Intraoperative ultrasound in robot-assisted partial nephrectomy: State of the art.

INTRODUCTION: Nephron-sparing surgery (NSS) is of one of the most studied fields in urology due to the balancing between renal function preservation and oncological safety of the procedure. Aim of this short review is to report the state of the art of intra-operative ultrasound as an operative tool to improve localization of small renal masses partially or completely endophytic during robotassisted partial nephrectomy (RAPN). MATERIAL AND METHODS: We performed a literature review by electronic database on Pubmed about the use of intra-operative US in RAPN to evaluate the usefulness and the feasibility of this procedure. RESULTS: Several studies analyzed the use of different US probes during RAPN. Among them some focused on using contrastenhanced ultra sonography (CEUS) for improving the dynamic evaluation of microvascular structure allowing the reduction of ischemia time (IT). We reported that nowaday the use of intraoperative US during RAPN could be helpful to improve the preservation of renal tissue without compromising oncological safety. Moreover, during RAPN there is no need for assistant to hand the US probe increasing surgeon autonomy. CONCLUSIONS: The use of a robotic ultrasound probe during partial nephrectomy allows the surgeon to optimize tumor identification with maximal autonomy, and to benefit from the precision and articulation of the robotic instrument during this key step of the partial nephrectomy procedure. Moreover US could be useful to reduce ischemia time (IT). The advantages of nephron-sparing surgery over radical nephrectomy is well established with a pool of data providing strong evidence of oncological and survival equivalency. With the progressive growth of robot-assisted partial nephrectomy (RAPN) techniques, the use of several tools has been progressively developed to help the surgeon in the identification of masses and its vascular net. In this short review we tried to analyze the current use of intra-operative ultrasound as an operative tool to improve localization of small renal masses partially or completely endophytic during RAPN.

A singular case of polyorchidism.

We report a case of polyorchidism, a rare congenital anomaly, frequently discovered by chance. At current knowledge is still not defined which is the best clinical and therapeutic approach as well the best follow- up scheme due to the unclear malignant potential and rate of complications if a conservative approach is used. MRI (Magnetic Resonance Imaging) seems to be a good method to discriminate this mass from others pathological findings but there is still not enough evidence to standardize the procedure.

Procalcitonin as prognostic factor in patients with Fournier's gangrene.

INTRODUCTION: Fournier's Gangrene (FG) has still a mortality rate up to 45%. Several studies identified prognostic factors but there is a knowledge gap concerning procalcitonin (PCT) levels and mortality risk in FG. This study is aimed to assess the role of PCT as prognostic factor in FG. MATERIALS AND METHODS: The medical records of 20 male FG patients admitted at the Department of Urology of "Cattinara" Hospital, University of Trieste between January 2019 and November 2020 were retrospectively reviewed. Clinical, demographic, microbiological data were collected. The Fournier's Gangrene Severity Index (FGSI) was calculated for each patient. RESULTS: Thirteen (65%) of 20 patients survived. Median age was 58 years (IQR 51-88), 15 patients (75%) had a Charlson Comorbidity Index (CCI) score ⩾2, 1 (5%) equal to 0, 4 to 1 (20%). Median FGSI score was 6 (IQR 2-12) and median PCT 0.8 ng/ml (IQR 0.04-2.12). At multivariate analysis PCT levels >0.05 ng/ml were associated with an increased overall mortality risk (OR 2.14, CI 1.25-4.27, p = 0.002). CCI score ⩾2 (OR 1.51, CI 1.01-2.59, p = 0.04), Streptococcical etiology (OR 3.41, CI 2.49-4.61, p = 0.002) and FGSI score >9 (OR 1.41, CI 1.19-2.21, p = 0.004) were associated with unfavorable outcome. CONCLUSION: PCT might be a prognostic factor in FG. CCI and FGSI are useful tools in mortality risk stratification. Streptococcical etiology is associated with unfavorable outcome. Further larger clinical trials are pending.

Perioperative Antimicrobial Prophylaxis for Preventing Infectious Complications After Transurethral Resection of the Bladder: To Use or Not to Use?

Purpose: Transurethral resection of the bladder (TURB) is a common endoscopic procedure. Perioperative antimicrobial prophylaxis (AMP) is used to reduce the risk of infectious complications. However, there is an absence of knowledge about both incidence of infectious complications after TURB and advantage of AMP in general. The objective of this study is to determinate the prevalence of postoperative infectious complications after routine TURB without AMP. Methods: We retrospectively reviewed clinical data of all patients who underwent TURB in the same Academic Urologic Department between January 2011 and December 2013. We consider as relevant for analysis, patients that underwent TURB without receiving any AMP. Infection was defined as a body temperature >37.5°C sustained for at least 24 hours. Sepsis was defined according to the third international consensus definition for sepsis and septic shock. Results: In the period of the study, 223 TURBs were performed without use of AMP. Mean age was 70.3 years (standard deviation [SD] 11.3). Mean operative time was 25.14 minutes (SD 16). Median length of hospital stay was 3 days (interquartile range [IQR]: 2-4). Six (2.7%) patients developed postoperative infective complications. No case of sepsis was reported. Two (0.9%) patients received an antimicrobial therapy with fluoroquinolones despite absence of any signs of infection. Two hundred fifteen (96.4%) patients of TURBs did not receive any antimicrobial drugs and did not develop any infectious complications. Conclusion: In our series, infectious complications after TURB occurred in <3% of cases. In conclusion AMP should not be routinely used prior TURB.

External validation of the Briganti nomogram predicting lymph node invasion in patients with intermediate and high-risk prostate cancer diagnosed with magnetic resonance imaging-targeted and systematic biopsies: A European multicenter study.

OBJECTIVE: To validate a nomogram predicting lymph node invasion (LNI) in prostate cancer patients undergoing radical prostatectomy taking into consideration multiparametric-magnetic resonance imaging (mp-MRI) parameters and targeted biopsies in a western European cohort. PATIENTS AND METHODS: A total of 473 men diagnosed by targeted biopsies, using software-based MRI-ultrasound image fusion system, and operated by radical prostatectomy with extended pelvic lymph node dissection across 11 Europeans centers between 2012 and 2019 were identified. Area under the curve of the receiver operator characteristic curve, calibration plot and decision curve analysis were used to evaluated the performance of the model. RESULTS: Overall, 56 (11.8%) patients had LNI on final pathologic examination with a median (IQR) of 13 (9-18) resected nodes. Significant differences (all P < 0.05) were found between patients with and without LNI in terms of preoperative PSA, clinical stage at DRE and mp-MRI, maximum diameter of the index lesion, PI-RADS score, Grade Group on systematic and targeted biopsies, total number of dissected lymph nodes, final pathologic staging and Grade Group. External validation of the prediction model showed a good accuracy with an area under the curve calculated as 0.8 (CI 95% 0.75-0.86). Graphic analysis of calibration plot and decision curve analysis showed a slight underestimation for predictive probability for LNI between 3% and 22% and a high net benefit. A cut-off at 7% was associated with a risk of missing LNI in 2.6%, avoiding unnecessary surgeries in 55.9%. CONCLUSIONS: We report an external validation of the nomogram predicting LNI in patients treated with extended pelvic lymph node dissection in a western European cohort and a cut-off at 7% seems appropriate.