Real world propensity score matched analysis evaluating the influence of en-bloc vs. non en-bloc techniques, energy and instrumentation on enucleation outcomes for large and very large prostates.

PURPOSE: The primary aim of the study was to evaluate if en-bloc vs. non en-bloc made a difference to intra-, peri- and post-operative surgical outcomes of anatomical endoscopic enucleation (AEEP) in large (> 80 cc) and very large prostates (> 200 cc). The secondary aim was to determine the influence of energy and instruments used. METHODS: Data of patients with > 80 cc prostate who underwent surgery between 2019 and 2022 were obtained from 16 surgeons across 13 centres in 9 countries. Propensity score matching (PSM) was used to reduce confounding. Logistic regression was performed to evaluate factors associated with postoperative urinary incontinence (UI). RESULTS: 2512 patients were included with 991 patients undergoing en-bloc and 1521 patients undergoing non-en-bloc. PSM resulted in 481 patients in both groups. Total operation time was longer in the en-bloc group (p < 0.001), enucleation time was longer in the non en-bloc group (p < 0.001) but morcellation times were similar (p = 0.054). Overall, 30 day complication rate was higher in the non en-bloc group (16.4% vs. 11.4%; p = 0.032). Rate of late complications (> 30 days) was similar (2.3% vs. 2.5%; p > 0.99). There were no differences in rates of UI between the two groups. Multivariate analysis revealed that age, Qmax, pre-operative, post-void residual urine (PVRU) and total operative time were predictors of UI. CONCLUSIONS: In experienced hands, AEEP in large prostates by the en-bloc technique yields a lower rate of complication and a slightly shorter operative time compared to the non en-bloc approach. However, it does not have an effect on rates of post-operative UI.

Incidence of complications and urinary incontinence following endoscopic enucleation of the prostate in men with a prostate volume of 80 ml and above: results from a multicenter, real-world experience of 2512 patients.

PURPOSE: To evaluate complications and urinary incontinence (UI) after endoscopic enucleation of the prostate (EEP) stratified by prostate volume (PV). METHODS: We retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with different energy sources in 14 centers (January 2019-January 2023). INCLUSION CRITERIA: prostate volume ≥ 80 ml. EXCLUSION CRITERIA: prostate cancer, previous prostate/urethral surgery, pelvic radiotherapy. PRIMARY OUTCOME: complication rate. SECONDARY OUTCOMES: incidence of and factors affecting postoperative UI. Patients were divided into 3 groups. Group 1: PV = 80-100 ml; Group 2 PV = 101-200 ml; Group 3 PV > 200 ml. Multivariable logistic regression analysis was performed to evaluate independent predictors of overall incontinence. RESULTS: There were 486 patients in Group 1, 1830 in Group 2, and 196 in Group 3. The most commonly used energy was high-power Holmium laser followed by Thulium fiber laser in all groups. Enucleation, morcellation, and total surgical time were significantly longer in Group 2. There was no significant difference in overall 30-day complications and readmission rates. Incontinence incidence was similar (12.1% in Group 1 vs. 13.2% in Group 2 vs. 11.7% in Group 3, p = 0.72). The rate of stress and mixed incontinence was higher in Group 1. Multivariable regression analysis showed that age (OR 1.019 95% CI 1.003-1.035) was the only factor significantly associated with higher odds of incontinence. CONCLUSIONS: PV has no influence on complication and UI rates following EEP. Age is risk factor of postoperative UI.

Current Evidence on Utility, Outcomes, and Limitations of Endoscopic Laser Ablation for Localized Upper Urinary Tract Urothelial Carcinoma: Results from a Scoping Review.

Context: The occurrence of upper urinary tract urothelial carcinoma (UTUC) is uncommon and is usually identified at an advanced and multifocal stage. Currently, there is growing interest in utilizing endoscopic laser ablation (ELA). Objective: To evaluate the survival rates and perioperative complications of ELA. Evidence acquisition: We performed a literature search through PubMed, Web of Science, and Scopus. The analysis included observational studies that examined the oncological outcomes of patients with UTUC treated with ELA. Evidence synthesis: Neodymium and diode lasers are no longer used due to their high complication rates. Holmium:yttrium-aluminum-garnet (YAG) and thulium:YAG lasers provided excellent tumor ablation and hemostasis in both the collecting system and the ureter. These lasers offer good disease-free and cancer-specific survival, especially for low-grade tumors. Conclusions: Advancements in laser technology and ablation techniques, and understanding of UTUC tumor biology hold significant promise in improving the use of conservative UTUC treatment, with excellent safety and good oncological outcomes for low-grade diseases. Patient summary: With the advancement of technology, the conservative approach utilizing endoscopic laser ablation for upper tract urothelial tumors has been proved to be both safe and effective, showcasing promising survival rates.

Comparing Same-Sitting Bilateral vs Unilateral Retrograde Intrarenal Surgery in the Elderly.

OBJECTIVE: To compare same-sitting bilateral vs unilateral retrograde intrarenal surgery (RIRS) in elderly patients, focusing on postoperative complications and stone-free rates (SFR). METHODS: Data from 2 multicenter databases, FLEXible ureteroscopy Outcomes Registry (FLEXOR) (unilateral RIRS) and same sitting bilateral-retrograde intrarenal surgery (SSB-RIRS) (bilateral RIRS), were analyzed, considering only patients aged 70+ with preoperative computed tomography. Patients were categorized into Group 1 (bilateral RIRS) and Group 2 (unilateral RIRS). Follow-up included imaging assessments and secondary treatments as needed. RESULTS: Group 1 included 146 patients, while group 2 had 495. Group 1's patients were slightly older and had a higher prevalence of recurrent stone formation. Group 2 often underwent RIRS for incidental stones. Group 1 had larger and more pelvic stones. Laser lithotripsy and total operation times were significantly longer in Group 1. Group 2 had significantly higher overall stone-free rates, although there were no significant differences in ancillary procedures for residual fragments. Group 1 experienced more pelvicalyceal injuries needing stenting, postoperative fever, and post-op hematuria not requiring transfusion. CONCLUSION: In conclusion, bilateral RIRS can be carefully considered in elderly patients. Preoperative counseling is essential for both primary and repeat RIRS procedures, and further research is needed to optimize instrument and laser strategies for better outcomes in elderly RIRS patients.

Near-Infrared Fluorescence Imaging with Indocyanine Green for Robot-Assisted Partial Nephrectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: We aimed to analyze the influence of near-infrared fluorescence (NIRF) using indocyanine green (ICG) with standard robot-assisted partial nephrectomy (RAPN) in patients with a kidney tumor (KT). METHODS: We performed a literature search on 12 September 2023 through PubMed, EMBASE, and Scopus. The analysis included observational studies that examined the perioperative and long-term outcomes of patients with a KT who underwent RAPN with NIRF. RESULTS: Overall, eight prospective studies, involving 535 patients, were eligible for this meta-analysis, with 212 participants in the ICG group and 323 in the No ICG group. For warm ischemia time, the ICG group showed a lower duration (weighted Mean difference (WMD) = -2.05, 95% confidence interval (CI) = -3.30--0.80, p = 0.011). The postoperative eGFR also favored the ICG group (WMD = 7.67, 95% CI = 2.88-12.46, p = 0.002). No difference emerged for the other perioperative outcomes between the two groups. In terms of oncological radicality, the positive surgical margins and tumor recurrence rates were similar among the two groups. CONCLUSIONS: Our meta-analysis showed that NIRF with ICG during RAPN yields a favorable impact on functional outcomes, whereas it exerts no such influence on oncological aspects. Therefore, NIRF should be adopted when preserving nephron function is a paramount concern.

Transperineal US-MRI Fusion-Guided Biopsy for the Detection of Clinical Significant Prostate Cancer: A Systematic Review and Meta-Analysis Comparing Cognitive and Software-Assisted Technique.

INTRODUCTION: We aimed to find potential differences in clinically significant prostate cancer (csPCa) detection rates between transperineal software-assisted fusion biopsy (saFB) and cognitive fusion biopsies (cFB). METHODS: A systematic review of the literature was performed to identify comparative studies using PubMed, EMBASE, and Scopus according to the PICOS criteria. Cancer detection and complication rates were pooled using the Cochran-Mantel-Haenszel method with the random effect model and reported as odds ratios (ORs), 95% confidence intervals (CI), and p-values. A meta-analysis was performed using Review Manager (RevMan) 5.4 software by Cochrane Collaboration. The quality assessment of the included studies was performed using the Cochrane Risk of Bias tool, using RoB 2 for randomized studies and ROBINS-I for retrospective and nonrandomized ones. RESULTS: Eight studies were included for the meta-analysis, including 1149 cases in software-based and 963 cases in cognitive fusion biopsy. The detection rates of csPCa were similar between the two groups (OR 1.01, 95% CI 0.74-1.37, p = 0.95). Study heterogeneity was low (I2 55%). CONCLUSION: There is no actual evidence of the superiority of saFB over cFB in terms of the csPCa detection rate. Operator experience and software availability can drive the choice of one fusion technique over the other.

Functional outcomes and safety of focal therapy for prostate cancer: a systematic review on results and patient-reported outcome measures (PROMs).

INTRODUCTION: Focal therapy (FT) is a promising alternative with curative intent for Low- to Intermediate-risk localized Prostate Cancer (PCa), claiming better functional outcomes and safety profile than standard whole-gland treatments. Ten different FT modalities have been described in the literature. The objective of our narrative review is to evaluate the safety profile and functional outcomes of these different modalities and the current most used tools of assessment for those outcomes. MATERIAL AND METHODS: Literature search was performed on 21st February 2023 using PubMed, EMBASE, and Scopus, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). Articles reporting whole-gland treatments were excluded. All articles reporting functional outcomes were included. RESULTS: One-hundred-seven studies, reporting data on 6933 patients, were included (26 on High Intensity Focal Ultrasound, 22 on Focal Cryotherapy, 14 on Irreversible Electroporation, 11 on Focal brachytherapy, 10 on Focal Laser Ablation, 8 on Photodynamic Therapy, 3 on Microwave ablation, 3 on Robotic Partial Prostatectomy, 2 on bipolar Radio Frequency Ablation, 1 on Prostatic Artery Embolization, and 7 studies comparing different FTs). Post-operative pad-free rate ranged between 92.3-100%. Greater heterogeneity exists considering the Change in Erectile Function, with Changing in Erectile function- rates ranging between 0-94.4% (Cryotherapy). The most used Patient-Reported Outcome Measures (PROMs) were the International Prostate Symptom Score and the International Index of Erectile Function for incontinence/urinary function and potency, respectively. The most common reported complications were hematuria, infections, and urethral strictures, with rates widely ranging among different treatments. The Clavien-Dindo Classification was the most used (40/88 papers) to describe adverse events. CONCLUSION: FT is a promising treatment for localized PCa, achieving excellent results in terms of safety and functional outcomes. There is a wide heterogeneity in the definition of PROMS and time of collection between studies. High quality comparative studies with standard treatments are needed to reinforce these findings.

The current evidence on surgical management for synchronous bilateral renal tumors: results from a scoping review.

PURPOSE: Synchronous bilateral renal masses (SBRM) account for a low percentage of kidney tumors, and there is no current recommendation for their management. The objective was to review evidence regarding the best surgical approach for SBRM in terms of type and timing of surgery. METHODS: A broad literature search was performed on 28th January 2023 using Scopus, PubMed, and EMBASE. Only English papers dealing with adults were included. Meeting abstracts were excluded. RESULTS: Twenty-four papers were accepted and included. SBRM behave less aggressively than metachronous tumors, and partial nephrectomy (PN) is the preferred therapeutic option to preserve renal function. Open, laparoscopic, and robot-assisted approaches were found to be similar in oncological outcomes, though robot-assisted surgery resulted in lower comorbidities. Same-sitting PN was demonstrated to be a safe approach, particularly in the robotic-assisted one. Finally, the same-siting and staged NSS were similar in preserving renal function. CONCLUSIONS: PN should be the desirable treatment for SBRM whenever feasible and if patients are fit, but surgeon expertise should also be taken into the account.

Oncological results and cancer control definition in focal therapy for Prostate Cancer: a systematic review.

INTRODUCTION: Focal therapy (FT) is a promising alternative to whole-gland treatments for Localized Prostate Cancer. Ten different FT modalities have been described in literature. However, FT is not yet recommended by the International Guidelines, due to the lack of robust data on Oncological Outcomes. The objective of our Narrative Review is to evaluate the oncological profile of the available FT modalities and to offer a comprehensive overview of the definitions of Cancer Control for FT. MATERIAL AND METHODS: Literature search was performed on 21st February 2023 using PubMed, EMBASE, and Scopus, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). Articles reporting whole gland-treatments were excluded. All articles reporting oncological outcomes were included. RESULTS: One-hundred-twenty-four studies, reporting data on more than 8000 patients treated with FT, were included. Overall, 40 papers were on High Intensity Focal Ultrasound (HIFU), 24 on Focal Cryotherapy, 13 on Irreversible Electroporation (IRE), 11 on Focal brachytherapy, 10 on Focal Laser Ablation (FLA), 8 on Photo-Dynamic Therapy (PDT), 3 on Microwave ablation, 3 on Robotic Partial Prostatectomy, 2 on bipolar Radio Frequency Ablation (bRFA), 1 on Prostatic Artery Embolization (PAE) and 9 comparative papers. Overall, the Biochemical Recurrence (BCR) rate ranged from 0% (Focal Brachytherapy) to 67.5% (HIFU); the Salvage treatment rate ranged from 1% (IRE) to 54% (HIFU) considering re-treatment with FT and from 0% (Focal Brachytherapy) to 66.7% considering standard Radical Treatments. There is no univocal definition of Cancer Control, however the "Phoenix criteria" for BCR were the most commonly used. CONCLUSIONS: FT is a promising alternative treatment for localized prostate cancer in terms of Oncological Outcomes, however there is a wide heterogeneity in the definition of cancer control, the reporting of oncological outcomes and a lack of high-quality clinical trials. Solid comparative studies with standard treatments and an unambiguous consensus on how to describe Cancer Control in the field of Focal Therapy are needed.

Improving Outcomes of Same-sitting Bilateral Flexible Ureteroscopy for Renal Stones in Real-world Practice-Lessons Learnt from Global Multicenter Experience of 1250 Patients.

Background: Bilateral kidney stones are commonly treated in staged procedures. Objective: To evaluate outcomes after same-sitting bilateral retrograde intrarenal surgery (SSB-RIRS) for renal stones. Design setting and participants: Data from adults who underwent bilateral RIRS in 21 centers were retrospectively reviewed (from January 2015 to June 2022). The inclusion criteria were unilateral/bilateral symptomatic bilateral stone(s) of any size/location in both kidneys and bilateral stones on follow-up with symptom/stone progression. Stone-free rate (SFR) was defined as absence of any fragment >3 mm at 3 mo. Outcome measurements and statistical analysis: Continuous variables are presented as medians and 25-75th percentiles. A multivariable logistic regression analysis was performed to evaluate independent predictors of sepsis and bilateral SFR. Results and limitations: A total of 1250 patients were included. The median age was 48.0 (36-61) yr. Of the patients, 58.2% were prestented. The median stone diameter was 10 mm on both sides. Multiple stones were present in 45.3% and 47.9% of the left and right kidneys, respectively. Surgery was stopped in 6.8% of cases. The median surgical time was 75.0 (55-90) min. Complications were transient fever (10.7%), fever/infection needing prolonged stay (5.5%), sepsis (2%), and blood transfusion (1.3%). Bilateral and unilateral SFRs were 73.0% and 17.4%, respectively. Female (odds ratio [OR] 2.97, 95% confidence interval [CI] 1.18-7.49, p = 0.02), no antibiotic prophylaxis (OR 5.99, 95% CI 2.28-15.73, p < 0.001), kidney anomalies (OR 5.91, 95% CI 1.96-17.94, p < 0.001), surgical time ≥100 min (OR 2.86, 95% CI 1.12-7.31, p = 0.03) were factors associated with sepsis. Female (OR 1.88, 95% CI 1.35-2.62, p < 0.001), bilateral prestenting (OR 2.16, 95% CI 1.16-7.66, p = 0.04), and the use of high-power holmium:YAG laser (OR 1.63, 95% CI 1.14-2.34, p < 0.01) and thulium fiber laser (OR 2.50, 95% CI 1.32-4.74, p < 0.01) were predictors of bilateral SFR. Limitations were retrospective study and no cost analysis. Conclusions: SSB-RIRS is an effective treatment with an acceptable complication rate in selected patients with kidney stones. Patient summary: In this large multicenter study, we looked at outcomes after same-sitting bilateral retrograde intrarenal surgery (SSB-RIRS) for renal stones in a large cohort. We found that SSB-RIRS was associated with acceptable morbidity and good stone clearance after a single session.

Nephrostomy tube versus double J ureteral stent in patients with malignant ureteric obstruction. A systematic review and meta-analysis of comparative studies

ABSTRACT Purpose: We aimed to perform a systematic review to assess perioperative outcomes, complications, and survival in studies comparing ureteral stent and percutaneous nephrostomy in malignant ureteral obstruction. Materials and Methods: This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Meta-analyses were performed on procedural data; outcomes; complications (device-related, accidental dislodgement, febrile episodes, unplanned device replacement), dislodgment, and overall survival. Continuous variables were pooled using the inverse variance of the mean difference (MD) with a fixed effect, and 95% confidence interval (CI). The incidences of complications were pooled using the Cochran-Mantel-Haenszel method with the random effect model and reported as Odds Ratio (OR), and 95% CI. Statistical significance was set two-tail p-value <0.05 Results: Ten studies were included. Procedure time (MD −10.26 minutes 95%CI −12.40-8.02, p<0.00001), hospital stay (MD −1.30 days 95%CI −1.69 − −0.92, p<0.0001), number of accidental tube dislodgments (OR 0.25 95% CI 0.13 - 0.48, p<0.0001) were significantly lower in the stent group. No difference was found in mean fluoroscopy time, decrease in creatinine level post procedure, overall number of complications, interval time between the change of tubes, number of febrile episodes after diversion, unplanned device substitution, and overall survival. Conclusion: Our meta-analysis favors stents as the preferred choice as these are easier to maintain and ureteral stent placement should be recommended whenever feasible. If the malignant obstruction precludes a stent placement, then PCN is a safe alternative.

Is endoscopic combined intrarenal surgery ready for primetime in endourology? Outcomes from a systematic review and meta-analysis.

Introduction: We aimed to review the outcomes of endoscopic combined intrarenal surgery (ECIRS) as compared to conventional percutaneous nephrolithotomy (PCNL) for kidney stones. Material and methods: We performed a systematic literature review using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. We included all studies comparing ECIRS and conventional PCNL. Surgical time, hemoglobin drop, and postoperative stay were pooled using the inverse variance of the mean difference (MD) with a random effect, 95% confidence intervals (CI), and p-values. Complications, stone-free rate, and retreatment were assessed using Cochran-Mantel-Haenszel method with random effect model and expressed as odds ratio (OR), 95% CI, and p-values. Results: A total of 17 studies were included. Surgical time and mean postoperative length did not significantly differ between the groups (MD -8.39 minutes 95%CI -21.30, 4.53, p = 0.20; 5.09 days 95%CI -19.51, 29.69, p = 0.69). Mean hemoglobin drop was significantly lower in the ECIRS group (MD -0.56 g/dl 95%CI -1.08, -0.05, p = 0.03), while blood transfusion rate did not differ between the two groups (OR 0.88 95%CI 0.64, 1.23, p = 0.15). While the incidence of postoperative sepsis did not differ between the two groups (OR 0.52 95% CI 0.17, 1.59, p = 0.25), the incidence of postoperative fever was lower in the ECIRS group but the difference was not significant (OR 0.61 95%CI 0.35, 1.06, p = 0.08). The stone-free rate was significantly higher in the PCNL group (OR 2.52 95%CI 1.64, 3.90, p <0.0001) and the retreatment rate was lower in the ECIRS group (OR 0.34 95%CI 0.14, 0.87, p = 0.002). Conclusions: ECIRS showed shorter operative time, lower complication rate, and retreatment compared to PCNL. Conventional PCNL showed a higher stone-free rate.

Nephrostomy tube versus double J ureteral stent in patients with malignant ureteric obstruction. A systematic review and meta-analysis of comparative studies.

PURPOSE: We aimed to perform a systematic review to assess perioperative outcomes, complications, and survival in studies comparing ureteral stent and percutaneous nephrostomy in malignant ureteral obstruction. MATERIALS AND METHODS: This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Meta-analyses were performed on procedural data; outcomes; complications (device-related, accidental dislodgement, febrile episodes, unplanned device replacement), dislodgment, and overall survival. Continuous variables were pooled using the inverse variance of the mean difference (MD) with a fixed effect, and 95% confidence interval (CI). The incidences of complications were pooled using the Cochran-Mantel-Haenszel method with the random effect model and reported as Odds Ratio (OR), and 95% CI. Statistical significance was set two-tail p-value < 0.05 Results: Ten studies were included. Procedure time (MD -10.26 minutes 95%CI -12.40-8.02, p< 0.00001), hospital stay (MD -1.30 days 95%CI -1.69 - -0.92, p< 0.0001), number of accidental tube dislodgments (OR 0.25 95% CI 0.13 - 0.48, p< 0.0001) were significantly lower in the stent group. No difference was found in mean fluoroscopy time, decrease in creatinine level post procedure, overall number of complications, interval time between the change of tubes, number of febrile episodes after diversion, unplanned device substitution, and overall survival. CONCLUSION: Our meta-analysis favors stents as the preferred choice as these are easier to maintain and ureteral stent placement should be recommended whenever feasible. If the malignant obstruction precludes a stent placement, then PCN is a safe alternative.

Lesion Volume in a Bi- or Multivariate Prediction Model for the Management of PI-RADS v2.1 Score 3 Category Lesions.

OBJECTIVE: This study aimed at improving the discrimination of Prostate Imaging - Reporting and Data System version 2.1 (PI-RADS v2.1) score 3 suspicious prostate cancer lesions using lesion volume evaluation. MATERIAL AND METHODS: Two hundred five PI-RADS v2.1 score 3 lesions were submitted to transperineal MRI/TRUS fusion-targeted biopsy. The lesion volumes were estimated on diffusion-weighted imaging sequence and distributed in PI-RADS 3a (LV < 0.5 mL) and PI-RADS 3b (LV ≥ 0.5 mL) subcategories, using a 0.5 mL cutoff value. Data were retrospectively matched with histopathological findings from the biopsy. Assuming that lesions with LV < or ≥ 0.5 mL were respectively not eligible (benign and indolent PCa lesions) or eligible for biopsy (significant PCa lesions), the diagnostic accuracy of lesion volume in determining clinically significant PCa at biopsy was evaluated using a bi- or multivariate model. RESULTS: About 55.1% and 44.9% of lesions were distributed in subcategories 3a and 3b, respectively. The overall PI-RADS score 3 detection rate was 273%. 3.5% (1.95% of total), and 25% (11.7% of total) significant PCa were found in PI-RADS 3a and 3b subcategory, respectively. The method showed 85.2% sensitivity, 61.2% specificity, 25% positive predictive value, and 96.5% negative predictive value and avoided 55.1% of unnecessary biopsies. The diagnostic accuracy in determining significant PCa at biopsy was 73.2% or 86.5% depending on whether lesion volume was used alone or in combination with prostate volume and patient age in a multivariate model. CONCLUSION: 0.5 mL lesion volume cutoff value significantly discriminates fusion-targeted biopsy need in PI-RADS v2.1 score 3 lesions and its diagnostic accuracy improves when it combines with prostate volume and age in a multivariate model.

Current trends in erectile rehabilitation after radical prostatectomy: Results from a worldwide survey.

We aimed to analyse the current trend of erectile rehabilitation (ER) following radical prostatectomy (RP) using a dedicated survey. An online survey was developed between July and September 2020, aiming to evaluate the ER protocols after RP in daily practice among urologists, andrologists, sexual medicine specialists and residents. We investigated demographics data, type of RP performed, and type, schedule, timing and duration of ER protocols. In total, 518 responders from 52 countries completed the survey. Surgical techniques reported were: 38.9% open, 22.9% laparoscopic and 38.2% robot-assisted RP. 33% of the responders begin ER at the catheter removal, 22% 1 month after surgery and 15% before surgery. Phosphodiesterase inhibitors were the most used medication as first-line treatment (99.4%). Tadalafil 20 mg was the most prescribed, and used daily in 48.2% of the cases, and 2-3 times/week in 46%. Intra-cavernosal injection of prostaglandin E1 was the second most common prescribed monotherapy (67.9%) followed by the association of phosphodiesterase inhibitors and vacuum-erection device (29.6%). The duration of ER was <6 months in 16.2%, between 6 and 11 months in 39%, between 12 and 18 months in 31.9%, between 19-24 months in 9.2% and >24 months in 3.7%. This study showed that the approach to ER after RP was inhomogeneous. International guidelines are urgently needed to standardise ER protocols.

Which factors can influence post-operative renal function preservation after nephron-sparing surgery for kidney cancer: a critical review.

Introduction: The aim of this article was to compare different surgical approaches to perform nephron-sparing surgery (NSS) in terms of preservation of renal function. Material and methods: We critically reviewed the literature from January 2000 to December 2020 including studies comparing different surgical techniques. Results: A total of 51 studies met the inclusion criteria. Functional outcomes were evalutated in terms of percentual change of estimated glomerular filtration rate (eGFR) and impaired renal function (IRF) on scintigraphy. In cases with a mean age <60 years, the mean decrease in eGFR after NSS was 11.7% and that of IRF 10.0%, whereas higher changes were found in cases with a mean age ≥60 years. For open NSS, the mean eGFR and IRF changes were 15.3% and 21.1%, respectively; using the laparoscopic approach, the mean percentual eGFR and IRF changes were 13.9% and 11.1%, respectively; in robotic cases, the mean eGFR and IRF changes were 10.8% and 13.1%, respectively. In cases performed with global ischemia, the mean eGFR and IRF changes were 12.7% and 15.1%, respectively. Similar results were found distinguishing ischemia time ≤20 and >20 minutes, whereas using the off-clamp technique the mean decreases in eGFR and IRF were only 4.2% and 6%, respectively. Conclusions: Patients' age, tumor size, off-clamp technique, and robot-assisted approach were significant independent predictive factors able to influence renal function changes after NSS. A lower reduction of eGFR and IRF after NSS was reported in patients aged <60 years, submitted to a robot-assisted procedure, and using selective and cold ischemia <20 minutes or an off-clamp technique.

Correlation Between Transurethral Interventions and Their Influence on Type and Duration of Postoperative Urinary Incontinence: Results from a Systematic Review and Meta-Analysis of Comparative Studies.

Objective: To perform a systematic review to assess the incidence of transient (<6 months) and persistent (>6 months) stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence (MUI) after transurethral surgeries for benign prostatic hyperplasia. Materials and Methods: A systematic literature search was performed using Embase, PubMed, and Web of Science. We included studies comparing monopolar (M)/bipolar (B) transurethral resection of the prostate (TURP) vs ablation vs enucleation procedures. Incidence of incontinence was assessed using Cochran-Mantel-Haenszel Method and reported as odds ratio (OR), 95% confidence interval (CI), and p-values. Statistical significance was set at p < 0.05 Evidence Synthesis: Twenty-eight studies were included. Incidence of transient SUI was 4.6%, 6.0%, 3.0%, and 2.4% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent SUI was 1.1% after ablation, 1.7% after enucleation and M-TURP, and 1.0% after B-TURP. Incidence of transient UUI was 2.0%, 7.3%, 4.4%, and 2.8% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent UUI was 2.2% after M-TURP. The incidence of transient MUI was 5.1%, 0.8%, 5.4%, and 0.9% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent MUI was 3.1% after ablation and 4.8% after M-TURP. Incidence of transient and persistent SUI and UUI did not differ after TURP vs enucleation. Incidence of transient (OR 3.32, 95% CI 0.41-26.65, p = 0.26) and persistent SUI (OR 4.79, 95% CI 0.52-43.89, p = 0.17) was not significantly higher after ablation. Incidence of transient UUI was not significantly higher after ablation (OR 2.62, 95% CI 0.04-166.01, p = 0.65), whereas persistent UUI did not differ. Incidence of transient MUI was significantly higher after enucleation (OR 3.26, 95% CI 1.51-7.05, p = 0.003). Incidence of transient and persistent MUI did not differ after TURP vs ablation. Conclusions: Ablation, enucleation, and TURP have an impact on all forms of incontinence, but this is transient in most cases with no difference between the groups, except for MUI, which was higher after enucleation vs M-TURP.