Surgical and Oncological Outcomes of Level III-IV Versus Level I-II Inferior Vena Cava Thrombectomy: A Decennial Experience of a High-Volume European Referral Center.

BACKGROUND: In patients with renal cell carcinoma (RCC) the role of the extent of tumor thrombus into the inferior vena cava (IVC) has never been addressed from a surgical and oncologic standpoint. This study aims to evaluate differences between level III-IV versus level I-II patients concerning peri- and postoperative morbidity, additional treatments and long-term oncological outcomes. PATIENTS AND METHODS: Overall, 40 patients with RCC underwent radical nephrectomy (RN) with IVC thrombectomy at a single European institution between 2010 and 2023. Complications were reported according to the European Union (EAU) guidelines recommendations. Spider chart served as graphical depiction of surgical and oncologic outcomes. RESULTS: Overall, 22 (55%) and 18 (45%) patients harbored level III-IV and I-II IVC thrombus. Level III-IV patients experienced significantly higher rates of intraoperative transfusions (68 vs 39%), but not significantly higher rates of intraoperative complications (32% vs 28%). Level III-IV patients had significantly higher rates of postoperative transfusions (82% vs 33%) and Clavien Dindo ≥3 complications (41% vs 15%). In level III-IV versus level I-II patients, median follow up was 482 and 1070 days, the rate of distant recurrence was 59% and 50%, the rate of systemic progression was 27% and 13%, and the rate of additional treatment/s was 64% and 61%, respectively (all p values > 0.05). Overall survival was 36% in level III-IV patients and 67% in level I-II (p = 0.001). CONCLUSIONS: Our findings suggest that patients with level III-IV RCC who are candidates for IVC thrombectomy should be counselled about the higher likelihood of postoperative severe adverse events and worse overall survival relative to level I-II counterparts.

Retzius sparing robot-assisted radical prostatectomy: optimizing functional results.

PURPOSE: The aim of this study is to critically evaluate the existing body of evidence regarding the efficacy of Retzius-sparing radical prostatectomy (RS-RARP) in achieving improved functional outcomes. Moreover, we explored possible strategies to further optimize functional outcomes. METHODS: Following PRISMA guidelines, a systematic review (PROSPERO ID CRD42024539915) was performed on 9th September 2023 on PubMed, Scopus, and Web of Science. Only original articles in the English language reporting functional outcomes after RS-RARP were included. RESULTS: Overall, the search string yielded 99 results on PubMed, 122 on Scopus, and 120 on Web Of Science. After duplicate exclusion, initial screening and eligibility evaluation, a total of 47 studies were included in the qualitative analysis, corresponding to a cohort of 13.196 patients. All studies reported continence recovery. RS-RARP appeared to achieve better and faster continence recovery compared to S-RARP. However, it should be noted that continence definition was heterogeneous and not based on validated condition-specific questionnaires. Seven (15%) studies provided for any sort of rehabilitation for urinary incontinence after RS-RARP. 22 studies analyzed potency recovery rates, showing no difference between RS-RARP and S-RARP. The evaluation of this outcome poses a great challenge due to the lack of standardized assessment tools and reporting methods. Only two studies reported on the consistent use of post-operative PDE5i as penile rehabilitation. CONCLUSIONS: The current review highlights the satisfactory functional results of Retzius-sparing robot assisted radical prostatectomy, which holds true irrespective of disease stage and prostate volume, with promising results even in patients previously treated for BPH or in the salvage setting. How can we optimize those results? The answer does not probably lie in further refinement of the surgical technique, but in giving greater attention to patient counselling and rehabilitation strategies in order to minimize regret and maximize satisfaction.

Prostate size ≥ 100 g and its association with long-term outcomes of Retzius-sparing robot-assisted radical prostatectomy.

BACKGROUND: It is unknown whether perioperative and functional outcomes of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) may be affected by large prostate sizes (PS). METHODS: All patients treated with RS-RARP were identified and compared according to PS. The definition of PS relied on the prostatic weight at final pathology (PS < 100 g vs ≥ 100 g). Multivariable logistic regression models tested immediate and 12-month urinary continence recovery (UCR, namely, 0-1 safety pad per-day), and positive surgical margins (PSM). Multivariable Poisson log-linear regression analyses tested operative time (OT), estimated blood loss (EBL), and length of stay (LOS). The analyses relied on the database of a high-volume European institution (2010-2022). RESULTS: Of 1,555 overall patients, 1503 (96.7%) had a PS < 100 g and 52 (3.3%) had a PS ≥ 100 g. No differences were recorded in LOS (3 days), and intraoperative (1.9 vs 2.3%) as well as postoperative complications (13 vs 12%; all p values > 0.05). No significant difference was recorded in PSM (25 vs 23%, p = 0.6). In patients with PS ≥ 100 g vs < 100 g, immediate UCR rate was 42 vs 64% (p = 0.002), and 12-month UCR rate was 87 vs 88% (p = 0.3). PV ≥ 100 g independently predicted worse immediate UCR (odds ratio 0.55, 95% CI 0.30-0.98, p = 0.044), but not worse 12-month UCR (p = 0.3) or higher PSM (p = 0.7). PV ≥ 100 g independently predicted longer OT (incidence rate ratio [IRR] 1.12, 95% CI 1.10-1.15, p < 0.001) and higher EBL (IRR 1.26, 95% CI 1.24-1.28, p < 0.001), but not longer LOS (p = 0.3). CONCLUSIONS: RS-RARP is a valid option for prostate cancer treatment, even in case of very large prostates. Specifically, no significant association was recognized between PS ≥ 100 g and PSM or 12-month UCR.

Use of the Schelin Catheter for transurethral intraprostatic anesthesia prior to Rezum treatment.

Minimally invasive surgery techniques (MIST) have become newly adopted in urological care.  Given this, new analgesic techniques are important in optimizing patient outcomes and resource management. Rezum treatment (RT) for BPH has emerged as a new MIST with excellent patient outcomes, including improving quality of life (QoL) and International Prostate Symptom Scores (IPSSs), while also preserving sexual function.  Currently, the standard analgesic approach for RT involves a peri-prostatic nerve block (PNB) using a transrectal ultrasound (TRUS) or systemic sedation anesthesia.  The TRUS approach is invasive, uncomfortable, and holds a risk of infection.  Additionally, alternative methods such as, inhaled methoxyflurane (Penthrox), nitric oxide, general anesthesia, as well as intravenous (IV) sedation pose safety risks or mandate the presence of an anesthesiology team.  Transurethral intraprostatic anesthesia (TUIA) using the Schelin Catheter (ProstaLund, Lund, Sweden) (SC) provides a new, non-invasive, and efficient technique for out-patient, office based Rezum procedures.  Through local administration of an analgesic around the prostate base, the SC has been shown to reduce pain, procedure times, and bleeding during MISTs.  Herein, we evaluated the analgesic efficacy of TUIA via the SC in a cohort of 10 patients undergoing in-patient RT for BPH.

The spread of retzius-sparing robotic prostatectomy: an update after 10 years.

PURPOSE OF REVIEW: Objective of our work is to provide an update of the state of the art concerning Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and to give a possible vision on the future developments of this new approach. RECENT FINDINGS: A nonsystematic literature review has been conducted, finding 27 comparative studies and 24 reviews published up to April 15, 2023. Most of these studies confirm the advantages of RS-RARP relative to standard RARP mainly on early continence recovery. Conversely, discordant findings are reported for the benefit of RS-RARP on late continence recovery. Uncertainty is still present on the impact on positive surgical margins (PSMs), but this statement is based on low level of evidence. Several data concerning the learning curve have shown the safety of RS-RARP, but the need of adequate tutoring. Recent studies also confirmed the feasibility of RS-RARP in the setting of high-risk prostate cancer (PCa), large prostate volume, patients with an history of benign prostatic hyperplasia surgery and patients with a transplanted kidney. Atypical advantages can be also seen in the reduction of risk of postoperative inguinal hernias and in case of concomitant rectal resection. SUMMARY: Retzius-sparing RARP has been confirmed to be one of the standard approaches for the treatment of PCa, with well documented advantages and uncertainty on PSMs.

Challenging cases in high-risk prostate cancer patients treated with Retzius-sparing robot-assisted radical prostatectomy.

OBJECTIVE: To evaluate the relationship between enlarged prostate, bulky median lobe (BML) or prior benign prostatic hyperplasia (BPH) surgery and perioperative functional, and oncological outcomes in high-risk (HR) prostate cancer (PCa) patients treated with Retzius-sparing robot-assisted radical prostatectomy (RS-RARP). METHODS: 320 HR-PCa patients treated with RS-RARP between 2011 and 2020 at a single high-volume center. The relationship between prostate volume, BML, prior BPH surgery and perioperative outcomes, Clavien-Dindo (CD) grade ≥ 2 90-day postoperative complications, positive surgical margins (PSMs), and urinary continence (UC) recovery was evaluated respectively in multivariable linear, logistic and Cox regression models. Complications were collected according to the standardized methodology proposed by EAU guidelines. UC recovery was defined as the use of zero or one safety pad. RESULTS: Overall, 5.9% and 5.6% had respectively a BML or prior BPH surgery. Median PV was 45 g (range: 14-300). The rate of focal and non-focal PSMs was 8.4% and 17.8%. 53% and 10.9% patients had immediate UC recovery and CD ≥ 2. The 1- and 2-yr UC recovery was 84 and 85%. PV (p = 0.03) and prior BPH surgery (p = 0.02) was associated with longer operative time. BML was independent predictor of time to bladder catheter removal (p = 0.001). PV was independent predictor of PSMs (OR: 1.02; p = 0.009). Prior BPH surgery was associated with lower UC recovery (HR: 0.5; p = 0.03). CONCLUSION: HR-PCa patients with enlarged prostate have higher risk of PSMs, while patients with prior BPH surgery have suboptimal UC recovery. These findings should help physicians for accurate preoperative counseling and to improve surgical planning in case of HR-PCa patients with challenging features.

Protocol of the Italian Radical Cystectomy Registry (RIC): a non-randomized, 24-month, multicenter study comparing robotic-assisted, laparoscopic, and open surgery for radical cystectomy in bladder cancer.

BACKGROUND: Bladder cancer is the ninth most common type of cancer worldwide. In the past, radical cystectomy via open surgery has been considered the gold-standard treatment for muscle invasive bladder cancer. However, in recent years there has been a progressive increase in the use of robot-assisted laparoscopic radical cystectomy. The aim of the current project is to investigate the surgical, oncological, and functional outcomes of patients with bladder cancer who undergo radical cystectomy comparing three different surgical techniques (robotic-assisted, laparoscopic, and open surgery). Pre-, peri- and post-operative factors will be examined, and participants will be followed for a period of up to 24 months to identify risks of mortality, oncological outcomes, hospital readmission, sexual performance, and continence. METHODS: We describe a protocol for an observational, prospective, multicenter, cohort study to assess patients affected by bladder neoplasms undergoing radical cystectomy and urinary diversion. The Italian Radical Cystectomy Registry is an electronic registry to prospectively collect the data of patients undergoing radical cystectomy conducted with any technique (open, laparoscopic, robotic-assisted). Twenty-eight urology departments across Italy will provide data for the study, with the recruitment phase between 1st January 2017-31st October 2020. Information is collected from the patients at the moment of surgical intervention and during follow-up (3, 6, 12, and 24 months after radical cystectomy). Peri-operative variables include surgery time, type of urinary diversion, conversion to open surgery, bleeding, nerve sparing and lymphadenectomy. Follow-up data collection includes histological information (e.g., post-op staging, grading, and tumor histology), short- and long-term outcomes (e.g., mortality, post-op complications, hospital readmission, sexual potency, continence etc). DISCUSSION: The current protocol aims to contribute additional data to the field concerning the short- and long-term outcomes of three different radical cystectomy surgical techniques for patients with bladder cancer, including open, laparoscopic, and robot-assisted. This is a comparative-effectiveness trial that takes into account a complex range of factors and decision making by both physicians and patients that affect their choice of surgical technique. TRIAL REGISTRATION: ClinicalTrials.gov , NCT04228198 . Registered 14th January 2020- Retrospectively registered.

Retzius-sparing robot-assisted radical prostatectomy: early learning curve experience in three continents.

OBJECTIVE: To assess the effect of surgical experience on peri-operative, functional and oncological outcomes during the first 50 Retzius-sparing robot-assisted radical prostatectomy (RsRARP) cases performed by surgeons naïve to this novel approach. MATERIALS AND METHODS: We retrospectively evaluated the initial cases operated by 14 surgeons in 12 different international centres. Pre-, peri- and postoperative features of the first 50 patients operated by each surgeon in all the participating centres were collected. The effect of surgical experience on peri-operative, functional and oncological outcomes was firstly evaluated after stratification by level of surgical experience (initial [≤25 cases] and expert [>25 cases]) and after using locally weighted scatterplot smoothing to graphically explore the relationship between surgical experience and the outcomes of interest. RESULTS: We evaluated 626 patients. The median follow-up was 13 months in the initial group and 9 months in the expert group (P = 0.002). Preoperative features overlapped between the two groups. Shorter console time (140 vs 120 min; P = 0.001) and a trend towards lower complications rates (13 vs 5.5%; P = 0.038) were observed in the expert group. The relationship between surgical experience and console time, immediate urinary continence recovery and Clavien-Dindo grade ≥2 complications was linear, without reaching a plateau, after 50 cases. Conversely, a non-linear relationship was observed between surgical experience and positive surgical margins (PSMs). CONCLUSIONS: In this first report of a multicentre experience of RsRARP during the learning curve, we found that console time, immediate urinary continence recovery and postoperative complications are optimal from the beginning and further quickly improve during the learning process, while PSM rates did not clearly improve over the first 50 cases.

Robot assisted radical prostatectomy in kidney transplant recipients: surgical, oncological and functional outcomes of two different robotic approaches.

BACKGROUND: To date, few series on robot-assisted radical prostatectomy (RARP) in kidney transplant recipients (KTRs) have been published. PURPOSE: To report the experience of two referral centers adopting two different RARP approaches in KTRs. Surgical, oncological and functional results were primary outcomes evaluated in the study. MATERIAL AND METHODS: We retrospectively analyzed data from 9 KTRs who underwent transperitoneal RARP or Retzius-sparing RARP for PCa from October 2012 to April 2016. Data were reported as median and interquartile range (IQR). Pre- and postoperative outcomes were compared by non-parametric Wilcoxon signed-rank test. Significant differences were accepted when p ≤ 0.05. Overall survival was assessed using Kaplan-Meier method. RESULTS: Four KTRs underwent a T-RARP and 5 a RS-RARP. Patient median age was 60 (56-63) years. Charlson comorbidity index was 6 (5-6). Preoperative median PSA was 5.6 (5-15) ng / mL. Preoperative Gleason score (GS) was 6 in 5 patients, 7 (3 + 4) in 3, and 8 (4 + 4) in one. Pre- and postoperative creatinine were 1.17 (1.1; 1.4) and 1.3 (1.07; 1.57) mg / dL (p = 0.237), while eGFR was 66 (60-82) and 62 (54-81) mL / min / 1.73m2 (p = 0.553), respectively. One (11.1%) Clavien-Dindo grade II complication occurred. Two extended template lymphadenectomies were performed, both with nodal invasion. These two patients experienced a biochemical recurrence and were subjected to RT. Two patients (22.2%) had PSMs. Median follow-up was 42 months. Seven patients (77.8%) were continent, 5 (55.6%) were potent. Two (22.2%) patients died during follow-up for oncologic unrelated causes. CONCLUSIONS: Our series suggests that both RARP approaches are safe and feasible techniques in KTRs for PCa.

A Comprehensive Overview of Intraoperative Complications during Retzius-Sparing Robot-Assisted Radical Prostatectomy: Single Series from High-Volume Center.

BACKGROUND: Intraoperative complications (ICs) are invariably underreported in urological surgery despite the recent endorsement of new classification systems. We aimed to provide a detailed overview of ICs during Retzius-sparing robot-assisted radical prostatectomy (RS-RARP). METHODS: We prospectively collected data from 1891 patients who underwent RS-RARP at a single high-volume European center from January 2010 to December 2022. ICs were collected based on surgery reports and categorized according to the Intraoperative Adverse Incident Classification (EAUiaiC). The quality criteria for accurate and comprehensive reporting of intraoperative adverse events proposed by the Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration Project were fulfilled. To better classify the role of the RS-RARP approach, ICs were classified into anesthesiologic and surgical ICs. Surgical ICs were further divided according to the timing of the complication in RARP-related ICs and ePNLD-related ICs. RESULTS: Overall, 40 ICs were reported in 40 patients (2.1%). Ten out of thirteen ICARUS criteria were satisfied. According to EAUiaiC grading of ICs, 27 (67.5%), 7 (17.5%), 2 (5%), 2 (5%), and 2 (5%) patients experienced Grade 1, 2, 3, 4A, and 4B, respectively. When we classified the ICs, two cases (5%) were classified as anesthesiologic ICs. Among the 38 surgical ICs, 16 (42%) were ePNLD-related, and 22 (58%) were RARP-related. ICs led to seven (0.37%) post-operative sequelae (four non-permanent and three permanent). Patients who suffered ICs were significantly older (67 years vs. 65 years, p = 0.02) and had a higher median BMI (27.0 vs. 26.1, p = 0.01), but did not differ in terms of comorbidities or tumor characteristics (all p values ≥ 0.05). CONCLUSIONS: Intraoperative complications during RS-RARP are relatively infrequent, but should not be underestimated. Patients suffering from ICs are older, have a higher body mass index, a higher rate of intraoperative blood transfusion, and a longer length of stay.

Use of a Schelin catheter for transurethral intraprostatic anesthesia (TUIA) prior to iTIND procedure.

BACKGROUND/OBJECTIVES: Endorsing the principles of minimal invasiveness in benign-prostatic hyperplasia (BPH) surgery, we conducted the first evaluation of transurethral intraprostatic anesthesia (TUIA) using Schelin catheter® (SC) prior to iTIND positioning. SUBJECTS/METHODS: Of 23 patients enrolled, 11 (48%) received TUIA via SC whereas the remaining underwent standard anesthesia protocol. Pain was assessed using visual analogue scale (VAS). RESULTS: No differences between cohorts were observed for pain during the device implantation and removal. Conversely, significantly lower median VAS scores were reported at 24- (1.0 vs. 3.0) and 48- (1.0 vs. 2.5) hour follow-up favoring TUIA. CONCLUSIONS: SC TUIA offers effective pain control during iTIND procedures, supporting its use in outpatient settings.

Can ChatGPT provide high-quality patient information on male lower urinary tract symptoms suggestive of benign prostate enlargement?

BACKGROUND: ChatGPT has recently emerged as a novel resource for patients' disease-specific inquiries. There is, however, limited evidence assessing the quality of the information. We evaluated the accuracy and quality of the ChatGPT's responses on male lower urinary tract symptoms (LUTS) suggestive of benign prostate enlargement (BPE) when compared to two reference resources. METHODS: Using patient information websites from the European Association of Urology and the American Urological Association as reference material, we formulated 88 BPE-centric questions for ChatGPT 4.0+. Independently and in duplicate, we compared the ChatGPT's responses and the reference material, calculating accuracy through F1 score, precision, and recall metrics. We used a 5-point Likert scale for quality rating. We evaluated examiner agreement using the interclass correlation coefficient and assessed the difference in the quality scores with the Wilcoxon signed-rank test. RESULTS: ChatGPT addressed all (88/88) LUTS/BPE-related questions. For the 88 questions, the recorded F1 score was 0.79 (range: 0-1), precision 0.66 (range: 0-1), recall 0.97 (range: 0-1), and the quality score had a median of 4 (range = 1-5). Examiners had a good level of agreement (ICC = 0.86). We found no statistically significant difference between the scores given by the examiners and the overall quality of the responses (p = 0.72). DISCUSSION: ChatGPT demostrated a potential utility in educating patients about BPE/LUTS, its prognosis, and treatment that helps in the decision-making process. One must exercise prudence when recommending this as the sole information outlet. Additional studies are needed to completely understand the full extent of AI's efficacy in delivering patient education in urology.

Evaluating the impact of gadolinium contamination on the marine bivalve Donax trunculus: implications for environmental health.

Gadolinium (Gd), commonly used in contrast agents for medical imaging, has been detected in hospital wastewater and aquatic environments, raising environmental concerns. This study examined the accumulation and cellular impacts of Gd in the clam species Donax trunculus, commonly used as bioindicator of contamination. Gadolinium accumulation in clams increased with exposure and over time. Biological responses varied with Gd levels: low concentrations (10 and 50µg/L) led to low metabolic activity and glycogen content, but high antioxidant activities and lipid peroxidation levels (LPO); high concentrations (250 and 500µg/L) resulted in increased metabolic activity, while antioxidant enzyme activity was inhibited and LPO levels were the lowest. Metabolic activity decreased after two weeks, suggesting limited long-term metabolic resilience. The study underscores D. trunculus as an effective early warning species for Gd pollution and highlights the ecological risks of rising Gd levels, emphasizing the need for environmental monitoring and regulation.

Does Retzius-Sparing robot-assisted radical prostatectomy guarantee optimal urinary continence recovery across all ages?

The association between age at surgery and urinary continence (UC) recovery after Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) is not well established. We addressed this knowledge gap, relying on a large series of 1,417 patients treated with RS-RARP at a high-volume centre between 2010 and 2021. Multivariable logistic models, as well as LOESS plot functions were performed. The probability of immediate, as well as 12-month UC-recovery progressively declined with increasing age at surgery, and per 5-years age at surgery increase reached the independent predictor status for both immediate and 12-month UC-recovery. These findings may significantly improve the quality of patient counseling regarding RS-RARP.

Evaluation of Peri-Operative Outcomes after Prostatic Urethral Lift with Emphasis on Urodynamic Changes, Symptom Improvement and Sexual Function.

Background and Aims: The aim of our study is to evaluate the possible urodynamic effect of prostatic urethral lift (PUL) in patients with lower urinary tract symptoms due to benign prostatic hyperplasia. Methods: A consecutive series of patients undergoing PUL placement were consecutively enrolled in two centers. Inclusion criteria: ≥50 years of age, benign prostatic obstruction (BPO), international prostate symptom score (IPSS) ≥ 13, prostate volume ≤ 60 mL, and no middle prostate lobe. All patients were evaluated using a detailed clinical history, a validated questionnaire, flexible cystoscopy, and pressure flow studies (PFS) at baseline. PFS were performed at 6 months to evaluate the urodynamic effect of PUL. Results: Overall, 20 patients with a median age of 63 were enrolled. At six months, statistically significant improvements in terms of median Qmax (11.5 vs. 8.5; p < 0.05) and median IPSS (16 vs. 10.5; p < 0.05) were recorded, and sexual function was maintained. All urodynamic parameters improved at 6 months, and significance was reached for all values except for PdetQmax. Finally, Schäfer's class improved from a median of III to a median of II. More specifically, 16/20 presented an improvement in the Schäfer class, and 12/20 patients presented a BOOI < 20 at 6 months. Conclusions: PUL represents an effective treatment in patients with LUTS due to BPH and improves bladder outlet obstruction without any effect on sexual function.

Proficiency score as a predictor of early trifecta achievement during the learning curve of robot-assisted radical prostatectomy for high-risk prostate cancer: Results of a multicentric series.

Background: Recently, an innovative tool called "proficiency score" was introduced to assess the learning curve for robot-assisted radical prostatectomy (RARP). However, the initial study only focused on patients with low-risk prostate cancer for whom pelvic lymph node dissection (PLND) was not required. To address this issue, we aimed to validate proficiency scores of a contemporary multicenter cohort of patients with high-risk prostate cancer treated with RARP plus extended PLND by trainee surgeons. Material and methods: Between 2010 and 2020, 4 Italian institutional prostate-cancer datasets were merged and queried for "RARP" and "high-risk prostate cancer." High-risk prostate cancer was defined according to the most recent European Association of Urology guidelines as follows: prostate-specific antigen >20 ng/mL, International Society of Urological Pathology ≥4, and/or clinical stage (cT) ≥ 2c on preoperative imaging. The selected cohort (n = 144) included clinical cases performed by trainee surgeons (n = 4) after completing their RARP learning curve (50 procedures for low-risk prostate cancer). The outcome of interest, the proficiency score, was defined as the coexistence of all the following criteria: a comparable operation time to the interquartile range of the mentor surgeon at each center, absence of any significant perioperative complications Clavien-Dindo Grade 3-5, no perioperative blood transfusions, and negative surgical margins. A logistic binary regression model was built to identify the predictors of 1-year trifecta achievement in the trainee cohort. For all statistical analyses, a 2-sided p < 0.05 was considered significant. Results: A proficiency score was achieved in 42.3% patients. At univariable level, proficiency score was associated with 1-year trifecta achievement (odds ratio, 8.77; 95% confidence interval, 2.42-31.7; p = 0.001). After multivariable adjustments for age, nerve-sparing, and surgical technique, the proficiency score independently predicted 1-year trifecta achievement (odds ratio, 9.58; 95% confidence interval, 1.83-50.1; p = 0.007). Conclusions: Our findings support the use of proficiency scores in patients and require extended PLND in addition to RARP.

Spermatic cord sarcoma: our experience and review of the literature.

INTRODUCTION: Spermatic cord tumors represent 4% of scrotal tumors. The most common neoplasms are lipomas. Spermatic cord sarcomas (SCS) of the genitourinary tract account for 2% of all urological tumors. Herein we presented our experience in the treatment of these tumors and a review of the literature. PATIENTS AND METHODS: A review of the literature was performed using the Medline database with no restriction on language and date of published papers. The literature search used the following terms: epidemiology, surgery, chemotherapy, radiotherapy and spermatic cord sarcomas. Four cases treated from December 2009 to May 2010 are described. RESULTS: All patients were treated with radical orchiectomy. The final pathological report showed different types of sarcomas. Two of the patients were treated with adjuvant chemotherapy. 12 months after surgery, 2/4 patients were alive without signs of relapse. CONCLUSION: SCS are very rare tumors with a poor prognosis. SCS's prognostic factors have been identified in grading, size, depth of invasion and surgical margin status. Age and performance status of the patient are however very important. Lymphatic and hematogenous dissemination is uncommon. Surgery is the most important treatment both in the first approach and in local relapse. The role of adjuvant chemotherapy and radiation therapy is still debated.

From city to sea: Spatiotemporal dynamics of floating macrolitter in the Tiber River.

Rivers are undoubtedly the main pathway of waste dispersed in the environment that from land reaches oceans and seas increasing the amount of marine litter. Major cities are a great source of riverine litter as large urbanization can originate pressure on the integrated waste management resulting in litter entering the rivers. Within this study, we aim to investigate the dynamic of floating riverine macrolitter (items >2.5 cm) in the city of Rome before it reaches the sea by assessing the composition, amount, and seasonal trends of litter transported from the urban centre to the main river mouth of Tiber River. Visual surveys for a whole year (March 2021-February 2022) were conducted from two bridges, Scienza Bridge (in the city) and Scafa Bridge (at the main river mouth) and followed JRC/RIMMEL protocol for riverine litter monitoring. Overall, similar litter composition was observed from the city centre to the mouth with a prevalence of plastic material, mainly related to fragmentation process (i.e. plastic pieces) and single use items, mainly in food and beverage sectors. An extrapolated annual loading of 4 × 105 items/year was estimated at the main mouth of Tiber River. The litter flux seems to be influenced by the seasonal variability and hydrometeorological parameters. The frequency of size classes decreases with increasing size in both sites, and more than half of the recorded items were below 10 cm. Specific categories belonging to "other plastics" have been reported related to anti-Covid-19 behaviour such as face masks and beverage sector, e.g. bottle lids and rings. The main colour of plastics was white, suggesting weathering process of floating riverine litter. This study contributes to increasing knowledge of the origin, composition and spatiotemporal dynamics of riverine floating litter from the city and entering the sea.