Role of inguinal and pelvic lymph node dissection for primary urethral carcinoma: a systematic review.

PURPOSE OF REVIEW: Primary urethral carcinoma (PUC) is a rare urologic tumor. There is limited evidence on this entity. This review summarizes the existing evidence on lymph node dissection (LND) in patients with PUC. RECENT FINDINGS: We performed a systematic search of the PubMed, EMBASE, and Web of Science databases to evaluate the impact of inguinal and pelvic LND on the oncological outcomes of PUC and to identify indications for this procedure. RESULTS: Three studies met the inclusion criteria. The cancer detection rate in clinically nonpalpable inguinal lymph node (cN0) was 9% in men and 25% in women. In clinically palpable lymph node (cN+), the malignancy rate was 84% and 50% in men and women, respectively. Overall cancer detection rate in pelvic lymph nodes in patients with cN0 was 29%. Based on tumor stage, the detection rate was 11% in cT1-2 N0 and 37% in cT3-4 N0. Nodal disease was associated with higher recurrence and worse survival. Pelvic LND seems to improve overall survival for patients with LND regardless of the location or stage of lymph nodes. Inguinal LND improved overall survival only in patients with palpable lymph nodes. Inguinal LND had no survival benefit in patients with nonpalpable lymph nodes. SUMMARY: The available, albeit scarce, data suggest that inguinal LND derives the highest benefit in women and in patients with palpable inguinal nodes, whereas the benefit of pelvic LND seems to be more pronounced across all stages of invasive PUC. Prospective studies are urgently needed to further address the prognostic benefit of locoregional LND in PUC.

First case-series of robot-assisted pudendal nerve release: technique and outcomes.

OBJECTIVE: Pudendal Nerve Entrapment (PNE) may determine chronic pelvic pain associated with symptoms related to its innervation area. This study aimed to present the technique and report the outcomes of the first series of robot-assisted pudendal nerve release (RPNR). PATIENTS AND METHODS: 32 patients, who were treated with RPNR in our centre between January 2016 and July 2021, were recruited. Following the medial umbilical ligament identification, the space between this ligament and the ipsilateral external iliac pedicle is progressively dissected to identify the obturator nerve. The dissection medial to this nerve identifies the obturator vein and the arcus tendinous of the levator ani, which is cranially inserted into the ischial spine. Following the cold incision of the coccygeous muscle at the level of the spine, the sacrospinous ligament is identified and incised. The pudendal trunk (vessels and nerve) is visualized, freed from the ischial spine and medially transposed. RESULTS: The Median duration of symptoms was 7 (5, 5-9) years. The median operative time was 74 (65-83) minutes. The median length of stay was 1 (1-2) days. There was only a minor complication. At 3 and 6 months after surgery, a statistically significant pain reduction has been encountered. Furthermore, the Pearson correlation coefficient reported a negative relationship between the duration of pain and the improvement in NPRS score, - 0.81 (p = 0.01). CONCLUSIONS: RPNR is a safe and effective approach for the pain resolution caused by PNE. Timely nerve decompression is suggested to enhance outcomes.

ZNF750: A Novel Prognostic Biomarker in Metastatic Prostate Cancer.

Prostate cancer is the most frequently diagnosed cancer and the fifth leading cause of cancer death among men in 2020. The clinical decision making for prostate cancer patients is based on the stratification of the patients according to both clinical and pathological parameters such as Gleason score and prostate-specific antigen levels. However, these tools still do not adequately predict patient outcome. The aim of this study was to investigate whether ZNF750 could have a role in better stratifying patients, identifying those with a higher risk of metastasis and with the poorest prognosis. The data reported here revealed that ZNF750 protein levels are reduced in human prostate cancer samples, and this reduction is even higher in metastatic samples. Interestingly, nuclear positivity is significantly reduced in patients with metastatic prostate cancer, regardless of both Gleason score and grade group. More importantly, the bioinformatics analysis indicates that ZNF750 expression is positively correlated with better prognosis. Overall, our findings suggest that nuclear expression of ZNF750 may be a reliable prognostic biomarker for metastatic prostate cancer, which lays the foundation for the development of new biological therapies.

Double-J stent placement during laparoscopic ureterolithotomy: the "seagull" technique.

OBJECTIVE: To present a new technique of double-j stent (DJ) placement during laparoscopic transperitoneal ureterolithotomy (LUL). PATIENTS AND METHODS: Following the extraction of the stone, a 6 French DJ open-end stent is prepared: two straight-tip hydrophilic guidewires are inserted into the appropriate lateral holes of the stent, as identified by the preoperative evaluation of the CT scan. Approximately 5 centimeters of each wire protrude from the proximal and distal ends of the stent to straighten its terminal curl, thus resembling the wings of a flying seagull. The remaining proximal portions of both guide wires are left within each guidewire dispenser. The two ends of the stent are grasped together in a U-fashion and inserted into the abdomen through a 10mm port. Once in the abdomen, the longer segment of the stent is inserted and pushed into the ureterotomy until it reaches the target site. The guide wire is then removed. The same procedure is repeated for the other end of the stent. A brief literature review on the currents techniques of laparoscopic DJ placement is also presented. RESULTS: Analyzing the outcomes of 21 LUL, the "seagull" technique is time-saving and safe. No perioperative complications were encountered. There is no risk of enlarging or tearing the ureterotomy and no need for patient replacement, extra cystoscopic or ureteroscopic procedures as well as of using modified guidewires and closed-tip stents. CONCLUSION: We described our step-by-step technique for DJ placement during LUL.

Increased risk of transurethral and suprapubic catheter self-extraction in COVID-19 patients: real-life experience.

INTRODUCTION: This study evaluated the prevalence of transurethral catheter self-removal in critically-ill COVID-19 non-sedated adult patients compared with non-COVID-19 controls. METHODS: COVID-19 patients who self-extracted transurethral or suprapubic catheters needing a urological intervention were prospectively included (group A). Demographic data, medical and nursing records, comorbidities and nervous system symptoms were evaluated. Agitation, anxiety and delirium were assessed by the Richmond Agitation and Sedation Scale (RASS). The control group B were non-COVID-19 patients who self-extracted transurethral/suprapubic catheter in a urology unit (subgroup B1) and geriatric unit (subgroup B2), requiring a urological intervention in the same period. RESULTS: 37 men and 11 women were enrolled in group A. Mean RASS score was 3.1 ± 1.8. There were 5 patients in subgroup B1 and 11 in subgroup B2. Chronic comorbidities were more frequent in group B than the COVID-19 group (P<0.01). COVID-19 patients had a significant difference in RASS score (P<0.006) and catheter self-extraction events (P<0.001). Complications caused by traumatic catheter extractions (severe urethrorrhagia, longer hospital stay) were greater in COVID-19 patients. CONCLUSION: This is the first study focusing on the prevalence and complications of catheter self-removal in COVID-19 patients. An increased prevalence of urological complications due to agitation and delirium related to COVID-19 has been demonstrated-the neurological sequelae of COVID-19 must be considered during hospitalisation.

Robotic radical prostatectomy: analysis of midterm pathologic and oncologic outcomes: A historical series from a high-volume center.

BACKGROUND: Identifying predictors of positive surgical margins (PSM) and biochemical recurrence (BCR) after radical prostatectomy (RP) may assist clinicians in formulating prognosis. Aim of the study was to report the midterm oncologic outcomes, to identify the risk factors for PSM and BCR and assess the impact of the PSM on BCR-free survival following robot-assisted laparoscopic radical prostatectomy (RALP). METHODS: From 2005 to 2010, 1679 consecutive patients underwent transperitoneal RALP. Data was retrospectively collected by an independent statistical company and analyzed in 2014. Median postoperative follow-up was 33.5 mo. BCR was defined as any detectable serum prostate-specific antigen (PSA) ≥ 0.2 ng/mL in two consecutive measurements. BCR-free survival was estimated using the Kaplan-Meier method. Univariate and multivariate analysis were applied to identify risk factors for PSM and BCR. RESULTS: In pN0/pNx cancers, pathologic stage was pT2 in 1186 patients (71.8%), pT3 in 455 patients (27.6%), and pT4 in 11 patients (0.6%). PSM rate was 17.4% and 36.9% of pT2 and pT3 cancers, respectively. Pathologic Gleason score was < 7, = 7 and > 7 in 42.1%, 53% and 4.9% of the patients, respectively. Overall BCR-free survival was 73.1% at 5 years; the 5-year BCR-free survival was 87.9% for pT2 with negative surgical margins. PSA, Gleason score (both bioptic and pathologic), pathologic stage (pT) and surgeon's volume were significant independent predictors of PSM. PSA, pathologic Gleason score, pT and PSM were significant independent predictors of BCR-free survival. Seminal vesicle-sparing, nerve-sparing approach and the extent of nerve-sparing (intra vs interfascial dissection) did not negatively affect margin status or BCR rates. CONCLUSIONS: PSMs are a predictor of BCR. Being the only modifiable factor influencing the PSM rate, surgical experience is confirmed as a key factor for high-quality oncologic outcomes.

Retzius-sparing versus standard robot-assisted radical prostatectomy: a prospective randomized comparison on immediate continence rates.

BACKGROUND: Post-prostatectomy urinary incontinence is an adverse event leading to significant distress. Our aim was to evaluate immediate urinary continence (UC) recovery in a single-surgeon prospective randomized comparative study between the traditional robot-assisted laparoscopic radical prostatectomy (TR-RALP) and the Retzius-sparing RALP (RS-RALP), for the treatment of the clinically localized prostate cancer (PCa). METHODS: 102 consecutive PCa patients were prospectively randomized to TR-RALP (57) or RS-RALP (45). Postoperative continence was defined as patient-reported absence of leakage or use of 0 pads/day. The immediate continence rate and 95% confidence interval (CI 95%) were calculated for each treatment. Univariable and multivariate logistic regressions were used to assess predictors of immediate continence following RALP. Continence rates from 1 to 6 months were calculated by Kaplan-Meier curves; log-rank test was used for the curve comparison. Two analyses were performed, considering a per-protocol (PP) population regarding all randomized patients that received nerve-sparing RALP and an Intention-To-Treat (ITT) population regarding all randomized patients that received RALP. RESULTS: In the PP analysis, the rates of immediate continence were 12/40 (30%) (CI 95% 17-47%) for the TR-RALP and 20/39 (51.3%) (CI 95% 35-68%) for the RS-RALP (p = 0.05). In the ITT analysis, the corresponding rates were 12/57 (21%) (CI 95% 11-34%) for the TR-RALP and 23/45 (51%) (CI 95% 36-66%) for the RS-RALP (p = 0.001). Median time to continence was 21 days for the TR-RALP and 1 day for RS-RALP, respectively (p = 0.02). The relative Kaplan-Meier curves regarding continence resulted statistically different when compared with the log rank test (p = 0.02). In the multivariate analysis, lower age and the Retzius-sparing approach were significantly associated to earlier continence recovery. CONCLUSIONS: The Retzius-sparing approach significantly reduces time to continence following RALP. Further studies are required to confirm the reproducibility of our results and investigate the role of the RS-RALP as an additional "protective" factor for postoperative continence in the elderly population.

Robotic partial nephrectomy performed with Airseal versus a standard CO2 pressure pneumoperitoneum insufflator: a prospective comparative study.

BACKGROUND: Airseal represents a new generation of valveless and barrier-free surgical trocars that enable a stable pneumoperitoneum with continuous smoke evacuation and carbon dioxide (CO2) recirculation during surgery. The aim of the current study was to evaluate the potential advantages of the Airseal compared to a standard CO2 insufflator in the field of robotic partial nephrectomy (RPN). METHODS: Between October 2012 and April 2015, two cohorts of 122 consecutive patients with clinically localized renal cell carcinoma underwent RPN by a single surgeon, with the use of a standard CO2 pressure insufflator (Group A, 55 patients) or Airseal (Group B, 67 patients) and were prospectively compared. RESULTS: The two groups were similar in baseline, preoperative characteristics. The mean dimension of the lesion, as evaluated by contrast-enhanced CT scan, was 30 (median 28; IQR 2) and 39 mm (median 40; IQR 2) for Groups A and B, respectively (p < 0.05). The complexity of the treated tumors was similar, as indicated by the mean RENAL nephrometry score. Positive surgical margins rate was similar in both groups (3.6 vs 4.5 %, p = 0.8) as well as the need for postoperative blood transfusion (9.1 vs 4.5 %, p = 0.3) and the development of postoperative acute kidney injury (16.4 vs 10.4 %, p = 0.3). Mean operative time and warm ischemia time were significantly shorter in Group B. Moreover, a significant increase in the cases performed as "zero ischemia" was observed in Group B (7.3 vs 30 %, p < 0.01). CONCLUSIONS: This is the first study comparing the Airseal with a standard CO2 insufflator system in the field of the RPN. The preliminary outcomes in terms of overall operative time, warm ischemia time and cases performed as "zero ischemia" are better with respect to standard insufflators. The feasibility, safety and efficacy of combining laser tumor enucleation with the valve-free insufflation systems should be evaluated.

Nerve Sparing, Robot-Assisted Radical Cystectomy with Intracorporeal Bladder Substitution in the Male.

PURPOSE: We provide a step-by-step description of our technique of nerve and seminal vesicle sparing robot-assisted radical cystectomy with an orthotopic neobladder. We also present preliminary oncologic and functional outcomes. MATERIALS AND METHODS: Nerve and seminal vesicle sparing robot-assisted radical cystectomy with a modified Y-shaped orthotopic neobladder was performed by the same surgeon in 40 men with clinically localized bladder cancer from January 2011 to September 2014. Operative, perioperative and pathological data as well as continence and erectile function outcomes are presented. RESULTS: Median followup was 26.5 months (range 8 to 52). A soft tissue positive surgical margin was found in a patient with pT3a disease. A global rate of 30% early and 32.5% late complications was observed. However, the grade III or higher complication rate was low in both settings at 2.5% and 5%, respectively. There was 1 cancer related death 23 months after surgery. Of the 40 patients 30 (75%) gained daytime continence (0 pad) within 1 month postoperatively. The 12-month nocturnal continence rate was 72.5% (29 of 40 patients). Mean preoperative IIEF-6 (International Index of Erectile Function-6) score was 24.4. Erectile function returned to normal, defined as an IIEF-6 score greater than 17, in 31 of 40 patients (77.5%) within 3 months while 29 of 40 patients (72.5%) returned to the preoperative IIEF-6 score within 12 months. CONCLUSIONS: In the hands of an experienced surgeon nerve and seminal vesicle sparing robot-assisted radical cystectomy with intracorporeal reconstruction of the neobladder seems feasible and safe. It provides short-term oncologic efficacy and promising functional outcomes. Yet comparative, long-term followup studies with standard open cystectomy are required.

Measurement of post-void residual urine.

AIMS: To present the teaching module "Measurement of Post-void residual urine." METHODS: This module has been prepared by a Working Group of the ICS Urodynamics Committee. The methodology used included comprehensive literature review, consensus formation by the members of the Working Group, and review by members of the ICS Urodynamics Committee core panel. RESULTS: In this ICS teaching module the evidence for and relevance of PVR measurement in patients with lower urinary tract dysfunction (LUTD) is summarized; in short: The interval between voiding and post-void residual (PVR) measurement should be of short duration and ultrasound bladder volume measurement is preferred to urethral catheterization. There is no universally accepted definition of a significant residual urine volume. Large PVR (>200-300 ml) may indicate marked bladder dysfunction and may predispose to unsatisfactory treatment results if for example, invasive treatment for bladder outlet obstruction (BOO) is undertaken. PVR does not seem to be a strong predictor of acute urinary retention and does not indicate presence of BOO specifically. Although the evidence base is limited, guidelines on assessment of LUTS generally include PVR measurement. CONCLUSION: Measurement of PVR is recommended in guidelines and recommendations on the management of LUTS and urinary incontinence, but the level of evidence for this measurement is not high. This manuscript summarizes the evidence and provides practice recommendations for teaching purposes in the framework of an ICS teaching module.

Laparoscopic pretransplant nephrectomy with morcellation in autosomic-dominant polycystic kidney disease patients with end-stage renal disease.

BACKGROUND: Laparoscopic nephrectomy (LN) in end-stage autosomic-dominant polycystic kidney disease (ADPKD) requires a large abdominal incision for the specimen extraction. OBJECTIVE: The objective of this study was to describe our technique of LN for end-stage ADPKD followed by morcellation (LNM) of the specimen and extraction through a minimal abdominal incision. METHODS: The medical records of 19 consecutive patients who underwent pretransplant LNM between 2008 and 2011 by a single experienced laparoscopic surgeon were analyzed. Morcellation was performed with the Gynecare Morcellex™ Tissue morcellator, Ethicon. RESULTS AND LIMITATIONS: All cases but one were completed laparoscopically. Mean specimen weight was 1,026.8 g. Mean duration of the procedure, estimated blood loss, and hospital stay were 131.3 min, 52.1 ml, and 7.9 days, respectively. Specimens were extracted through a 12-mm trocar in 10/18 patients and through a 3-cm incision in 9/18 cases. Postoperatively, three complications were observed (Clavien grades II, I, and II). The only case of incisional hernia was observed in the converted procedure. Major limitation of the study is its retrospective design. CONCLUSIONS: In our preliminary series and in the hands of a very experienced laparoscopist, LNM for ADPKD appears as a modern, mini-invasive, and safe technique. Specimen's extraction through a small abdominal incision reduces postoperative pain and incisional hernias and guarantees the final cosmetic result of laparoscopy. The reduced overall morbidity could reduce the period between nephrectomy and transplantation.

Retzius-sparing robot-assisted laparoscopic radical prostatectomy: Critical appraisal of the anatomic landmarks for a complete intrafascial approach.

To provide an overview of the anatomical landmarks needed to guide a retropubic (Retzius)-sparing robot-assisted laparoscopic prostatectomy (RALP), and a step-by-step description of the surgical technique that maximizes preservation of the periprostatic neural network. The anatomy of the pelvic fossae is presented, including the recto-vesical pouch (pouch of Douglas) created by the reflections of the peritoneum. The actual technique of the trans-Douglas, intrafascial nerve-sparing robotic radical prostatectomy is described. The technique allows the prostate gland to be shelled out from under the overlying detrusor apron and dorsal vascular complex (DVC-Santorini plexus), entirely avoiding the pubovesical ligaments. There is no need to control the DVC, since the line of dissection passes beneath the plexus. Three key points to ensure enhanced nerve preservation should be respected: (1) the tips of the seminal vesicles, enclosed in a "cage" of neuronal tissue; a seminal vesicle-sparing technique is therefore advised when oncologically safe; (2) the external prostate-vesicular angle; (3) the lateral surface of the prostate gland and the apex. The principles of tension and energy-free dissection should guide all the maneuvers in order to minimize neuropathy. Using robotic technology, a complete intrafascial dissection of the prostate gland can be achieved through the Douglas space, reducing surgical trauma and providing excellent functional and oncological outcomes.

Robotic radical nephrectomy for renal cell carcinoma: a systematic review.

BACKGROUND: Laparoscopic radical nephrectomy (LRN) is the actual gold-standard for the treatment of clinically localized renal cell carcinoma (RCC) (cT1-2 with no indications for nephron-sparing surgery). Limited evidence is currently available on the role of robotics in the field of radical nephrectomy. The aim of the current study was to provide a systematic review of the current evidence on the role of robotic radical nephrectomy (RRN) and to analyze the comparative studies between RRN and open nephrectomy (ON)/LRN. METHODS: A Medline search was performed between 2000-2013 with the terms "robotic radical nephrectomy", "robot-assisted laparoscopic nephrectomy", "radical nephrectomy". Six RRN case-series and four comparative studies between RRN and (ON)/pure or hand-assisted LRN were identified. RESULTS: Current literature produces a low level of evidence for RRN in the treatment of RCC, with only one prospective study available. Mean operative time (OT) ranges between 127.8-345 min, mean estimated blood loss (EBL) ranges between 100-273.6 ml, and mean hospital stay (HS) ranges between 1.2-4.3 days. The comparison between RRN and LRN showed no differences in the evaluated outcomes except for a longer OT for RRN as evidenced in two studies. Significantly higher direct costs and costs of the disposable instruments were also observed for RRN. The comparison between RRN and ON showed that ON is characterized by shorter OT but higher EBL, higher need of postoperative analgesics and longer HS. CONCLUSIONS: No advantage of robotics over standard laparoscopy for the treatment of clinically localized RCC was evidenced. Promising preliminary results on oncologic efficacy of RRN have been published on the T3a-b disease. Fields of wider application of robotics should be researched where indications for open surgery still persist.

Phimosis in Adults: Narrative Review of the New Available Devices and the Standard Treatments.

BACKGROUND: Phimosis is the inability to completely retract the foreskin and expose the glans. The treatment of phimosis varies depending on the age of the patient and the severity of the disease; a great number of conservative or surgical treatments are currently available. AIM: To provide the first review summarizing the available options for the treatment of adult phimosis. METHODS: A PubMed, Cochrane and Embase search for peer-reviewed studies, published between January 2001 and December 2022 was performed using the search terms "phimosis AND treatment". RESULTS: A total of 288 publications were initially identified through database searching. Thirty manuscripts were ultimately eligible for inclusion in this review. Conservative treatment is an option. and it includes topical steroid application and the new medical silicon tubes (Phimostop™) application for gentle prepuce dilation. Concerning the surgical approach, the gold-standard treatment is represented by circumcision in which tissue synthesis after prepuce removal can be also obtained with barbed sutures, fibrin glues or staples. Laser circumcision seems to be providing superior outcomes in terms of operative time and postoperative complication rate when compared to the traditional one. Several techniques of preputioplasty and use of in situ devices (which crush the foreskin and simultaneously create haemostasis) have been also described. These in situ devices seem feasible, safe and effective in treating phimosis while they also reduce the operative time when compared to traditional circumcision. Patient satisfaction rates, complications and impact on sexual function of the main surgical treatments are presented. CONCLUSION: Many conservative and surgical treatments are available for the treatment of adult phimosis. The choice of the right treatment depends on the grade of phimosis, results, complications, and cost-effectiveness.

Urodynamic Parameters and Continence Outcomes in Asymptomatic Patients with Ileal Orthotopic Neobladder: A Systematic Review and Metanalysis.

INTRODUCTION: The orthotopic neobladder is the type of urinary diversion (UD) that most closely resembles the original bladder. However, in the literature the urodynamic aspects are scarcely analysed. OBJECTIVE: To provide the first systematic review (SR) on the urodynamic (UDS) outcomes of the ileal orthotopic neobladders (ONB). Continence outcomes are also presented. METHODS: A PubMed, Embase and Cochrane CENTRAL search for peer-reviewed studies on ONB published between January 2001-December 2022 was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. RESULTS AND CONCLUSION: Fifty-nine manuscripts were eligible for inclusion in this SR. A great heterogeneity of data was encountered. Concerning UDS parameters, the pooled mean was 406.2 mL (95% CI: 378.9-433.4 mL) for maximal (entero)cystometric capacity (MCC) and 21.4 cmH2O (95% CI: 17.5-25.4 cmH2O) for Pressure ONB at MCC. Postvoid-residual ranged between 4.9 and 101.6 mL. The 12-mo rates of day and night-time continence were 84.2% (95% CI: 78.7-89.1%) and 61.7% (95% CI: 51.9-71.1%), respectively.Despite data heterogeneity, the ileal ONB seems to guarantee UDS parameters that resemble those of the native bladder. Although acceptable rates of daytime continence are reported the issue of high rates of night-time incontinence remains unsolved. Adequately designed prospective trials adopting standardised postoperative care, terminology and methods of outcome evaluation as well as of conduction of the UDS in the setting of ONB are necessary to obtain homogeneous follow-up data and to establish UDS guidelines for this setting.

Laparoscopic versus robot-assisted bilateral nerve-sparing radical prostatectomy: comparison of pentafecta rates for a single surgeon.

BACKGROUND: This study aimed to compare the pentafecta rates between laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RALP) and to identify prognostic factors predicting the pentafecta for each technique. METHODS: This prospective comparative study enrolled 248 consecutive male patients 70 years of age or younger with clinically localized prostate cancer [PCa: age ≤ 70 years, prostate-specific antigen (PSA) ≤ 10 ng/ml, biopsy Gleason score ≤ 7] who were fully continent, potent, and candidates for bilateral nerve-sparing (BNS) LRP or RALP. The pentafecta rates between LRP and RALP were compared. A logistic regression model was created to evaluate independent factors for achieving pentafecta. RESULTS: In the final analysis, 91 LRP and 136 RALP patients were evaluated. The median follow-up period was 21 months for the 91 LRP patients and 18 months for the 136 RALP patients (p = 0.07). Of the 227 patients, 87 reached pentafecta [25 LRP patients (27.5 %) vs 62 RALP patients (45.6 %), p = 0.006]. Of the 140 patients who failed pentafecta, 90 (64.3 %) missed a single parameter. In these cases, erectile deficit was the leading cause of pentafecta failure, with a significant [corrected] difference between groups (80 % LRP cases that missed potency recovery [corrected] vs 53.3 % RALP, p = 0.007). Lower age, lower pathologic stage, and RALP are significantly associated with pentafecta as independent factors. For the pT3 disease, the two techniques did not differ significantly. CONCLUSIONS: Patients submitted to BNS RP have low possibilities of achieving pentafecta. Use of the robotic platform by a single surgeon significantly enhances the possibility of achieving pentafecta independently of age and pathologic stage. Potency was the most difficult outcome to reach after surgery, and it was the main factor leading to pentafecta failure. LRP and RALP provide equivalent pentafecta rates for the pT3 disease and similar "tetrafecta" outcomes when potency recovery is not included among the postoperative expectations of the patient.

Practice change: No benefit of extended lymphadenectomy at radical cystectomy in patients with muscle invasive bladder cancer.

For many decades, extended pelvic lymph node dissection has been an integral part during radical cystectomy for patients with muscle invasive bladder cancer. This practice was based on large retrospective meta-analyses suggesting an oncologic benefit to an extended dissection. This mini review and meta-analysis includes the two available randomized trials in the current literature. Therefore, it can be considered as the strongest level of evidence regarding the prognostic benefit of an extended pelvic lymphadenectomy. Based on current randomized data, standard pelvic lymph node dissection up to the level of iliac bifurcation is sufficient, and extension of the dissection above this level does not provide any additional oncologic benefit.

Traumatic testicular dislocation in the abdomen: diagnosis and management.

Testicular dislocation in the abdomen after scrotal trauma is a rare and sometimes unrecognised event.Early detection and timely management reduce possible complications which include the risk of fertility loss, endocrine dysfunction, and future malignancy.We present the case of a man who suffered a traumatic dislocation of the right testis in the abdomen after a motorcycle crash. The large scrotal haematoma did not permit adequate physical examination. Furthermore, during the clinical management of the polytrauma, the main focus was on active arterial bleeding, multiple pelvic fractures and clinical investigation of the integrity of the lower urinary tract. Therefore, the diagnosis and surgical management of the testicular dislocation were delayed.The patient underwent abdominal-inguinal surgical exploration, haematoma evacuation, identification of the right testis and right orchidopexy.After 6 months, the right testis of the patient is of regular volume, consistency and physiologic echogenicity on ultrasound evaluation.Hormonal evaluation and semen analysis were normal after 3 months.

The Role of Local Agents for the Treatment of Localized Upper Tract Urothelial Carcinoma: A Review of the Current Evidence.

Kidney-sparing surgery (KSS) for upper urinary tract urothelial carcinoma (UTUC) is a promising alternative to radical nephroureterectomy, especially for low-risk cases. However, due to the established risk of ipsilateral UTUC recurrence caused by the implantation of floating neoplastic cells after endoscopic resection, adjuvant endocavitary (endoureteral) instillations have been proposed. Instillation therapy may be also used as primary treatment for UTUC. The two most studied drugs that have been evaluated in both the adjuvant and primary setting of endocavitary instillation are mitomycin C and Bacillus Calmette-Guerin. The current paper provides an overview of the endocavitary treatments for UTUC, focusing on methods of administration, novel formulations, oncologic outcomes (in terms of endocavitary recurrence and progression), as well as on complications. In particular, the role of UGN-101 as a primary chemoablative treatment of primary noninvasive, endoscopically unresectable, low-grade, UTUC has been analysed. The drug achieved a complete response rate of 58% after the induction cycle, with a durable response independently of the maintenance cycle. The cumulative experience on the role of UUT instillation therapy appears encouraging; however, no definitive conclusions can be drawn about its therapeutic benefit. Given the current state of the art, any decision to administer adjuvant endoureteral therapy for UTUC should be carefully weighed against the potential adverse events. Nevertheless, newer investigations that improve visualization during ureteroscopy, genomic characterization, novel drugs and innovative strategies of improved drug delivery are under evaluation. The landscape of KSS for the treatment of the UTUC is evolving and seems promising.

Not Only Length Matters! Impact of the Ileal Width on the Capacity of the Orthotopic Neobladder: The AADAPT Formula Tested on the Animal Model.

Background: The capacity of a given shape of an orthotopic ileal neobladder (ONB) varies significantly, although the same length of preterminal ileum is utilised. Objective: To investigate the variability of the human ileal width and to create a mathematical formula that calculates its impact on the neobladder capacity. Design setting and participants: During 50 consecutive cases of robotic pelvic surgery, a segment of preterminal ileum was identified and the width was measured. A mathematical formula was created to calculate, for a given ileal length and width, the neobladder capacity and, for a given ileal width and neobladder capacity, the length of the (pre)terminal ileum to harvest. The accuracy of our model was tested on 28 pouches created by swine ileum. Outcome measurements and statistical analysis: The interindividual variability of the ileal width and its impact on the ileal neobladder capacity was investigated. Results and limitations: The mean hemicircumference of the human distal ileum is 2.43 ± 0.39 cm (range 2-3.5 cm). According to our geometric model and as confirmed in the swine model, an increase of 1 cm in ileal width increases the neobladder capacity by 85%. The Pearson correlation coefficient reported a strong positive relationship between the formula-calculated and effective volumes of the pouch (r = 0.97). Moreover, for the same target capacity, 1 cm of difference in the ileal width implies harvesting 20 cm less ileum. A lack of testing on humans and application only to spheroidal neobladders are the main limits. Conclusions: The ileal width impacts the capacity of the ONB. For a given type of ONB, no standard length of ileum should be harvested; instead, the length should be tailored to the width of the ileum for a given patient. Clinical studies are required to confirm our model. Patient summary: We demonstrated the variability of the ileal width among humans, and we provided a mathematical formula tested on swine that evaluates the impact of the ileal width on the capacity of the orthotopic ileal neobladder.