Mid-term outcomes of minimally invasive infrapubic approach for inflatable penile prosthesis implantation: A single-center study and literature review.

BACKGROUND: The minimally invasive infrapubic approach (MIIA) for inflatable penile prosthesis (IPP) placement has shown favorable peri-operative safety and efficacy profile, but scarce data exist on long-term follow-up. OBJECTIVES: We investigated the safety and efficacy of IPP implantation via the MIIA after a minimum 5-year follow-up. MATERIALS AND METHODS: We identified data of implanted patients prospectively included in our institutional database. Complications and functional outcomes were assessed by using validated tools. Specifically, quality of life and patient satisfaction were evaluated by the Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire. Kaplan-Meier method was used to analyze IPP survival (defined as a working IPP). RESULTS: Overall, 67 patients implanted by MIIA with a median (IQR) age of 64 years (61-70) were included. The median (IQR) follow-up duration was 71 months (63-80). Fifteen (22%) patients experienced complications: minor (Clavien ≤2) events included changes in penile sensitivity (n = 1; 1.5%), orgasmic dysfunction (n = 1; 1.5%), pain (n = 5; 7%), urinary tract infection (n = 2; 3%), and chronic discomfort (n = 1; 1.5%); major (Clavien 3) complications were represented by mechanical failure (n = 3; 4.5%), IPP infection (n = 1; 1.5%), and cylinder protrusion (n = 1; 1.5%). The estimated IPP survival was 94% (95% CI, 91.4-96.6), 92.5% (95% CI, 89.7-95.3), and 92.5% (95% CI, 89.7-95.3) at 3, 5, and 7 years after implantation, respectively. In patients using the device at follow-up (n = 61; 91%), median (IQR) scores for QoLSPP domains demonstrated favorable functional outcomes and patient satisfaction: functional 21 (19-23), personal 16 (15-18), relational 14 (12-15), and social 12 (11-14). DISCUSSION AND CONCLUSION: This study represents the longest follow-up using validated tools to assess the outcomes of IPP implantation via MIIA so far. IPP placement via MIIA confirms to be safe and to offer high satisfaction to both patients and partners at mid-term evaluation.

The role of perioperative chemotherapy for upper tract urothelial carcinoma patients treated with radical nephroureterectomy.

PURPOSE: To summarize evidence regarding the use of neoadjuvant (NAC) and adjuvant chemotherapy (AC) among patients treated with radical nephroureterectomy (RNU). METHODS: A comprehensive literature search of PubMed (MEDLINE), EMBASE and the Cochrane library was performed to identify any original or review article on the role of perioperative chemotherapy for UTUC patients treated with RNU. RESULTS: With regards to NAC, retrospective studies consistently suggested that it may be associated with better pathological downstaging (pDS) ranging from 10.8 to 80% and complete response (pCR) ranging from 4.3 to 15%, while decreasing the risk of recurrence and death as compared to RNU alone. Even higher pDS ranging from 58 to 75% and pCR ranging from 14 to 38% were observed in single-arm phase II trials. With regards to AC, retrospective studies provided conflicting results although the largest report from the National Cancer Database suggested an overall survival benefit in pT3-T4 and/or pN + patients. In addition, a phase III randomized controlled trial showed that the use of AC was associated with a disease-free survival benefit (HR = 0.45; 95% CI = [0.30-0.68]; p = 0.0001) in pT2-T4 and/or pN + patients with acceptable toxicity profile. This benefit was consistent in all subgroups analyzed. CONCLUSIONS: Perioperative chemotherapy improves oncological outcomes associated with RNU. Given the impact of RNU on renal function, the rational is stronger for the use of NAC which impacts final pathology and potentially prolongs survival. However, the level of evidence is stronger for the use of AC that has been proven to decrease the risk of recurrence after RNU with a potential survival benefit.

Incidence of urological cancers in neurological patients: a review of the literature from the EAU Young Academic Urologist Functional Group.

INTRODUCTION: Urological cancers can be challenging in the diagnosis and treatment of patients with neurological diseases. As a result, there are still uncertainties regarding the incidence and risk factors favouring the development of urological cancers in these patients. The aim of this study was to review the available evidence regarding the incidence for the development of urological cancers in neurological patients to provide a basis for future recommendations and research. EVIDENCE ACQUISITION: A narrative review of the literature in Medline and Scopus up to June 2019 was performed. EVIDENCE SYNTHESIS: After screening 1729 records, 30 retrospective studies were retained. For bladder cancer (BC), 21 articles were identified, including a total of 673,663 patients. Among these patients, 4744 had a diagnosis of BC (1265 females, 3214 males, gender not reported in 265). In this group, 2514 were diagnosed with BC associated with a neurological disease. For prostate cancer (PC), 14 articles were identified, including a total of 831,889 men. Among these patients, 67,543 had a diagnosis of PC and 1457 had PC and a neurological disease. Two articles reported kidney cancer (KC), one reported testicular cancer (TC) and none described penile cancer or urothelial carcinomas of the upper urinary tract in neurological patients. CONCLUSIONS: The incidence of urological cancers, especially BC and PC, in patients with neurological diseases appears comparable to the general population. However due to the paucity of studies, specific recommendations for the management are lacking in neurologically disabled patients. In this report we investigated the frequency of urinary tract cancers in patients with neurological diseases. We conclude that urological cancers, especially bladder and prostate cancer, in patients with neurological diseases occur with similar frequency as in the general population.

Patients' perceptions of quality of care delivery by urology residents: A nationwide study.

OBJECTIVE: To present the results of a nationwide survey among urological patients to evaluate their perception of the quality of care provided by residents. METHODS: An anonymous survey was distributed to patients who were referred to 22 Italian academic institutions. The survey aimed to investigate the professional figure of the urology resident as perceived by the patient. RESULTS: A total of 2587 patients were enrolled in this study. In all, 51.6% of patients were able to correctly identify a urology resident; however, almost 40% of respondents discriminated residents from fully trained urologists based exclusively on their young age. Overall, 98.2% patients rated the service provided by the resident as at least sufficient. Urology trainees were considered by more than 50% of the patients interviewed to have good communication skills, expertise and willingness. Overall, patients showed an excellent willingness to be managed by urology residents. The percentage of patients not available for this purpose showed an increasing trend that directly correlated with the difficulty of the procedure. Approximately 5-10% of patients were not willing to be managed by residents for simple procedures such as clinical visits, cystoscopy or sonography, and up to a third of patients were not prepared to undergo any surgical procedure performed by residents during steps in major surgery, even if the residents were adequately tutored. CONCLUSIONS: Our data showed that patients have a good willingness to be managed by residents during their training, especially for medium- to low-difficulty procedures. Furthermore, the majority of patients interviewed rated the residents' care delivery as sufficient. Urology trainees were considered to have good communication skills, expertise and willingness.

Primary versus revision implant for inflatable penile prosthesis: A propensity score-matched comparison.

Inflatable penile prosthesis (IPP) provides excellent outcomes after virgin implants. However, few data on IPP after revision surgery are available. This study aimed at comparing the outcomes of IPP in patients undergoing primary or revision implant surgery. Patients who underwent revision implant surgery (Group 1) between 2013 and 2020 were identified. Overall, 20 patients (Group 1) could be matched with a contemporary matched pair cohort of surgery-naive patients (Group 2) in a 1:1 ratio. Patients in Group 2 had a significantly shorter operative time [median (IQR): 84 (65-97) vs. 65 (51-75) min; p = .01] and lower rate of overall complications (25% vs. 10%; p = .01). Of note, mean (SD) scores for the Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire demonstrated high satisfaction and IPP efficacy in both Groups 1 and 2: functional domain [3.9 (1.0) vs. 4.0 (1.2); p = .4], personal [3.9 (1.1) vs. 4.0 (1.1); p = .3], relational [3.8 (1.3) vs. 3.9 (1.1); p = .5] and social [3.9 (1.1) vs. 4.0 (1.2); p = .2]. These results suggest that in experienced hands, IPP offers high satisfaction to both patients and partners even in the setting of revision implant. However, it is mandatory to inform those patients about the increased risk of perioperative complications.

Long-term outcomes after penile prosthesis placement for the Management of Erectile Dysfunction: a single-Centre experience.

BACKGROUND: Penile prothesis (PP) is the gold-standard treatment of drug-refractory erectile dysfunction (ED). While postoperative outcomes have been widely described in the literature, there are few data about patient satisfaction and intraoperative events. We aimed to assess long-term patient satisfaction and perioperative outcomes after PP implantation in a single-centre cohort of unselected patients using validated scales. RESULTS: A total of 130 patients received a PP (median age: 62.5 years [IQR: 58-69]; median International Index of Erectile Function (IEEF-5) score: 6 [IQR: 5-7]). Median follow-up was 6.3 years [IQR: 4-9.4]. Thirty-two (24.6%) patients underwent surgical revision, of which 20 were PP removals (15.4%). Global PP survival rate was 84.6% and previous PP placement was a risk factor for PP removal (p = 0.02). There were six (4.6%) non-life-threatening intraoperative events including two which resulted in non-placement of a PP (1.5%). EAUiaic grade was 0 for 124 procedures (95.4%), 1 for four procedures (3.1%) and 2 for two procedures (1.5%). Of patients who still had their PP at the end of the study, 91 (80.5%) expressed satisfaction. CONCLUSIONS: PP implantation is a last-resort treatment for ED with a satisfactory outcome. PPs are well accepted by patients.

RéSUMé: CONTEXTE: La prothèse pénienne (PP) est. le traitement de référence de la dysfonction érectile (DE) réfractaire aux médicaments. Le but de ce travail est. d'évaluer les résultats à long terme chez les patients traités par prothèses péniennes (PP) dans notre hôpital. RéSULTATS: Un total de 130 patients a eu une pose de PP (âge médian: 62,5 ans [IQR: 58­69]; score médian de l'indice international de la fonction érectile (IEEF-5): 6 [IQR: 5­7]). Le suivi médian était de 6.3 ans [IQR: 4­9.4]. Trente-deux (24,6%) patients ont eu une reprise chirurgicale, dont 20 étaient des retraits de PP (15,4%). La durée de vie global des PP était de 84,6% et la pose antérieure de PP était un facteur de risque pour l'ablation (p = 0,02). Il y a eu six (4,6%) événements peropératoires ne mettant pas la vie en danger, dont deux qui ont empêché la pose de PP (1,5%). Le score EAUiaic était de 0 pour 124 procédures (95,4%), 1 pour quatre procédures (3,1%) et 2 pour deux procédures (1,5%). Parmi les patients qui avaient encore leur PP à la fin de l'étude, 91 (80,5%) ont exprimé leur satisfaction. CONCLUSIONS: L'implantation de PP est. un traitement de dernier recours pour la dysfonction érectile avec un résultat satisfaisant. Les PP sont bien acceptés par les patients.

Robot-assisted Supratrigonal Cystectomy and Augmentation Cystoplasty with Totally Intracorporeal Reconstruction in Neurourological Patients: Technique Description and Preliminary Results.

BACKGROUND: Augmentation cystoplasty as a third-line therapy for neurogenic detrusor overactivity performed by an open approach has long been studied. Few laparoscopic and robot-assisted series have been reported. OBJECTIVE: To evaluate the feasibility, safety, and functional outcomes of completely intracorporeal robot-assisted supratrigonal cystectomy and augmentation cystoplasty (RASCAC) in patients with refractory neurogenic detrusor overactivity. DESIGN, SETTING, AND PARTICIPANTS: We identified all patients undergoing RASCAC, as treatment for refractory neurogenic detrusor overactivity, from August 2016 to April 2018. SURGICAL PROCEDURE: RASCAC was performed in all cases using a standardized technique with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in a four-arm configuration. MEASUREMENTS: Perioperative data, and functional and urodynamic results at 1-yr follow-up were assessed. Statistical analysis was performed using Stata version 15.1. RESULTS AND LIMITATIONS: Ten patients were identified. No conversion to open surgery was needed. The median operative time was 250 (interquartile range 210-268) min, the median estimated blood loss was 75 (50-255) ml, and the median hospitalization time was 12 (10.5-13) d. The 30-d major complication rate was 10%. Two patients presented a late urinary fistula; in one of the cases, surgical revision was needed. In both cases, low compliance to intermittent self-catheterization was identified. At 1-yr follow-up, functional and urodynamic outcomes were excellent. CONCLUSIONS: Robot-assisted augmentation cystoplasty has been shown to be safe and feasible, with a reasonable operative time and low complication rate in experienced hands. A higher number of patients and longer follow-up are, however, warranted to draw definitive conclusions. PATIENT SUMMARY: In this report, we look at the outcomes of robot-assisted supratrigonal cystectomy and augmentation cystoplasty in neurourological patients. Perioperative, functional, and urodynamic results are promising. Further studies with a longer follow-up are needed to confirm these findings.

Clear Cell carcinoma of the urinary bladder, A case report: Surgical and oncological management.

INTRODUCTION: Bladder cancer is a condition characterized by a broad spectrum of histological variants and clinical courses. The morphological description of histological variants is becoming increasingly important. The 75% of cases of these cancers are classified as pure urothelial carcinoma, while the remaining 25% is represented by other histological variants. The clear cell carcinoma is part of urothelial group and is a very rare entity. Oncological outcomes of this variant are still uncertain, but seems to be worst than for patiens with pure urothelial carcinoma. Moreover it seems to metastasize more easily to the lymph nodes. CASE REPORT: We present a case of a Caucasian 73 year old woman who, after an episode of gross hematuria, underwent an ultrasound of the urinary system, a cystoscopy and a total body computed tomography (CT) which confirmed the presence of a bladder neoformation. A transurethral resection of the bladder (TURB) was performed: the result of the histological examination was "poorly differentiated clear cell carcinoma". Given the rarity of histological characterization, we required a PET CT scan for more accurate staging, at which a suspected right pelvic lymph node was detected. We proposed a radical cystectomy with hysteroannessiectomy and extended lymphadenectomy. During the pre-hospitalization process, the patient developed anuria, with acute renal failure and bilateral hydronephrosis, which required the placement of bilateral nephrostomies; we performed the planned surgical procedure and the histological exam confirmed: high grade urothelial carcinoma with a high percentage (more than 70%) of clear cell carcinoma, with a strong local aggression and lymphnode metastates. We referred the patient to the oncologist who suggested a treatment plan within an immunotherapy based clinical trial and cisplatin. CONCLUSIONS: The morphological description of histological variants in bladder cancer is gaining increasing importance, especially for infiltrating and aggressive forms. The clear cell carcinoma is a very rare entity part of the urothelial group; they would seem more aggressive forms with an early lymph node involvement. This evidence is confirmed by the clinical case described, in which we have seen a large local aggression with an involvement of the lymph nodes of the right side of the pelvis of the pre-sacral ones. In these cases, the multimodal approach is crucial.

The association of cigarette smoking and pathological response to neoadjuvant platinum-based chemotherapy in patients undergoing treatment for urinary bladder cancer - A prospective European multicenter observational study of the EAU Young Academic Urologists (YAU) urothelial carcinoma working group.

OBJECTIVE: To prospectively study the impact of smoking on pathological response to neoadjuvant chemotherapy (NAC) in patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB). MATERIALS & METHODS: We collected standard clinicopathological variables, including smoking status (never, former, current) in patients undergoing NAC and RC for UCB at 12 European tertiary care centers between 12/2013-12/2015. Clinicopathological variables were compared according to smoking status. Multivariable logistic regression models were built to assess the association of smoking status and a) complete (no residual disease), b) partial (residual, non-muscle invasive disease), c) no pathological response (residual muscle invasive or lymph node positive disease). Kaplan-Meier and Cox regression analyses were employed to study the impact of response to NAC on survival. RESULTS AND LIMITATIONS: Our final cohort consisted of 167 NAC patients with a median follow-up of 15 months (interquartile range (IQR) 9-26 months) of whom 48 (29%), 69 (41%), and 50 (30%) where never, former, and current smokers, respectively. Smoking was significantly associated with advanced age (p = 0.013), worse ECOG performance status (p = 0.049), and decreased pathological response to NAC (p = 0.045). On multivariable logistic regression analyses, former and current smoking status was significantly associated with lower odds of complete pathological response (odds ratio (OR) 0.37, 95% confidence interval (CI) 0.16-0.87, p = 0.023, and OR 0.34, 95% CI 0.13-0.85, p = 0.021), while current smoking status was significantly associated with a greater likelihood of no pathological response (OR 2.49, 95% CI 1.02-6.06, p = 0.045). Response to NAC was confirmed as powerful predictor of survival. CONCLUSIONS: Smoking status is adversely associated with pathological response to NAC. Smokers should be informed about these adverse effects, counseled regarding smoking cessation, and possibly be considered for immunotherpeutics as they may be more effective in smokers.

Robot-Assisted Laparoscopic Partial Nephrectomy Vs Conventional Laparoscopic Partial Nephrectomy: Functional and Surgical Outcomes of a Prospective Single Surgeon Randomized Study.

Background: Laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) are commonly used techniques for treating small renal masses. Regarding renal function (RF) preservation, no superiority of one technique over the other has yet been definitely demonstrated. Objective: To compare functional and surgical outcomes of LPN and RAPN. Patients and Methods: Between 2015 and 2019, we prospectively randomized 115 patients with cT1-T2 renal masses to LPN in total ischemia or RAPN in selective ischemia. Primary endpoint was RF preservation, assessed by renal scintigraphy (RS). RS assessments were performed preoperatively and at 6 months follow-up. Secondary endpoints included clinical, histopathologic, and surgical outcomes. Results: One hundred eight patients were included in the final analysis. Patient and tumor characteristics were comparable. No significant difference in RS values after 6 months was observed between both groups. Median (interquartile range) RF change after 6 months was -18.0% (-26.5 to -11.0) in LPN group and -20.0 (-33.2 to -12.0) in RAPN group (p = 0.3). Mean (standard deviation [SD]) warm ischemia time was 21.1 (6.1) minutes in LPN group and 19.6 (7.7) minutes in RAPN group (p = 0.2). No positive surgical margins (PSMs) occurred in the LPN group, whereas RAPN group had PSM in 4.9% (n = 3); p = 0.099. Renal volume loss after 6 months was 27.5% (22.7-45.7) in the LPN group vs 37.5 (13.7-54.2) in the RAPN group (p = 0.5). Mean operative times were lower in the LPN group (192.3 minutes [SD 44.5] vs 230.2 minutes [SD 59.6], p = 0.001). More complications occurred in the LPN group (31% vs 21%, p = 0.075). Transfusion rates were 15% for LPN and 11% for RAPN. Conclusions: In terms of preserving RF, LPN in total ischemia and RAPN in selective ischemia are comparable. In most patients, RF decrease of the affected kidney after PN seems to not exceed 25%, regardless of the surgical approach.

Standardized and Simplified Robot-assisted Superextended Pelvic Lymph Node Dissection for Prostate Cancer: The Monoblock Technique.

BACKGROUND: Extended pelvic lymph node dissection (ePLND) remains the most accurate procedure for lymph node staging in intermediate- and high-risk prostate cancer (PCa) patients undergoing radical prostatectomy (RP). A superextended pelvic lymph node dissection (sePLND) can be considered in selected very-high-risk PCa patients. OBJECTIVE: To demonstrate a reproducible robot-assisted technique for sePLND at the time of RP for PCa. DESIGN, SETTING, AND PARTICIPANTS: From June 2016 to August 2019, 41 consecutive patients with localized PCa and very high risk for lymph node invasion (LNI) received a robot-assisted RP and a standardized 10-step monoblock ePLND, followed by a 5-step monoblock sePLND. Very high risk for LNI was defined as ≥30% risk for LNI, as calculated by the Briganti 2017 nomogram. SURGICAL PROCEDURE: After performing the ePLND template resection (harvesting lymph nodes from the obturator region, external and internal iliac vessels, and common iliac vessels up to the ureter crossing), the 5-step monoblock sePLND approach was performed. The sePLND template was tailored to the common iliac vessels up to the aortic and caval bifurcation as well as the presacral region. MEASUREMENTS: Lymph node yield, perioperative complications. RESULTS AND LIMITATIONS: Overall, 41 patients received sePLND, reporting a median (interquartile range [IQR]) number of nodes removed of 23 (19-29). Median operative time (including RP, ePLND, and sePLND) was 256 min. Median preoperative prostate-specific antigen was 12 ng/mL (IQR 6.45-17.6). Disease stage pT <3 was found in 10 (24.4%) patients, pT3a in nine (22%) patients, pT3b in 21 (51.2%) patients, and pT4 in one (2.4%) patient. Of the treated patients, 54% revealed LNI: five (4.9%) in a solitary node, five (4.9%) in two to five nodes, and 12 (29.3%) in more than five nodes. Considering perioperative complications, three (7.3%) patients experienced Clavien I-II and four (9.7%) experienced Clavien ≥ III complications. Median hospital stay was 6 d. No patient underwent postoperative blood transfusion. CONCLUSIONS: The 5-step sePLND approach is a reproducible and feasible technique for PCa patients at a very high risk of LNI. PATIENT SUMMARY: In our study, we aimed to provide surgeons with a step-by-step technique for lymph node dissection, which aims to collect possibly metastatic lymph nodes of prostate cancer in an even more extended version ("superextended") than a standard ("extended") lymph node dissection.

Morbidity, perioperative outcomes and complications of robot-assisted radical prostatectomy in kidney transplant patients: A French multicentre study.

OBJECTIVE: Evaluate the safety, feasibility and efficiency of robot-assisted radical prostatectomy (RARP) in kidney transplant recipients, performed in high-volume French referral centres, and describe intra- and postoperative, oncological and functional outcomes. MATERIALS AND METHODS: A multicentre study was conducted on prospective RARP databases from 5 centres between 2008 and 2017. We retrospectively identified a first group (G1) of transplant patients. The following data were collected: age, body mass index, prostate-specific antigen, ISUP score, TNM stage, stratification according to d'Amico, renal function, renal disease, time between renal transplant and prostate cancer (PCa), operating time, bleeding, pre- and postoperative complications (according to Clavien). Group 1 data were matched with a second group (G2) of nontransplanted PTRA patients. RESULTS: A total of 321 patients were included (G1 N = 39 and G2 N = 282). The median operating time was 180 minutes (interquartile range 125-227) for G1 and 150 minutes (120-180) in G2 (P = 0.0623) and the median bleeding volume was 150 mL (150-400) and 250 mL (175-400), respectively (P = 0.1826). No grafts were damaged by RARP. Postoperative complication rate was significantly higher in G1: 51.2% vs. G2: 8.2% with a majority of minor complications (41%) according to Clavien Dindo (P < 0.001). Pathological assessment was as follows in G1: T2 = 28 (71.8%), T3 = 11 (28.2%), and G2: T2 = 206 (73.3%), T3 = 75 (26.7%) (P = 0.77). Postoperative ISUP scores were mainly grade 1: G1 = 14 (35.9%) vs. 99 (35.2%) in G2 and grade 2: respectively 18 (46.1%) 94 (33.5%). The rate of positive surgical margins was comparable in both groups: 13.2% for transplant patients vs. 18.1% (P = 0.65). Renal function was not significantly different at one year (P = 0.07). The median follow-up was 47.9 months (42.3; 52.5). CONCLUSION: RARP is conceivable to treat localized prostate cancer in kidney transplant recipients. This procedure does not appear to have any negative impact on graft renal function and cancer prognosis.

How many surgically-treated angiomyolipomas are related to tuberous sclerosis complex? Insights from a retrospective multicenter study.

BACKGROUND: Patients with TSC - related renal angiomyolipoma (AML) are eligible for targeted therapy with mTOR inhibitors, avoiding the morbidity of interventional management. Despite clinical criteria for TSC diagnosis have been defined, their use in routine clinical practice is likely suboptimal, leading to potential misclassification of TSC-related AML. The study aims to assess the proportion and characteristics of surgically-treated patients with putative sporadic AML that would have been re-classified as TSC-related. METHODS: We retrospectively reviewed a prospectively collected multi-institutional database to select patients with suspected TSC-related AML among those undergoing surgery at three referral Centers over 11-years (2005-2015). Possible diagnosis of TSC was defined according to the 2012 International Tuberous Sclerosis Complex Consensus (ITSCC) criteria. The proportion and characteristics of patients with possible TSC-related AML (as compared to those of patients with sporadic AML) were considered the main study endpoints. RESULTS: Overall, 132 patients were included. Of these, 10 (7.6%) were considered TSC-related. Most patients (84%) were female. Patients with TSC-related AML were likely to be younger (median age 53 vs. 56 years, P=0.29), symptomatic at diagnosis (70% vs. 21%, P=0.002), with slightly worse preoperative physical status (median ASA score 2 vs. 1, P=0.001) and bilateral disease (30% vs. 7.4%, P=0.04) as compared to patients with sporadic AML. Anatomic complexity and tumor size were also higher among TSC-related AMLs. CONCLUSIONS: A non-negligible proportion of surgically-treated, putative sporadic AMLs were reclassified as potentially hereditary (TSC-related). As TSC patients may be treated with targeted therapies, our findings may increase urologists' awareness of TSC-related AML and prompt the design of future studies evaluating targeted diagnostic pathways for these patients.

Satisfaction and surgical outcomes in patients undergoing penile prosthesis implantation for drug-refractory erectile dysfunction: mid-term results in a single center French cohort.

INTRODUCTION: To investigate the mid-term results of penile prosthesis (PP) implantation in patients with erectile dysfunction (ED) from a "real-life" historic cohort in a French academic center. MATERIALS AND METHODS: All patients receiving an inflatable PP between 2004 and 2014 in our institution were included in this study. ED was assessed preoperatively using the IEEF-5 questionnaire. Postoperative satisfaction with the PP was assessed using the EDITS questionnaire at each follow up visit. Postoperative complications were classed according to the Clavien classification. Surgical and functional outcomes were recorded prospectively. RESULTS: Seventy-six men received a PP during the 10 year study period. Median (IQR) age was 62 (58-69) years. The main causes of ED were radical prostatectomy (n = 40; 53%) and diabetes mellitus (n = 28; 36.8%). Five patients (6.6%) had a non-functioning PP in place requiring complete substitution or a previous penile implant which had already been removed at the time of surgery. Sixty-nine (90.8%) patients received an AMS 700 CX device and seven (9.2%) a Coloplast Titan. The surgical approach was penoscrotal in 45 (59.2%) and infrapubic in 31 (40.8%). Intraoperative complications occurred in four (5%) patients, without compromising the intervention. Postoperative complications occurred in 27 (35.5%) patients: 17 (22%) were Clavien I-II and 10 (15%) Clavien III. All major complications resulted in prosthesis removal (n = 9; 11.8%) or revision (n = 1; 1.3%). Median (IQR) follow up was 43 (34-55) months. At the end of follow up, 70 (92.1%) patients had a functional implant. Fifty-four (71.1%) patients were satisfied with the device at the 6 month follow up visit and beyond. Early satisfaction (at 3 months) was reported by 44 (57.9%) patients. A previous PP was the only significant risk factor for prosthesis removal (p = 0.001). CONCLUSION: PP implantation is a safe and satisfactory treatment for ED. However, patient selection remains crucial in determining the post-surgical success of this procedure.

Safety and efficacy of retroperitoneal sutureless zero ischemia laparoscopic partial nephrectomy for low nephrometry score masses.

OBJECTIVES: To evaluate oncological feasibility and oncological and functional results of retroperitoneal sutureless zero ischemia laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: Patients with posterior renal masses with low nephrometry score (RENAL ≤ 7) treated who underwent retroperitoneal sutureless zero ischemia.in a single center from January 2016 to November 2017. Clinical, surgical and pathological data were prospectively collected. Complications were reported according to the modified Clavien classification. RESULTS: Retroperitoneal sutureless zero ischemia laparoscopic partial nephrectomy was performed on 15 patients. The indication for nephron-sparing surgery was elective in 11 (73%) patients and imperative in 4 (27%). Median RENAL score was 5 (IQR: 5-7), median tumor diameter 25 mm (IQR: 20-35). In 11 cases, the tumor was located polar (85%), and in 2 cases hilar (15%). There were no intraoperative complications. No cases were converted to radical nephrectomy, and in no case parenchyma suture was necessary. Median operative time was 90 min (IQR:40-150), in no case clamping of the renal artery was necessary, median hospital stay was 4 days, median estimated blood loss (EBL) was 310 (180-500) ml. Pathological analysis showed renal cell carcinoma in 11 patients (85%), 9 (60%) staged T1a and 2 (13%) T1b. In 4 (27%) an oncocytoma was found. There were no positive surgical margins. One patient developed a major postoperative complication (postoperative renal bleeding requiring super-selective embolization). Trifecta rate was 93%. CONCLUSIONS: Sutureless retroperitoneal zero ischemia LPN for the treatment of low-complexity posterior renal masses showed to be safe and feasible. Longer follow-up and higher numbers of patients are, however, warranted to draw definitive conclusions on functional outcomes.

Large primary leiomyosarcoma of the seminal vesicle: A case report and literature revision.

Primary Leiomyosarcoma of the seminal vesicle is a very rare condition. We report a case of a 74-year-old man with a tumour detected by rectal symptoms with pelvic pain and dysuria at ultrasonography. Computed tomography and magnetic resonance imaging suggest an origin in the left seminal vesicle and did not show a clear cleavage plan with the rectum and a right hydroureteronephrosis was also present. A radical vesiculo-cystoprostatectomy with ileal conduit and bilateral pelvic lymphadenectomy was performed, a sigmoidectomy with end colostomy was performed also. Pathological examination showed a high grade (G3) leiomyosarcoma of the seminal vesicle.

Minimally invasive management of a symptomatic case of Zinner's syndrome: Laparoscopic seminal vesiculectomy and ipsilateral nephroureterectomy.

INTRODUCTION: Zinner syndrome is a rare developmental anomaly of the Wolffian (mesonephric) duct which is characterized by a triad of obstruction of the ejaculatory duct, the ipsilateral seminal vesicle cyst, and the ipsilateral renal agenesis. Usually is totally asymptomatic, however it can also determine symptoms such as lower urinary tract symptoms, perineal pain, ejaculatory disorders such as painful ejaculation or hematospermia, and infertility. CASE REPORT: We present a case of a 51 years old men with a 3-year history of lower urinary tract symptoms, perineal pain, obstructed defecation, recurrent urinary tract infections and infertility. CT scan showed a voluminous cystic neoformation of the left seminal vesicle, hypoplasia of the left kidney and ipsilateral ureteronephrosis. The mass was removed using laparoscopic "en block" seminal vesiculectomy with associated ipsilateral nephroureterectomy. No post-operative complications occurred. At 2-month post-operative control the patient reported an improvement of urinary and rectal symptoms.

Outcomes after salvage radical prostatectomy and first-line radiation therapy or HIFU for recurrent localized prostate cancer: results from a multicenter study.

INTRODUCTION: Despite no consensus on the optimal management of recurrent prostate cancer after primary radiation or HIFU therapy, salvage prostatectomy (sRP) is reserved for only 3% of patients because of technical challenges and frequent post-operative complications. We assessed outcomes after sRP in a series of patients with localized PCa and that had received radiation therapy or HIFU as a first-line treatment. MATERIALS AND METHODS: Data from nine French referral centers on patients treated with sRP between 2005 and 2017 were collected. Pre- and post-operative data, including oncological and functional outcomes after first treatment and sRP, were analyzed to determine the predictors for biochemical recurrence (BCR) and cancer-specific survival (CSS) after sRP. RESULTS: First-line treatments were external beam-radiation therapy (EBRT) for 30 (55%), brachytherapy (BT) for 10 (18%), and high-intensity focused ultrasound (HIFU) for 15 (27%). Median (IQR) PSA at diagnosis was 6.4 (4.9-9.5) ng/mL, median PSA at nadir was 1.9 (0.7-3.0) ng/mL, and median (IQR) to first BCR was 13 (6-20) months. Of the 55 patients, 44 (80%) received robot-assisted salvage radical prostatectomy and 11 (20%) received salvage retropubic radical prostatectomy. Restoration of continence was achieved in 90% of preoperatively continent patients; 24% that had received nerve-sparing (NS) procedures were potent after surgery. Prolonged catheterization due to anastomotic leakage was the most common complication. Age, preoperative clinical stage, NS procedure, and a pathological Gleason score were predictors for BCR. CONCLUSIONS: sRP was safe, feasible, and effective using either an open or robot-assisted approach, in experienced hands. Age, preoperative clinical stage, NS procedure, and pathological GS were linked with BCR after sRP.

Bladder mapping of tumour recurrence after radical nephroureterectomy for upper tract urothelial carcinoma and its influence on oncological outcomes.

OBJECTIVES: To assess the location of intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC), to determine the main predictive factors for IVR in the bladder-cuff area (BCA), and to assess the effect of BCA recurrence (BCAR) on prognosis. PATIENTS AND METHODS: This was a multicentre, retrospective study using the French collaborative database on UTUC, which includes data for all patients treated in 24 referral uro-oncology centres across the country. All patients who underwent RNU with bladder-cuff excision and who developed IVR between 1995 and 2010 were selected. Patients were divided into two groups: Group A: BCAR; and Group B: recurrence elsewhere in the bladder. The Kaplan-Meier method was used to estimate the probability of BCAR-free survival. Groups were compared using the log-rank test. Independent risk factors for BCAR were identified using a Cox proportional hazard regression model, with univariate and multivariate analyses. RESULTS: Overall, 163 patients were included in the final analysis: Group A, 87 patients (53.4%) and Group B, 76 (46.6%). The clinicopathological characteristics were similar in the groups. The median (interquartile range [IQR]) follow-up was 36 (31.7-40.39) months. The median (IQR) time to IVR was 10.0 (8.6-13.39) months [Group A: 11.0 (8.8-13.2)  months vs Group B: 10.0 (8.5-11.5) months; P = 0.35]. The probability of BCAR at 1, 2, and 3 years was 45.5% (95% confidence interval [CI] 40.1-50.9), 17.9% (95% CI 13.7-22.1), and 10.8% (95% CI 7.4-14.2) respectively, whereas the probability of recurrence elsewhere in the bladder was 42.1% (95% CI 36.4-47.8), 14.7% (95% CI 10.6-18.8), and 4.4% (95% CI 1.9-6.9), respectively (P = 0.35). Pathological tumour stage (≥pT3) was significantly related to the risk of BCAR (P = 0.03). CONCLUSION: There were more BCARs after RNU in advanced UTUC. However, no preferred site for recurrence was detected.

Perioperative outcomes and complications of intracorporeal vs extracorporeal urinary diversion after robot-assisted radical cystectomy for bladder cancer: a real-life, multi-institutional french study.

PURPOSE: To compare perioperative outcomes and complications of extracorporeal (ECUD) vs intracorporeal urinary diversion (ICUD) in patients after undergoing robot-assisted radical cystectomy (RARC) at five referral centers in France. METHODS: We retrospectively reviewed our multi-institutional, prospectively-collected database to select patients undergoing RARC between 2010 and 2016 with at least 3 months of follow-up. At each center, the surgery was performed by one surgeon with extensive experience in robotic surgery and radical cystectomy but no prior experience in RARC. RESULTS: Overall, 108 patients were included. ECUD and ICUD were performed in 34 (31.5%) and 74 (68.5%) patients, respectively. Patient characteristics were comparable among the two groups, except for a higher proportion of patients with high surgical risk (ASA score ≥ 3) in the ECUD group. Ileal conduit and ileal neobladder were performed in 63/108 (58%) and 45/108 (42%) cases, respectively. Ileal conduit was performed more often with an extracorporeal approach while ileal neobladder with an intracorporeal approach. Overall, operative time, length of hospital stay, positive margin rate, and number of lymph nodes removed did not significantly differ among the two cohorts. Estimated blood loss and transfusion rates were significantly higher in the ECUD group. Rate of early (38.2 vs 47.3%, p = 0.4) and late (29.4 vs 18.9%, p = 0.2) surgical complications did not significantly differ between the ECUD and ICUD groups. Results were comparable in the subgroup analysis in the ileal conduit subpopulation. CONCLUSION: In our real-life, multi-institutional study, RARC with ICUD achieved perioperative outcomes and complication rates comparable to those of RARC with ECUD.