Anatomic endoscopic enucleation of the prostate using a novel hybrid thulium:yttrium-aluminium-garnet laser generator: surgical technique and clinical outcomes.

PURPOSE: We aim to report here the first clinical series of patients treated with AEEP using a novel hybrid thulium:yttrium-aluminium-garnet (Tm:YAG) laser generator (RevoLix HTL, LISA Laser Products, Germany), i.e. capable of emitting both in pulsated and continuous-wave. METHODS: We included 39 consecutive patients who underwent hybrid Tm:YAG AEEP (hybrid ThuLEP) at a single center starting from July 2022 and were followed-up until 3 months after surgery. Complete baseline, intraoperative, and follow-up demographic and clinical data were collected. The International Prostatic Symptoms Score (IPSS) questionnaire was used to quantify urinary symptoms at baseline and during follow-up. Post-operative follow-up further included a PSA test, uroflowmetry with post-void residual volume (PVR) measurement. Clavien-Dindo classification was used to classify complications. RESULTS: Median (IQR) age at surgery and prostate volume were 68 (IQR 63-74) years and 85 (60-105) cc. Both en-bloc or two-lobes technique enucleation were performed according to the intraoperative and endoscopic anatomy, with a median operative time of 85 (63-108) minutes. Bladder catheter was removed in all cases on postoperative day two. Intraoperative bleeding requiring conversion to bipolar enucleation was observed in two patients. After discharge, one patient developed arm phlebitis which was treated with anticoagulants leading to new onset haematuria requiring short term catheterisation (Clavien-Dindo grade II) and two more patients had a single episode of acute urinary retention (Clavien-Dindo grade I). Median pre- vs postoperative Qmax and IPSS were 8.0 (7.0-9.4) vs. 25.0 (22.5-32.5) ml/s and 22 (20-28) vs. 1 (0-2), whereas PVR decreased from 70 (50-115) to 0 (0-26) ml. CONCLUSIONS: Hybrid ThuLEP is a feasible and effective surgical procedure for the management of benign prostatic obstruction.

What to expect from the novel pulsed thulium:YAG laser? A systematic review of endourological applications.

INTRODUCTION: Several preclinical studies about a novel pulsed-thulium:yttrium-aluminum-garnet (p-Tm:YAG) device have been published, demonstrating its possible clinical relevance. METHODS: We systematically reviewed the reality and expectations for this new p-Tm:YAG technology. A PubMed, Scopus and Embase search were performed. All relevant studies and data identified in the bibliographic search were selected, categorized, and summarized. RESULTS: Tm:YAG is a solid state diode-pumped laser that emits at a wavelength of 2013 nm, in the infrared spectrum. Despite being close to the Ho:YAG emission wavelength (2120 nm), Tm:YAG is much closer to the water absorption peak and has higher absorption coefficient in liquid water. At present, there very few evaluations of the commercially available p-Tm:YAG devices. There is a lack of information on how the technical aspects, functionality and pulse mechanism can be maximized for clinical utility. Available preclinical studies suggest that p-Tm:YAG laser may potentially increase the ablated stone weight as compared to Ho:YAG under specific condition and similar laser parameters, showing lower retropulsion as well. Regarding laser safety, a preclinical study observed similar absolute temperature and cumulative equivalent minutes at 43° C as compared to Ho:YAG. Finally, laser-associated soft-tissue damage was assessed at histological level, showing similar extent of alterations due to coagulation and necrosis when compared with the other clinically relevant lasers. CONCLUSIONS: The p-Tm:YAG appears to be a potential alternative to the Ho:YAG and TFL according to these preliminary laboratory data. Due to its novelty, further studies are needed to broaden our understanding of its functioning and clinical applicability.

Laparoscopic Pyelolithotomy for treating urolithiasis in ectopic pelvic kidneys.

INTRODUCTION: The management of urolithiasis ectopic pelvic kidneys (EPK) can be challenging because of the aberrant anatomy (1-4). We demonstrate the step-by-step technique of the laparoscopic approach for treating urolithiasis in EPK. PATIENTS AND METHODS: Three men with EPK (2 left, 1 right) underwent laparoscopic pyelolithotomy through a transperitoneal approach. After establishing the pneumoperitoneum, the parietal peritoneum was opened at the parietal colic sulcus and the bowel displaced medially. The kidney was identified in the retroperitoneum and the renal pelvis exposed after removal of the perirenal adipose tissue. The renal pelvis was opened, and the stones were identified and retrieved with forceps in 2 cases and with a flexible nephroscope in 1 case. The renal pelvis was closed with a 3/0 running barbed suture. A DJ stent was placed in all patients. RESULTS: For the first time, a laparoscopic technique for treating stones in the ectopic kidney is demonstrated in detail. Mean patient age was 52.6 years (44-58). The mean stone size was 22.3 mm (20-24 mm). Stones were in the renal pelvis in 2 cases and in the inferior calyx in 1 case. Mean operative time was 146 minutes (135-155 min). Mean estimated blood loss was 116 ml (60-140 ml). No complications were observed. The mean hospital stay was 3 days. The DJ stents were removed after 3 weeks. All patients were stone free at the postoperative CT scan with a mean follow-up of 3.3 months (1-6 months). CONCLUSIONS: Laparoscopic pyelolithotomy can be an effective and reproducible minimally invasive technique for treating urolithiasis in EPK.

Lupus anticoagulant and mortality in patients hospitalized for COVID-19.

Coronavirus disease 2019 (COVID-19) is characterized by a procoagulant state that can lead to fatal thromboembolic events. Several studies have documented a high prevalence of lupus anticoagulant that may at least partially explain the procoagulant profile of COVID-19. However, the association between lupus anticoagulant and thrombotic complications in COVID-19 is controversial and no study has specifically evaluated the impact of lupus anticoagulant on mortality. The aim of our study was to investigate the association between lupus anticoagulant and mortality in a large group of 192 consecutive patients hospitalized for COVID-19. Lupus anticoagulant was found in 95 patients (49.5%). No difference in the percentage of patients with lupus anticoagulant was observed between 130 survivors and 62 non-survivors (47.7 versus 53,2%; p = 0.4745). When the combined outcome of death or need for mechanical ventilation in survivors was taken into account, the difference in the prevalence of patients with lupus anticoagulant between the patients with the combined outcome (n = 76) and survivors who did not require mechanical ventilation (n = 116) was not significant (52.6% versus 47.4%; p = 0.4806). In multivariate analysis predictors of mortality or need for mechanical ventilation in survivors were obesity, low oxygen saturation and elevated troponin levels measured on admission. In conclusion, our study did not show any association of lupus anticoagulant with mortality and with need for mechanical ventilation in survivors. The role of obesity, low SaO2 and elevated troponin levels as predictors of a worse prognosis in patients hospitalized for COVID-19 was confirmed.

Partial versus radical nephrectomy in very elderly patients: a propensity score analysis of surgical, functional and oncologic outcomes (RESURGE project).

PURPOSE: To compare the outcomes of PN to those of RN in very elderly patients treated for clinically localized renal tumor. PATIENTS AND METHODS: A purpose-built multi-institutional international database (RESURGE project) was used for this retrospective analysis. Patients over 75 years old and surgically treated for a suspicious of localized renal with either PN or RN were included in this database. Surgical, renal function and oncological outcomes were analyzed. Propensity scores for the predicted probability to receive PN in each patient were estimated by logistic regression models. Cox proportional hazard models were estimated to determine the relative change in hazard associated with PN vs RN on overall mortality (OM), cancer-specific mortality (CSM) and other-cause mortality (OCM). RESULTS: A total of 613 patients who underwent RN were successfully matched with 613 controls who underwent PN. Higher overall complication rate was recorded in the PN group (33% vs 25%; p = 0.01). Median follow-up for the entire cohort was 35 months (interquartile range [IQR] 13-63 months). There was a significant difference between RN and PN in median decline of eGFR (39% vs 17%; p < 0.01). PN was not correlated with OM (HR = 0.71; p = 0.56), OCM (HR = 0.74; p = 0.5), and showed a protective trend for CSM (HR = 0.19; p = 0.05). PN was found to be a protective factor for surgical CKD (HR = 0.28; p < 0.01) and worsening of eGFR in patients with baseline CKD. Retrospective design represents a limitation of this analysis. CONCLUSIONS: Adoption of PN in very elderly patients with localized renal tumor does not compromise oncological outcomes, and it allows better functional preservation at mid-term (3-year) follow-up, relative to RN. Whether this functional benefit translates into a survival benefit remains to be determined.

Ex vivo fluorescence confocal microscopy: the first application for real-time pathological examination of prostatic tissue.

OBJECTIVE: To report the first application of ex vivo fluorescence confocal microscopy (FCM) - a novel optical technology that is capable of providing fast microscopic imaging of unfixed tissue specimens- in the urological field assessing its diagnostic accuracy for non neoplastic and cancerous prostate tissue (prostatic adenocarcinoma) compared to the 'gold standard' histopathological diagnoses. PATIENTS AND METHODS: In all, 89 specimens from 13 patients with clinically localised prostate cancer were enrolled into the study. All patients underwent robot-assisted laparoscopic radical prostatectomy with fresh prostatic tissue biopsies taken at the end of each intervention using an 18-G biopsy punch. Specimens were randomly assigned to the three collaborating pathologists for evaluation. Intra- and inter-observer agreement was tested by the means of Cohen's κ. The diagnostic performance was evaluated on receiver operating characteristic curve analysis. RESULTS: The overall diagnostic agreement between FCM and histopathological diagnoses was substantial with a 91% correct diagnosis (κ = 0.75) and an area under the curve of 0.884 (95% confidence interval 0.840-0.920), 83.33% sensitivity, and 93.53% specificity. CONCLUSION: FCM seems to be a promising tool for enhanced specimens' reporting performance, given its simple application and very rapid microscopic image generation (<5 min/specimen). This technique may potentially be used for intraoperative pathological specimens' analysis.

Comparison between prone and supine nephrolithotomy in pediatric population: a double center experience.

PURPOSE: Stone disease in the pediatric age is an increasing issue. Percutaneous Nephrolithotomy (PNL) can be used for larger and complex stones. As in adults it can be performed in the supine or prone position. METHODS: We retrospectively reviewed two centers' experience in prone and supine PNL in children to analyze its results and complications. RESULTS: 33 patients underwent prone and 19 supine procedures. Patients in the prone group were younger than in the supine, while no significant differences were found in stone burden, access size, operative time or complications. Complications were: 8 and 4 Clavien 1 for the prone and supine group, respectively, one case of urosepsis (4b) in the prone and 2 cases of Clavien 3 in the supine group (double J stent placement for renal colic and ureteroscopy for steinstrasse). Tubeless procedures and mean nephrostomy time were in favor of the supine group, whereas fluoroscopy time and ureteral drainage stay were in support of the prone group. Stone free rate was better in the supine group (83.3 vs 66.6%), possibly reflecting the capability to perform a combined approach in 12 patients (allowing to reach all the calyx with simultaneous anterograde and retrograde access) or younger age in the prone group (13 vs 2 patients ≤5 years), with no differences in stone burden. CONCLUSIONS: Supine approach seems to guarantee higher stone-free rates. Larger series are necessary to determine what the best technique is in terms of X-ray exposure, operative time and complications.

Initial Experience and Evaluation of a Nomogram for Outcome Prediction in Management of Medium-sized (1-2 cm) Kidney Stones.

BACKGROUND: The gold standard treatment for solitary medium-sized (1-2 cm) renal stones is not defined by recent guidelines, since management modalities including shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotomy (PNL) are recommended. Improved ability to predict patient outcomes would aid in patients' counseling and decision-making. OBJECTIVE: To develop a nomogram predicting treatment failure, based on preoperative clinical variables, to be used in the preplanning setting. DESIGN, SETTING, AND PARTICIPANTS: We recruited 2605 patients from 14 centers and carried out a multicenter retrospective analysis of 699 SWL, 1290 RIRS, and 616 PN L procedures performed as first-line treatment for 1-2-cm kidney stones. The variables evaluated included age, gender, previous renal surgery, body mass index, stone size, location, stone density, skin-to-stone distance, presence of urinary tract infections (UTIs), and hydronephrosis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariate logistic regression was fitted to predict treatment failure, defined as the presence of residual fragments >4 mm. A nomogram was developed based on the coefficients of the logit function. RESULTS AND LIMITATIONS: A total of 2431 (93.3%) patients were stone free; 174 (6.7%) treatment failures were recorded and considered the event to be predicted. On univariate analysis, type of procedure, preoperative hydronephrosis, stone density, stone location, and laterality turned out to be statistically significant. Skin-to-stone distance, UTIs, and previous renal surgery were predictors of failure on multivariate analysis. Each variable was given a score based on statistical relevance. The main limitation of the current study is its retrospective nature. CONCLUSIONS: This nomogram provides a prediction of treatment failure and need of reintervention for medium-sized kidney stones. External validation is needed to determine its reproducibility and validity. PATIENT SUMMARY: We developed a preoperative model of treatment outcomes for 1-2-cm kidney stones. Its application may assist urologists to counsel patients with regard to stone management modality.

"Real-time" Assessment of Surgical Margins During Radical Prostatectomy: State-of-the-Art.

Histopathologic examination of the pathologic specimens using hematoxylin & eosin stains represents the backbone of the modern pathology. It is time-consuming; thus, "real-time" assessment of prostatic and periprostatic tissue has gained special interest in the diagnosis and management of prostate cancer. The current study focuses on the review of the different available techniques for "real-time" evaluation of surgical margins during radical prostatectomy (RP). We performed a comprehensive search of the Medline database to identify all the articles discussing "real-time" or intraoperative assessment of surgical margins during RP. Several filters were applied to the search to include only English articles performed on human subjects and published between January 2000 and March 2019. The search revealed several options for pathologic assessment of surgical margins including intraoperative frozen sections, confocal laser endomicroscopy, optical spectroscopy, photodynamic diagnosis, optical coherence tomography, multiphoton microscopy, structured illumination microscopy, 3D augmented reality, and ex vivo fluorescence confocal microscope. Frozen section represents the gold standard technique for real-time pathologic examinations of surgical margins during RP; however, several other options showed promising results in the initial clinical trials, and considering the rapid development in the field of molecular and cellular imaging, some of these options may serve as an alternative to frozen section.

Ex vivo fluorescence confocal microscopy: prostatic and periprostatic tissues atlas and evaluation of the learning curve.

Ex vivo fluorescence confocal microscopy (FCM) is an optical technology that provides fast H&E-like images of freshly excised tissues, and it has been mainly used for "real-time" pathological examination of dermatological malignancies. It has also shown to be a promising tool for fast pathological examination of prostatic tissues. We aim to create an atlas for FCM images of prostatic and periprostatic tissues to facilitate the interpretation of these images. Furthermore, we aimed to evaluate the learning curve of images interpretation of this new technology. Eighty fresh and unprepared biopsies obtained from radical prostatectomy specimens were evaluated using the FCM VivaScope® 2500 M-G4 (Mavig GmbH, Munich, Germany; Caliber I.D.; Rochester NY, USA) by two pathologists. Images of FCM with the corresponding H&E are illustrated to create the atlas. Furthermore, the two pathologists were asked to re-evaluate the 80 specimens after 90 days interval in order to assess the learning curve of images' interpretation of FCM. FCM was able to differentiate between different types of prostatic and periprostatic tissues including benign prostatic glands, benign prostatic hyperplasia, high-grade intraepithelial neoplasm, and prostatic adenocarcinoma. As regards the learning curve, FCM demonstrated a short learning curve. We created an atlas that can serve as the base for urologists and pathologists for learning and interpreting FCM images of prostatic and periprostatic tissues. Furthermore, FCM images is easily interpretable; however, further studies are required to explore the potential applications of this new technology in prostate cancer diagnosis and management.

A diagnostic-therapeutic pathway for patients with kidney stone disease: 2020 update / Percorso diagnostico-terapeutico per il paziente con calcolosi renale: update 2020

The natural history of urinary kidney stone disease includes the risk of relapses and can be associated with the risk of chronic kidney disease, bone and cardiovascular disease. For this reason, a wide clinical-metabolic assessment of the kidney stone patient is of great importance since the first presentation of the stone, to set an appropriate preventive treatment. The proposed diagnostic-therapeutic pathway includes a careful medical history, in order to highlight a secondary kidney stone disease and the main risk factors for kidney stones, chronic renal disease, or cardiovascular and bone disease; a metabolic evaluation on multiple levels, according to the severity of the disease, and the presence or absence of risk factors, and appropriate instrumental investigations. Thus, the information collected makes it possible to set a preventive treatment consisting of general rules and, if necessary, specific pharmacological or nutritional interventions. This paper has been prepared by the Italian Multidisciplinary Study Group for Kidney Stone Disease, and it is addressed to the several professional figures involved in the management of patients suffering from nephrolithiasis, from the emergency doctor to the general practitioner, urologist, nephrologist, radiologist, and dietician. A diagnostic-therapeutic pathway for patients with kidney stone disease was first published on this Journal in 2010. The present contribution aims at amending and updating the article published exactly ten years ago, to serve as an easy-to-use reference and to guide good clinical practice in this field.

Drug-Induced Urolithiasis in Pediatric Patients.

Drug-induced nephrolithiasis is a rare condition in children. The involved drugs may be divided into two different categories according to the mechanism involved in calculi formation. The first one includes poorly soluble drugs that favor the crystallization and calculi formation. The second category includes drugs that enhance calculi formation through their metabolic effects. The diagnosis of these specific calculi depends on a detailed medical history, associated comorbidities and the patient's history of drug consumption. There are several risk factors associated with drug-induced stones, such as high dose of consumed drugs and long duration of treatment. Moreover, there are some specific risk factors, including urinary pH and the amount of fluid consumed by children. There are limited data regarding pediatric lithogenic drugs, and hence, our aim was to perform a comprehensive review of the literature to summarize these drugs and identify the possible mechanisms involved in calculi formation and discuss the management and preventive measures for these calculi.

Outcomes of Partial and Radical Nephrectomy in Octogenarians - A Multicenter International Study (Resurge).

OBJECTIVE: To analyze the outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) in octogenarian patients. METHODS: The RESURGE (REnal SUrgery in the Eldely) multi-institutional database was queried to identify patients ≥80 years old who had undergone a PN or RN for a renal tumor. Multivariable binary logistic regression estimated the association between type of surgery and occurrence of complications. Multivariable Cox regression model assessed the association between type of surgery and All-Causes Mortality. RESULTS: The study analyzed 585 patients (median age 83 years, IQR 81-84), 364 of whom (62.2%) underwent RN and 221 (37.8%) PN. Patients undergoing RN were older (P = .0084), had larger tumor size (P < .0001) and higher clinical stage (P < .001). At multivariable analysis for complications, the only significant difference was found for lower risk of major postoperative complications for laparoscopic RN compared to open RN (OR: 0.42; P = .04). The rate of significant (>25%) decrease of eGFR in PN and RN was 18% versus 59% at 1 month, and 23% versus 65% at 6 months (P < .0001). After a median follow-up time of 39 months, 161 patients (31%) died, of whom 105 (20%) due to renal cancer. CONCLUSION: In this patient population both RN and PN carry a non-negligible risk of complications. When surgical removal is indicated, PN should be preferred, whenever technically feasible, as it can offer better preservation of renal function, without increasing the risk of complications. Moreover, a minimally invasive approach should be pursued, as it can translate into lower surgical morbidity.

Laparoscopic Pyelolithotomy for treating urolithiasis in ectopic pelvic kidneys

ABSTRACT Introduction: The management of urolithiasis ectopic pelvic kidneys (EPK) can be challenging because of the aberrant anatomy (1-4). We demonstrate the step-by-step technique of the laparoscopic approach for treating urolithiasis in EPK. Patients and methods: Three men with EPK (2 left, 1 right) underwent laparoscopic pyelolithotomy through a transperitoneal approach. After establishing the pneumoperitoneum, the parietal peritoneum was opened at the parietal colic sulcus and the bowel displaced medially. The kidney was identified in the retroperitoneum and the renal pelvis exposed after removal of the perirenal adipose tissue. The renal pelvis was opened, and the stones were identified and retrieved with forceps in 2 cases and with a flexible nephroscope in 1 case. The renal pelvis was closed with a 3/0 running barbed suture. A DJ stent was placed in all patients. Results: For the first time, a laparoscopic technique for treating stones in the ectopic kidney is demonstrated in detail. Mean patient age was 52.6 years (44-58). The mean stone size was 22.3 mm (20-24 mm). Stones were in the renal pelvis in 2 cases and in the inferior calyx in 1 case. Mean operative time was 146 minutes (135-155 min). Mean estimated blood loss was 116 ml (60-140 ml). No complications were observed. The mean hospital stay was 3 days. The DJ stents were removed after 3 weeks. All patients were stone free at the postoperative CT scan with a mean follow-up of 3.3 months (1-6 months). Conclusions: Laparoscopic pyelolithotomy can be an effective and reproducible minimally invasive technique for treating urolithiasis in EPK.

Does topical hemostatic agent (Floseal®) have a long-term adverse effect on erectile function recovery after nerve-sparing robot-assisted radical prostatectomy?

OBJECTIVES: To investigate the long-term effects of Floseal® on erectile function recovery (EFR) after nerve-sparing robot-assisted radical prostatectomy (RALP). METHODS: We prospectively collected results of the self-administered International Index Erectile Function Questionnaire 1-5 and 15 (IIEF 1-5 and 15) of 532 consecutive patients who underwent RALP for prostate cancer in our institution between October 2007 and December 2015. Patients were divided into two groups according to Floseal® application after prostatectomy. They were enrolled according to the following criteria: (a) bilateral nerve-sparing procedure; (b) preoperative IIEF ≥ 17; adherence to our erectile rehabilitation protocol; (c) 1-year follow-up. Outcomes were measured as mean IIEF score, EFR (IIEF < 17 or ≥17), grade of ED: severe (IIEF < 17), moderate (17-21), mild (22-25) and no ED (>25). RESULTS: A total of 120 patients were enrolled. Group A included 40 consecutive patients who received traditional hemostasis, and Group B included 80 consecutive patients in which Floseal® was additionally used. No differences were observed in terms of preoperative mean IIEF score (p = 0.65). Group B patients showed a trend toward a higher mean IIEF score 3 months after surgery (p = 0.06) but no differences in terms of EFR (p = 1.000). Long-term results (6, 9, 12 months after surgery) showed a significantly and progressively higher mean IIEF score (p = 0.04, 0.003, 0.003) and EFR (p = 0.043, 0.027, 0.004) in Group A patients. Comparison between the groups in terms of severe, moderate, mild and no ED becomes significant at 9 and 12 months (p = 0.002, 0.006). CONCLUSION: The results of our study suggest that local use of Floseal® worsens the long-term erectile function recovery in patients selected for nerve-sparing RALP.

Value of triphasic MDCT in the differentiation of small renal cell carcinoma and oncocytoma.

INTRODUCTION: Although differentiation between benign and malignant small renal tumors (≤4 cm) is still difficult, it is a demand for decision making and determining the treatment strategy. Our aim is to evaluate the role of multidetector row computed tomography (MDCT) in the differentiation of small renal clear cell carcinoma (RCC) and renal oncocytoma (RO). METHODS: We reviewed triphasic computed tomographic (CT) scans performed in 43 patients diagnosed with RCC (n = 23) and RO (n = 21). After an unenhanced CT phase of the upper abdomen, triple-phase acquisition included a cortico-medullary phase (CMP), a nephrographic phase (NP), and a pyelographic phase (PP), and lesions were evaluated both qualitatively and quantitatively. RESULTS: RCCs were hypervascular in 13 cases and hypovascular in 10 cases, while ROs were hypervascular in nine cases and hypovascular in 12 cases. Mean attenuation values (MAVs) for hypervascular RCCs and hypervascular ROs on unenhanced examination were 34.0 ± 7.1 and 31.3 ± 8.1 HU, respectively. Enhancement in CMP was 173.1 ± 45.2 HU for RCCs and 151.1 ± 36.0 HU for ROs and a gradual wash-out in NP (148.8 ± 34.3 and 137.1 ± 33.9 HU for RCCs and ROs, respectively) and in PP (98.2 ± 36.0 HU for RCCs and 79.4 ± 21.5 HU for ROs) was observed. MAV for hypovascular RCCs and hypovascular ROs on unenhanced examination were 32.4 ± 12.0 and 28.9 ± 8.0 HU, respectively. Both hypovascular RCCs and ROs showed a statistically significant difference in each post contrastographic phase. CONCLUSIONS: Absolute attenuation and the quantitative amount of the enhancement were not strong predictors for RO and RCC differentiation.