PSA and PSA Kinetics as Predictors for 18F-Fluciclovine PET/CT Positivity in Biochemically Recurrent Prostate Cancer.

INTRODUCTION: 18F-Fluciclovine PET/CT is one of the imaging techniques currently employed to restage prostate cancer (PCa). Due to the conflicting results reported in the literature, it is not yet known at what PSA threshold 18F-fluciclovine PET/CT could reliably demonstrate the presence of recurring disease. We explored the association between 18F-fluciclovine PET/CT positivity and prescan PSA, PSA doubling time, and PSA velocity in patients with biochemical recurrence (BCR) of PCa after curative-intent treatment. METHODS: Data from 59 patients who underwent 18F-fluciclovine PET/CT for BCR after radical prostatectomy or radiotherapy were retrieved from a single institution database. Patients already undergone salvage treatments at the time of PET/CT, with newly diagnosed PCa or with initial diagnosis of metastatic PCa were excluded. A 2-sided independent samples Bayesian t test and Bayesian Mann-Whitney U test were used to assess the association between PET/CT and prescan PSA, PSA doubling time, and PSA velocity. RESULTS: Evidence for no difference between PET/CT-positive and -negative patients for log-transformed PSA was found (BF01 3.61, % error: 0.01). Robustness check and sequential analysis showed stability across a wide range of prior distribution specifications. The hypothesis of no difference in terms of PSA-dt and for PSA-vel between groups was found to be more likely compared to the alternative hypothesis (BF01 of 3.44 and 3.48, respectively). CONCLUSION: PSA and PSA kinetics are unlikely to be associated with 18F-fluciclovine PET/CT positivity in patients with BCR, and none of these serum biomarkers might be used as single predictors of PET/CT detection. Larger studies might be needed to evaluate the role of different predictors.

Retroperitoneal versus transepritoneal robot-assisted partial nephrectomy for postero-lateral renal masses: an international multicenter analysis.

PURPOSE: To assess the outcomes of retroperitoneal robot-assisted partial nephrectomy (r-RAPN) in a large cohort of patients with postero-lateral renal masses comparing to those of transperitoneal RAPN (t-RAPN). METHODS: Patients with posterior (R.E.N.A.L. score grading P) or lateral (grading X) renal mass who underwent RAPN in six high-volume US and European centers were identified and stratified into two groups according to surgical approach: r-RAPN ("study group") and t-RAPN ("control group"). Baseline characteristics, intraoperative, and postoperative data were collected and compared. RESULTS: Overall, 447 patients were identified for the analysis. 231 (51.7%) and 216 (48.3%) patients underwent r-RAPN and t-RAPN, respectively. Baseline characteristics were not statistically significantly different between the groups. r-RAPN group reported lower median operative time (140 vs. 170 min, p < 0.001). No difference was found in ischemia time, estimated blood loss, and intraoperative complications. Overall, 47 and 54 postoperative complications were observed in r-RAPN and t-RAPN groups, respectively (20.3 vs. 25.1%, p = 0.9). 1 and 2 patients reported major complications (Clavien-Dindo ≥ III grade) in the retroperitoneal and transperitoneal groups (0.4 vs. 0.9%, p = 0.9). There was no difference in hospital re-admission rate, median length of stay, and PSM rate. Trifecta criteria were achieved in 90.3 and 89.2% of r-RAPN and t-RAPN, respectively (p = 0.7). CONCLUSION: r-RAPN and t-RAPN offer similar postoperative, functional, and oncological outcomes for patients with postero-lateral renal tumors. Our analysis suggests an advantage for r-RAPN in terms of shorter operative time, whereas it does not confirm a difference in terms of length of stay, as suggested by previous reports.

Evolution of robotic-assisted kidney transplant: successes and barriers to overcome.

PURPOSE OF REVIEW: The aim of this study was to provide an updated review of robotic-assisted kidney transplant (RAKT) with an emphasis on advantages over the open kidney transplant (OKT), utility in special populations and resources available to overcome the learning curve of robotic surgery. RECENT FINDINGS: The majority of the reported studies showed that RAKT and OKT have similar functional outcomes including similar ischemia times and time to postoperative normalization of creatinine. However, RAKT results in fewer wound complications, decreased estimated blood loss and pain. Given these benefits, RAKT is a promising approach for obese patient across BMI subtypes and several studies showed decreased wound complications in this population compared with the open approach. Moreover, new 3D-print techniques are promising resources for robotic simulation, which may decrease the learning curve of robotic surgery. SUMMARY: Overall, RAKT is a feasible approach especially in obese patients. However, more data with long-term follow-up are needed to fully elucidate the advantages over OKT before universal implementation of this approach is possible.

Robotic versus other nephroureterectomy techniques: a systematic review and meta-analysis of over 87,000 cases.

PURPOSE: To perform a systematic review and meta-analysis of the literature inherent robotic nephroureterectomy (RNU) and to compare its outcomes with those of other nephroureterectomy (NU) techniques. METHODS: A systematic literature search was performed up to April 2019 using PubMed, Embase®, and Web of Science. The Preferred Reporting Items for Systematic Review and Meta-analysis Statement was followed for study selection. The following data were extracted for each study: baseline features, surgical outcomes, oncological outcomes, and survival outcomes. Stata® 15.0 was used for statistical analysis. RESULTS: Literature search identified 80 studies eligible for the meta-analysis and overall 87,291 patients were included in the analysis: open NU (ONU; n = 45,601), hand-assisted laparoscopic NU (HALNU; n = 442), laparoscopic NU (LNU n = 31,093), and RNU (n = 10,155). RNU was more likely to be performed in those patients with multifocal tumor location (proportion: 0.19; 95% CI 0.14, 0.24) and high-grade disease (proportion: 0.70; 95% CI 0.53, 0.68). The lowest EBL was recorded in the RNU group (weighted mean (WM) 163.31 mL; 95% CI 88.94, 237.68), whereas the highest was in the ONU group (414.99 mL; 95% CI 378.52, 451.46). Operative time was shorter for ONU (224.98 mL; 95% CI 212.26, 237.69). RNU had lower rate of intraoperative complications (0.02; 95% CI 0.01, 0.05). ONU showed higher odds of transfusions (0.20; 95% CI 0.15, 0.25). LOS was statistically significantly shorter for the RNU group (5.35 days; 95% CI 4.97, 5.82). HALNU seemed to present lower risk of PSM (0.02; 95% CI - 0.01, 0.05), and lower risk of recurrence (0.22; 95% CI 0.15, 0.30), metastasis (0.07; 95% CI 0.05, 0.10), and cancer-related death (0.03; 95% CI 0.01, 0.06). ONU showed the lowest 5 years cancer specific survival (proportion: 0.77; 95% CI 0.74, 0.80). No correlation was found between the surgical technique and recurrence-free and cancer-specific survival. CONCLUSIONS: Evidence regarding RNU for the treatment of UTUC is increasing but it remains quite sparse and of low quality. Despite this, RNU seems to be safe, and to offer the advantages of a minimally invasive approach without impairing the oncological outcomes. Nevertheless, ONU, HALNU, and LNU still represent a valid, and commonly used surgical treatment option. As RNU becomes more popular, and concerns related to its use remain, the best surgical technique for NU remains to be determined.

Minimally Invasive Radical Prostatectomy after Previous Bladder Outlet Surgery: A Systematic Review and Pooled Analysis of Comparative Studies.

PURPOSE: Prostate cancer surgery after previous bladder outlet surgery of benign prostatic hyperplasia is an uncommon yet challenging scenario. We performed a systematic review and pooled analysis of comparative studies on laparoscopic and robotic minimally invasive radical prostatectomy after bladder outlet surgery. MATERIALS AND METHODS: We searched the literature on PubMed®, Embase® and Web of Science™ up to February 2019 according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to identify eligible studies. Surgical, oncologic and functional outcomes in patients who underwent minimally invasive radical prostatectomy after bladder outlet surgery were compared to those without a history of bladder outlet surgery. Sensitivity analysis was done according to surgical technique (laparoscopic or robotic). RevMan 5.3 was used for statistical analysis. RESULTS: A total of 12 comparative studies were included in analysis. Patients who underwent minimally invasive radical prostatectomy after bladder outlet surgery were older (p ≤0.00001) and had a smaller prostate (p = 0.04) and lower prostate specific antigen (p = 0.003). The previous bladder outlet surgery group had lower odds of nerve sparing procedures, longer operative time, a higher rate of bladder neck reconstruction (each p <0.0001) and longer catheter time (p = 0.03). They were at higher risk for intraoperative (p = 0.001), overall (p <0.00001) and major complications (p = 0.0008), a higher positive surgical margin rate (p = 0.0005) and biochemical recurrence (p = 0.05). Moreover, potency (p = 0.03) and continence recovery (p = 0.007) at 12 months were lower in men with previous bladder outlet surgery. Robotic surgery seemed to offer better outcomes than laparoscopy. CONCLUSIONS: Minimally invasive radical prostatectomy after previous bladder outlet surgery represents a challenging surgical task with a higher risk of complications, and higher odds of worse functional and oncologic outcomes. Patients should be aware of these drawbacks and these factors should be considered during patient counseling. When surgery is pursued, robot-assisted radical prostatectomy should be preferred over laparoscopic radical prostatectomy since it can offer superior outcomes. The overall literature on this topic is of low quality and further efforts should be made to obtain higher levels of evidence.

Robotic versus laparoscopic radical nephrectomy: a large multi-institutional analysis (ROSULA Collaborative Group).

OBJECTIVE: To compare the outcomes of robotic radical nephrectomy (RRN) to those of laparoscopic radical nephrectomy (LRN) for large renal masses. METHODS: This was a retrospective analysis of RRN and LRN cases performed for large (≥ cT2) renal masses from 2004 to 2017 and collected in the multi-institutional international database (ROSULA: RObotic SUrgery for LArge renal masses). Peri-operative, functional, and oncologic outcomes were compared between each approach. Descriptive analyses were performed and presented as medians with interquartile ranges. Inverse probability of treatment weighting-adjusted multivariable analyses were used to identify predictors of peri-operative complications. Kaplan-Meier analysis and Cox regression models were used to assess survival outcomes. RESULTS: A total of 941 patients (RRN = 404, LRN = 537) were identified. There was no difference in terms of gender, age, and clinical tumor size. Over the study period, RRN had an annual increase of 11.75% (95% CI [7.34, 17.01] p < 0.001) and LRN had an annual decline of 5.39% (95% CI [-6.94, -3.86] p < 0.001). Patients undergoing RRN had higher BMI (27.6 [IQR 24.8-31.1] vs. 26.5 [24.1-30.0] kg/m2, p < 0.01). Operative duration was longer for RRN (185.0 [150.0-237.2] vs. 126 [90.8-180.0] min, p < 0.001). Length of stay was shorter for RRN (3.0 [2.0-4.0] vs. 5.0 [4.0-7.0] days, p < 0.001). RRN cases presented more advanced disease (higher pathologic staging [pT3-4 52.5 vs. 24.2%, p < 0.001], histologic grade [high grade 49.3 vs. 30.4%, p < 0.001], and rate of nodal disease [pN1 5.4 vs. 1.9%, p < 0.01]). Surgical approach did not represent an independent risk factor for peri-operative complications (OR 1.81 95% CI [0.97-3.39], adjusted p = 0.2). The main study limitation is the retrospective design. CONCLUSIONS: This study represents the largest known multi-center comparison between RRN and LRN. The two procedures seem to offer similar peri-operative outcomes. Notably, RRN has been increasingly utilized, especially in the setting of more advanced and surgically challenging disease without increasing the risk of peri-operative complications.

Robotic assisted simple prostatectomy: recent advances.

PURPOSE OF REVIEW: Robotic assisted simple prostatectomy (RASP) represents a minimally invasive evolution of traditional open simple prostatectomy for the surgical treatment of severe lower urinary tract symptoms (LUTS) because of benign prostatic enlargement (BPE). Aim of the present review is to summarize the most recent evidence on this novel procedure, and to better define its current role in the surgical armamentarium for the treatment of BPE. RECENT FINDINGS: Several studies demonstrated that RASP can be safely and effectively performed in centers with sufficient expertise. The procedure can duplicate its open counterpart with the advantage of lower perioperative morbidity, and ultimately faster patient recovery. Overall, the status of RASP seems to be well beyond that of an 'investigational' procedure, and guidelines should be amended accordingly.Nevertheless, it remains to be determined what the place of the RASP procedure in the surgical armamentarium for the treatment of symptomatic BPE will be. Over the most recent years, few comparative studies have been reported, allowing in part to draw some conclusions. RASP seems to be attractive when compared with open simple prostatectomy as it can offer less blood loss, and shorter hospital stay. However, its advantages over transurethral enucleation techniques - such as HoLEP - remain unclear. There are some specific indications, such as the presence of concomitant bladder diverticula or stones, for example, where a robotic approach could represent an appealing solution. Ultimately, further research should look at a cost analysis to determine which technique can be more cost effective. Last, the issue of the learning curve for the different procedures for symptomatic BPE remain to be further scrutinized. SUMMARY: RASP offers potential advantages over other available techniques for the treatment of large prostate glands. In centers, wherever a solid robotic program is already in place, this procedure is likely to be increasingly implemented.

Outcomes of Laparoscopic and Robotic Partial Nephrectomy for Large (>4 Cm) Kidney Tumors: Systematic Review and Meta-Analysis.

PURPOSE: The aim of this study was to assess the outcomes of minimally invasive (laparoscopic and robotic) partial nephrectomy (MIPN) for large renal masses. MATERIALS AND METHODS: A systematic literature review was performed up to September 2016 using multiple search engines to identify studies comparing MIPN for tumors larger than 4 cm (>cT1a) with MIPN for tumors smaller than 4 cm (cT1a). The preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria were used for article selection. Baseline demographics and surgical, functional, and oncological parameters were extracted from the included studies whenever available. An overall analysis including all studies was performed, then sensitivity analyses were performed for studies on laparoscopic partial nephrectomy (PN) only, and, finally, for studies on robotic PN only. RESULTS: Overall, 13 case-control studies comparing the outcomes of PN in tumors <4 cm (n = 4441) with those of PN for tumors >4 cm (n = 1024) were included. Warm ischemia time was shorter for the <4 cm group [weighted mean difference (WMD) 3.75 min; 95% confidence interval (CI) -6.4 to -0.7; p = 0.01] and the odds of perioperative complications was lower [odds ratio (OR) 0.62; 95% CI 0.5-0.8; p < 0.001]. There were no significant differences in terms of postoperative estimated glomerular filtration rate (WMD 4.2 ml/min; 95% CI 0.45-8.97; p = 0.08), as well as onset of postoperative chronic kidney disease (risk ratio 0.71; 95% CI 0.48-1.04; p = 0.08). In addition, no difference was found in the likelihood of positive surgical margins (OR 0.74; 95% CI 0.43-1.28; p = 0.29). CONCLUSIONS: MIPN represents a viable treatment option for renal masses larger than 4 cm (higher than cT1a) as it offers good functional outcomes, without increased risk of positive surgical margins. An increased rate of complications should be taken into account when approaching these tumors.

Impact of diagnostic ureteroscopy on intravesical recurrence in patients undergoing radical nephroureterectomy for upper tract urothelial cancer: a systematic review and meta-analysis.

Aim of this study was to analyse the association between the use of diagnostic ureteroscopy (URS) and the development of intravesical recurrence (IVR) in patients undergoing radical nephroureterectomy (RNU) for high-risk upper tract urothelial carcinoma. A systematic review of the published data was performed up to December 2016, using multiple search engines to identify eligible studies. A formal meta-analysis was conducted of studies comparing patients who underwent URS before RNU with those who did not. Hazard ratios (HRs), with their 95% confidence intervals (CIs), from each study were used to calculate pooled HRs. Pooled estimates were calculated using a fixed-effects or random-effects model according to heterogeneity. Statistical analyses were performed using RevMan, version 5. Seven studies were included in the systematic review, but only six of these were deemed fully eligible for meta-analysis. Among the 2 382 patients included in the meta-analysis, 765 underwent diagnostic URS prior to RNU. All examined studies were retrospective, and the majority examined Asian populations. The IVR rate ranged from 39.2% to 60.7% and from 16.7% to 46% in patients with and without prior URS, respectively. In the pooled analysis, a statistically significant association was found between performance of URS prior to RNU and IVR (HR 1.56, 95% CI 1.33-1.88; P < 0.001). There was no heterogeneity in the observed outcomes, according to the I2 statistic of 2% (P = 0.40). Within the intrinsic limitations of this type of analysis, these findings suggest a significant association between the use of diagnostic URS and higher risk of developing IVR after RNU. Further research in this area should be encouraged to further investigate the possible causality behind this association and it potential clinical implications.

A review of post-stroke urinary incontinence.

INTRODUCTION: Cerebrovascular accidents, or strokes, are a common cause of morbidity and mortality in the United States. Urinary incontinence is a prevalent morbidity experienced by post-stroke patients that is associated with long term disability and institutionalization effects on these patients. MATERIALS AND METHODS: An extensive literature review was conducted using multiple academic search engines using the keywords: 'stroke,' 'CVA,' 'urinary incontinence,' 'urodynamics,' 'pharmacologic treatments,' and 'conservative treatments.' Articles were reviewed and summarized to explain incidence, assessment, and treatments of urinary incontinence in post-stroke individuals. RESULTS: Twenty-eight percent to seventy-nine percent of stroke survivors experience urinary incontinence with detrusor overactivity being the most common type of incontinence assessed by urodynamic studies. There continues to be insufficient data studying the effects and benefits of non-pharmacologic and pharmacologic treatments in post-stroke patients. Similarly, urinary incontinence remains an indicator of increased morbidity, disability, and institutionalization rates in the post-stroke patient. CONCLUSIONS: Stroke is a debilitating disease which causes urinary incontinence in many patients. As a result, patients have increased rates of hospitalization and disability compared to post-stroke patients without urinary incontinence. The history and physical exam are key in diagnosing the type of urinary incontinence with urodynamic studies being an adjunctive study. Non-pharmacologic treatment, such as behavioral therapy, and pharmacologic agents including antimuscarinics and beta adrenergic medications, are not well studied in the post-stroke patient. Urinary incontinence in stroke patients needs to be further studied to help decrease morbidity and mortality rates within this population.

The role of cystectomy for non-malignant bladder conditions: a review.

INTRODUCTION: Few studies have adequately addressed the indications, efficacy, and quality-of-life for cystectomy performed for non-malignant bladder conditions. Patients with debilitating non-malignant bladder conditions who have failed all previous conservative therapies may undergo various forms of cystectomy, including partial, simple or radical cystectomy. We provide a review of the current literature and recommendations for cystectomy for various non-malignant bladder conditions. MATERIALS AND METHODS: A systematic review of MEDLINE was conducted to find prospective and retrospective studies using the keywords "cystectomy", "benign", and `non-malignant`. Articles were reviewed and triaged, background articles were added as supplements, leaving a final review of 67 papers. RESULTS: Data from the final review suggests that common benign indications for cystectomy are interstitial cystitis/painful bladder syndrome (IC/PBS), neurogenic bladder, hemorrhagic/radiation cystitis, infectious diseases of the bladder and miscellaneous conditions of the bladder such as endometriosis and total refractory incontinence. The most common perioperative complications include urinary tract and wound infections. Efficacy of cystectomy in patients with IC/PBS is greater than 80%, while efficacy in patients with neurogenic bladder is greater than 90%. Finally, improved urinary quality-of-life has been demonstrated in patients with neurogenic bladder post-cystectomy. CONCLUSION: Cystectomy for non-malignant conditions can be considered for patients who have failed previous conservative therapy. The limited data in existence suggests fertility can be adequately preserved after cystectomy in younger males. The data regarding the forms of urinary diversion suggests no significant advantage between any of the major forms of urinary diversion. Finally, while newer pharmacologics and technological advances are widely used in the treatment of various benign urological conditions, their role in preventing or treating refractory benign bladder conditions have not been fully characterized.

The New WHO Category of "Molecularly Defined Renal Carcinomas": Clinical and Diagnostic Features and Management Implications.

The evolution of classification of renal tumors has been impacted since the turn of the millennium by rapid progress in histopathology, immunohistochemistry, and molecular genetics. Together, these features have enabled firm recognition of specific, classic types of renal cell carcinomas, such as clear cell renal cell carcinoma, that in current practice trigger histologic-type specific management and treatment protocols. Now, the fifth Edition World Health Classification's new category of "Molecularly defined renal carcinomas" changes the paradigm, defining a total of seven entities based specifically on their fundamental molecular underpinnings. These tumors, which include TFE3-rearranged, TFEB-altered, ELOC-mutated, fumarate hydratase-deficient, succinate dehydrogenase-deficient, ALK-rearranged, and SMARCB1-deficient renal medullary carcinoma, encompass a wide clinical and histopathologic phenotypic spectrum of tumors. Already, important management aspects are apparent for several of these entities, while emerging therapeutic angles are coming into view. A brief, clinically-oriented introduction of the entities in this new category, focusing on relevant diagnostic, molecular, and management aspects, is the subject of this review.

The Outcome of the Miniaturized Percutaneous Nephrolithotomy in Lateral Position with Guidance of Non-Rotational C-Arm.

Objective: Evaluation of the outcome of the miniaturized percutaneous nephrolithotomy in the treatment of nephrolithiasis with a lateral position based on the principle of a right triangle under the guidance of a C-Arm without contrast fluid. Materials and Methods: Sixty-nine cases of Mini-PCNL with the assistance of a vacuum-assisted sheath in the lateral position were performed at Central Hospital from March 2021 to August 2022. Percutaneous renal access was under the guidance of a non-rotational C-arm without contrast medium, and we determined the puncture location and depth of the needle based on the principle of right triangles. Results: The median age was 51.6 ± 12.5 years, and males accounted for 68.1% of the cases. 60.9% of all patients had normal weight. The median stone surface area was 361.1mm2, and 59.4% of all cases were graded as 2 regarding Guy's stone score. The successful renal access rate was 100%. The tunnel access from the middle and lower calyx accounted for 94.2%. The median access duration, fluoroscopy duration, and hospital length of stay were 271.7 seconds, 14.79 seconds, and 6.3 days, respectively. The complete stone clearance rate was 78.3%. Bleeding complications occurred in 2 patients without mortality. Three patients required an additional procedure. Conclusion: The puncture technique into the renal calyxes based on the principle of the right triangle under the guidance of a non-rotational C-Arm without contrast medium in PCNL is a fast, exact, and safe technique.

Percutaneous thermal ablation for cT1 renal mass in solitary kidney: A multicenter trifecta comparative analysis versus robot-assisted partial nephrectomy.

INTRODUCTION: Renal cell carcinoma (RCC) in solitary kidney (SK) represents a challenging scenario. We sought to compare outcomes of robot-assisted partial nephrectomy (RAPN) versus percutaneous thermal ablation (PTA) in SK patients with renal tumors cT1. MATERIALS AND METHODS: We performed a multicenter retrospective analysis of SK patients treated for RCC. The PTA group included cryoablation or radiofrequency ablation. We collected baseline characteristics, intraoperative, pathological, and post-operative data. We applied an arbitrary composite "trifecta" to assess surgical, functional, and oncological outcomes, only for malignant histology. RFS analysis was performed using the Kaplan-Meier method. Multivariable regression analysis was performed to determine independent predictors of "trifecta" achievement. RESULTS: We included 198 SK patients (RAPN, n = 50; PTA n = 119). Mean clinical tumor size was not significantly different while R.E.N.A.L. score was higher for RAPN (p < 0.001). No differences in intra and major post-procedural complications. Recurrence rate was higher in PTA group but not statistically significant (p < 0.328). No difference in metastasis rate was found (p = 0.435). RFS was 96.1% in RAPN and 86.8% in PTA cohort (p = 0.003) while no difference in PFS was detected (p = 0.1). Trifecta was achieved in 72.5% of RAPN vs 77.3% of PTA (p = 0.481). Multivariable analysis has not detected predictors for Trifecta achievement. CONCLUSION: PTA offers good outcomes in the management of SK patients with RCC. Compared with RAPN, it might carry a higher risk of recurrence; on the other hand, re-treatment is possible. Overall, PTA can be safely offered to treat SK patients presenting RCC. In general, it should be preferred in more frail patients to minimize the risk of complications.

Microwave versus cryoablation and radiofrequency ablation for small renal mass: a multicenter comparative analysis.

BACKGROUND: Ablative techniques emerged as effective alternative to nephron-sparing surgery for treatment of small renal masses. Radiofrequency ablation (RFA) and cryoablation (CRYO) are the two guidelines-recommended techniques. Microwave ablation (MWA) represents a newer technology, less described. The aim of the study was to compare outcomes of MWA to those of CRYO and RFA. METHODS: Retrospective investigation of patients who underwent MWA, CRYO, or RFA from seven high-volume US and European centers was performed. The first group included patients who underwent CRYO or RFA; the second MWA. We collected baseline characteristics, clinical, intraoperative, and postoperative data. Oncological data included technical success, local recurrence, and progression to metastasis. Multivariate analysis was performed to find predictors for postoperative complications. A composite outcome of "trifecta" was used to assess surgical, functional, and oncological outcomes. RESULTS: 739 patients underwent CRYO or RFA and 50 MWA. CRYO/RFA group had significantly longer operative time (P<0.001), but no difference in LOS, postprocedural Hb mean, intraprocedural complications (P=0.180), overall postprocedural complication rates (P=0.126), and in the 30-day re-admission rate (P=0.853) were detected. No predictive parameter of postprocedural complications was found. Concerning functional outcome, no differences were detected in terms of eGFR at 1 year (P=0.182), ΔeGFR at 1 year (P=0.825) and eGFR at latest follow-up (P=0.070). "Technical success" was achieved in 98.6% of the cases (MWA=100%, CRYO/RFA=98.5%; P=0.775), and there was no significant difference in terms of 2-year recurrence rate (P=0.114) and metastatic progression (P=0.203). Trifecta was achieved in 73.0% of CRYO/RFA vs. 69.6% of MWA cases (P=0.719). CONCLUSIONS: MWA is a safe and effective treatment option for small renal masses. Compared with CRYO/RFA, it seems to offer low complication rates, shorter operation time, and equivalent surgical and functional outcomes.

Percutaneous Ablation vs Robot-Assisted Partial Nephrectomy for Completely Endophytic Renal Masses: A Multicenter Trifecta Analysis with a Minimum 3-Year Follow-Up.

Purpose: To compare outcomes of robot-assisted partial nephrectomy (RAPN) and percutaneous tumor ablation (PTA) for completely endophytic renal masses. Methods: Data of patients who underwent RAPN or PTA for treatment of completely endophytic (three points for "E" domain of R.E.N.A.L. score) were collected from seven high-volume U.S. and European centers. PTA included cryoablation, radiofrequency, or microwave ablation. Baseline characteristics, clinical, surgical, and postoperative outcomes were compared. Recurrence-free survival (RFS) was calculated with Kaplan-Meier analysis. Trifecta was used as arbitrary combined outcome parameter as proxy for treatment "quality." Multivariable logistic regression model assessed predictors of trifecta failure. Results: One hundred fifty-two patients (RAPN, n = 60; PTA, n = 92) were included in the analysis. RAPN group was younger (p < 0.001), had lower American Society of Anesthesiologists score (p = 0.002), and higher baseline estimated glomerular filtration rate (p < 0.001). There was no difference in clinical tumor size, clinical T stage, and tumor complexity scores. PTA had significantly lower rate of overall (p < 0.001) and minor (p < 0.001) complications. ΔeGFR at 1 year was statistically higher for RAPN (-15.5 mL/min vs -3.1 mL/min; p = 0.005), no difference in ΔeGFR at last follow-up (p = 0.22) was observed. No difference in recurrences (RAPN, n = 2; PTA, n = 6) and RFS was found (p = 0.154). Trifecta achievement was higher for RAPN but not statistically different (65.3% vs 58.8%; p = 0.477). R.E.N.A.L. Nephrometry Score resulted predictive of trifecta failure (odds ratio = 1.47; confidence interval = 1.13-1.90; p = 0.004). Conclusions: PTA confirms to be an effective treatment for completely endophytic renal masses, offering low complications and good mid-term functional and oncologic outcomes. These outcomes compare favorably with those of RAPN, which seem to be the preferred option for younger and less comorbid patients.

Management of Bladder Neck Contracture in the Age of Robotic Prostatectomy: An Evidence-based Guide.

The incidence of bladder neck contracture (BNC), or postprostatectomy vesicourethral anastomosis, has declined since the advent of robotic surgery. However, men with peripheral vascular comorbidities, among other factors, still have a high risk of developing this complication after any surgery that involves manipulation of the prostate. The best strategy for BNC management remains uncertain because of inconsistency in success for different approaches across studies. We reviewed the available evidence on BNC, including the results for endoscopic treatments, scar modulation therapies, and open and robotic bladder neck reconstruction. On the basis of these data, we propose a management flowchart. Patient baseline status and subjective goals and preferences remain crucial in management choices. PATIENT SUMMARY: Contracture of the bladder neck can occur as a complication after surgery to the prostate. We reviewed the evidence for various treatment approaches and propose a flowchart for management of this condition.

Estimated Glomerular Filtration Rate Decline at 1 Year After Minimally Invasive Partial Nephrectomy: A Multimodel Comparison of Predictors.

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.

Single-stage Xi® robotic radical nephroureterectomy for upper tract urothelial carcinoma: surgical technique and outcomes.

BACKGROUND: Radical nephroureterectomy (RNU) represents the standard of care for high grade upper tract urothelial carcinoma (UTUC). Open and laparoscopic approaches are well-established treatments, but evidence regarding robotic RNU is growing. The introduction of the Xi® system facilitates the implementation of this multi-quadrant procedure. The aim of this video-article is to describe the surgical steps and the outcomes of Xi® robotic RNU. METHODS: Single stage Xi® robotic RNU without patients repositioning and robot re-docking were done between 2015 and 2019 and collected in a large worldwide multi-institutional study, the ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST). Institutional review board approval and data share agreement were obtained at each center. Surgical technique is described in detail in the accompanying video. Descriptive statistics of baseline characteristics and surgical, pathological, and oncological outcomes were analyzed. RESULTS: Overall, 148 patients were included in the analysis; 14% had an ECOG >1 and 68.2% ASA ≥3. Median tumor dimension was 3.0 (IQR:2.0-4.2) cm and 34.5% showed hydronephrosis at diagnosis. Forty-eight% were cT1 tumors. Bladder cuff excision and lymph node dissection were performed in 96% and 38.1% of the procedures, respectively. Median operative time and estimated blood loss were 215.5 (IQR:160.5-290.0) minutes and 100.0 (IQR: 50.0-150.0) mL, respectively. Approximately 56% of patients took opioids during hospital stay for a total morphine equivalent dose of 22.9 (IQR:16.0-60.0) milligrams equivalent. Post-operative complications were 26 (17.7%), with 4 major (2.7%). Seven patients underwent adjuvant chemotherapy, with median number of cycles of 4.0 (IQR:3.0-6.0). CONCLUSIONS: Single stage Xi® RNU is a reproducible and safe minimally invasive procedure for treatment of UTUC. Additional potential advantages of the robot might be a wider implementation of LND with a minimally invasive approach.

Renal Autotransplantation for the Treatment of Complete Ureteral Loss: A Case Report.

We present an exceptional case of a patient with complete ureteral loss. The injury of the patient's right ureter resulted as a complication of prior ureteroscopic and laparoscopic. For the treatment of complete ureteral loss, the right kidney was removed and placed into the left iliac fossa. Revascularization of the kidney was performed by anastomosis of the renal vasculatures to the external iliac vasculature. Ureteral reconstruction was performed through a Boari bladder flap. At the six-month follow-up visit, the resistive indices of the transplanted kidney proved to be in the normal range.