by a lozenge incision of the rectal wall, parallel to the rectal axis. Under the healthy flap of the rectal wall the urothelium is located and the fistulous tract is sutured with interrupted stitches. After a leakage test of the bladder, the rectal wall is sutured with interrupted stitches. Electrocoagulation is never used during this procedure. MEASUREMENTS: Fistula closure, postoperative complications, and recurrence. RESULTS AND LIMITATIONS: Median follow-up was 21 (range, 12-74) mo. Median operative time was 58 (range, 50-70) min. Median hospital stay was 1.5 (range, 1-4) d. Early surgical complications occurred in one patient (8.3%). Recurrence did not occur in any of the cases. Limitations included retrospective analysis, small case load, and lack of experience with radiation-induced fustulas. CONCLUSIONS: MITAR is a safe, effective, and reproducible procedure. Its advantages are low morbidity and quick recovery, and no need for a colostomy. PATIENT SUMMARY: We studied the treatment of rectourethral fistulas. Our technique, transanally performed using laparoscopic instruments, was found to be safe, feasible, and effective, with limited risk of complications.

Conservative approach for a solitary fibrous tumor of the kidney.

INTRODUCTION: Solitary fibrous tumor (SFT) of the kidney represents a rare neoplasm, and its malignant potential seems to be scarce. Classically, a radical nephrectomy is regarded as the treatment of choice for this condition. CASE REPORT: We present the case of a 37-year-old male patient who underwent left robotic clampless partial nephrectomy of an SFT of the kidney. Our patient has been followed-up carefully, and at 15-month examination, he is free of recurrence. This is the second case of an SFT managed through a conservative approach. CONCLUSIONS: In our opinion, according to tumor's dimensions, partial nephrectomy may be considered for treating small SFTs.

Use of sigmoid colon in orthotopic neobladder reconstruction: Long-term results.

OBJECTIVES: To present our experience with a sigmoid orthotopic neobladder. METHODS: We retrospectively evaluated the functional and oncological outcomes of 160 patients who underwent orthotopic neobladder reconstruction using a detubularized 20-25-cm sigmoid segment at our institution. Each patient was evaluated every 3 months the first year, every 6 months for the next 4 years and annually thereafter. Urodynamic studies of all consenting patients were carried out after 6 months, and 2, 5 and 10 years. We carried out the log-rank test, and used Cox regression models and Kaplan-Meier survival analysis. The anova test was used to compare urodynamic findings over time. RESULTS: Mean follow up was 6.8 years (range 0.65-21.7 years). Overall survival was 58.1% at 5 years, and 47.1% at 10 years. Early complications occurred in 36 patients (22.6%); late complications in 40 (25%). Stage V chronic kidney disease developed in two patients (1.3%). Complete (daytime and night-time) continence, defined as no need for pads or condom devices, was achieved by 45% of patients at 5 years, daytime continence was achieved by just 36% of patients; both were unchanged at 10 years. A significant difference emerged in maximal neobladder capacity and post-void residual values between 6 months and 2 years, and between 2 and 5 years (P < 0.01 and P = 0.03, respectively). CONCLUSIONS: Sigmoid neobladder continence and capacity significantly improve over the first 5 years, and they remain stable over the long term. Upper urinary tract function is not affected by endoluminal pressure, and the rate of metabolic imbalance is negligible.

[Surgical overview on kidney and pancreas transplantation]. / Problemi chirurgici nel trapianto di rene e di pancreas - Position paper.

The main purpose of this paper, written by a group of Italian expert transplant surgeons, is to provide clinical support and to help through the decision-making process over pre-transplant surgical procedures in potential kidney recipients, as well as selection of pancreas transplant candidates and perioperative management of kidney recipient. Current topics such as different approaches in minimally invasive donor nephrectomy, methods of graft preservation and treatment of failed allograft were addressed.

Conservative Treatment of Serous Borderline Paratesticular Tumor in a Pediatric Patient.

Serous borderline tumors are rare neoplasms. Herein we report our conservative approach, whose rationale is neoplasm low-malignant potential. Tumor was removed under general anesthesia, and frozen section ruled out a germinal malignancy or a stromal tumor such as rhabdomyosarcoma. Ultrasound evaluation was initially performed every 3 months during the first 2 years, every 6 months during the next 3 years, and annually thereafter. After 8 years, the patient has not experienced any relapse, either clinical or ultrasonographical. In our opinion, conservative approach, whose final decision relies on intraoperative frozen section, represents the best option and does not jeopardize long-term oncological outcome.

The impact of prior TURP on radical prostatectomy surgical margins: a multicenter analysis.

OBJECTIVE: To analyze positive surgical margins (PSM) after radical prostatectomy (RP) in the overall population and in patients previously treated with transurethral resection of the prostate (TURP). MATERIALS AND METHODS: 2,408 patients treated with RP for clinically localized prostate cancer (PCa) were consecutively enrolled in 135 departments. We correlated PSM rates and all preoperative, surgical and pathological features. We stratified the site of PSM as unique or multifocal. Moreover, we analyzed differences between 75 patients who had undergone previous TURP and the remaining 2,333 patients. RESULTS: In the entire study population, we identified 702 patients with PSM (29%). Using univariate analysis, we reported a significant correlation between overall PSM and prostate-specific antigen (PSA), stage cT, biopsy Gleason score, number of biopsy cores, number of positive cores, percentage of positive cores and nerve-sparing approach. PSM proved to be strongly dependent on pT in particular in patients with pT2 PCa. When we compared the data from 75 patients previously treated with TURP and those from 2,333 without previous prostatic surgery, a statistically significant difference in margin localization was found. Moreover, we analyzed the 75 patients mentioned above, stratified in incidental PCa diagnosed at TURP or PCa detected with prostate biopsy for PSA rising during the post-TURP follow-up: no statistical differences were found between the 2 groups regarding margin status, even if PSM were more frequent in incidental PCa with no significance deriving from the stratification for PSM location at the apex or base. CONCLUSION: Men treated with TURP before RP presented an overall incidence of PSM similar to those without previous TURP, but with a higher risk of PSM at the bladder neck and a lower risk of PSM at the prostatic apex.

Adjuvant and salvage radiotherapy after prostatectomy: outcome analysis of 307 patients with prostate cancer.

AIM: In men with adverse pathology after radical prostatectomy, the most appropriate timing to administer radiotherapy (RT) remains a topic of debate. We analyzed in terms of efficacy, prognostic factors and toxicity the two therapeutic strategies: immediate postoperative radiotherapy (PORT) and salvage radiotherapy (SART). MATERIALS AND METHODS: Between January 1995 and November 2010, 307 patients underwent adjuvant or salvage radiotherapy, after prostatectomy. RESULTS: In the PORT group, 42 patients (20.7 %) had biochemical failure, with a median time to biochemical failure of 1.8 years; two parameters (age at diagnosis and PSA pre-RT) resulted to be significant at the survival analysis for overall survival (p = 0.003 and p = 0.046, respectively). In the SART group, 33 patients (31.7 %) had biochemical relapse; sixteen patients died of prostate cancer; postoperative hormones therapy, conformal radiotherapy and level of PSA pre-RT >1.0 ng/ml resulted to be significant at the survival analysis, p = 0.009, p = 0.039 and p = 0.002, respectively. CONCLUSION: Our study is limited by its retrospective and nonrandomized design. As such, decisions to treat with adjuvant or salvage radiotherapy and the time to initiate therapy were based on patient preference and physician counseling. Our recommendation is to suggest adjuvant radiotherapy for all patients with adverse prognostic factors and to reserve salvage radiotherapy for low-risk patients, when the biochemical recurrence occurs.

Predictive factors of [18F]-Choline PET/CT in 170 patients with increasing PSA after primary radical treatment.

AIM: The purpose of this study was to evaluate the potential usefulness of [18F]-Choline PET/CT in the restaging of prostate cancer patients, who presented a rising PSA. MATERIALS AND METHODS: We evaluated 170 prostate cancer patients, previously radically treated, that were referred for restaging with [18F]-Choline PET/CT. RESULTS: A total of 129 patients (median PSA 4.29 ng/ml at relapse) showed one or more areas of high uptake on PET/CT scan, while 41 patients with a median PSA of 1.07 ng/ml at relapse showed negative PET/CT scans. No false negative was found, while 31 patients were identified as false positive. Specificity of Choline PET/CT in our series was 56.9 %, while sensibility was 100 %. At the time of restaging, a PSA value superior or equal to 1 ng/ml was found to be a statistically significant predictive factor of PET positivity, either at the univariate (p < 0.0001) and at the multivariate analysis (p < 0.0001). CONCLUSIONS: Based on our findings, [18F]-Choline PET/CT is confirmed as a useful diagnostic tool to detect early recurrence, in patients with increasing PSA after primary treatment. However, in case of a mild increase in PSA, positive results must be validated with other techniques, as specificity and positive predictive value of [18F]-Choline PET/CT decrease with the lower values of PSA.