Icarifil® in Association with Daily Use of Tadalafil (5 mg) versus Standard Tadalafil Daily Dose (5 mg) or Alone: Results from a Controlled, Randomized Clinical Trial.

Background: The management of erectile dysfunction (ED) shows several grey zones and new treatments are required to reduce the percentage of patients discontinuing treatment. Here, we aim to evaluate the role of a natural mixture named Icarifil® (L-Citrulline, L-Carnitine, Eruca vesicaria, Panax ginseng, Tribulus terrestris, Turnera diffusa, Taurine, Vitamin E, Zinc) in the management of patients with ED. Methods: From September 2022 to March 2023, all patients attending 3 urological institutions due to ED were randomized to receive the following for 3 months: Icarifil® 1 sachet every 24 h (Group 1) or Icarifil® 1 sachet + tadalafil 5 mg 1 tablet every 24 h (Group 2) or tadalafil 5 mg 1 tablet daily (Group 3). All patients underwent urologic visits and dedicated questionnaires (IIEF-5, SEP-2, SEP-3) at enrollment and at the follow-up evaluation (3 months). Patient-Reported Outcomes (PROs) at the follow-up evaluation were used. The primary endpoint was the difference in the questionnaires at the follow-up visit compared to the one at enrollment among the study groups. Results: In the per-protocol analysis, 52 patients in Group 1, 55 in Group 2 and 57 in Group 3 were analyzed. At the follow-up evaluation, IIEF-5 scores improved in all the 3 groups between enrollment and the follow-up evaluation, but a statistically significant difference was reported between Group 2 (+7.4) and Group 1 (+4.1) or Group 3 (+5.1), (p < 0.001; p < 0.001). Moreover, 47 patients (94.0%) in Group 2 showed an improvement in the SEP questionnaires, when compared with the baseline, while 29 in Group 1 (56.9%) and 42 in Group 3 (82.3%) showed a statistically significant difference (p = 0.004; p = 0.003) among the groups. The PRO analysis reported better efficacy and patient satisfaction in Group 2 when compared with Group 1 or Group 3. Conclusions: In conclusion, Icarifil® is able to improve penile erectile function in mild-moderate ED and significantly improve the clinical efficacy of daily used tadalafil 5 mg. Icarifil® could represent an interesting alternative treatment in patients experiencing adverse effects or with contraindications for chronic treatment with PDE5-is.

Phytotherapy Might Have a Role in Reducing Unnecessary Prostate Biopsies: Results from an Exploratory, Randomized Controlled Trial of Two Different Phytotherapeutic Agents.

BACKGROUND: We aimed to evaluate the impact of two different phytotherapeutic agents on decision making regarding prostate biopsy for patients with higher-than-normal prostate-specific antigen (PSA) levels. METHODS: From June 2022 to May 2023, all patients attending two urological institutions due to higher-than-normal PSA levels were randomized to receive either oral capsules of Curcuma Longa, Boswellia, Pinus pinaster and Urtica dioica (Group A) or Serenoa Repens 320 mg (Group B) for 3 months. At the follow-up visit after 3 months, all patients underwent PSA tests and multiparametric magnetic resonance imaging (mpMRI). RESULTS: In the per-protocol analysis, data from 66 patients in Group A and 76 in Group B were analyzed. Fifty patients in Group A (75.7%) showed a significant reduction in total PSA compared to forty-nine in Group B (64.4%) (p < 0.001). Twenty-eight patients had PI-RADS III or higher in mpMRI: twelve in Group A and fourteen in Group B. Twenty-three patients (34.8%) in Group A and fifty-nine (77.6%) in Group B (p < 0.001) underwent prostate biopsy based on the mpMRI findings and PSA values. Three patients in Group A showed a significant reduction in total PSA values while having positive mpMRI findings (6%) compared with nine in Group B (19.5%) (p < 0.001). On the contrary, 7 patients in Group A did not show significant reduction in total PSA values and had negative mpMRI findings (43%) compared to 22 in Group B (81.4%) (p < 0.001). CONCLUSIONS: In conclusion, a three-month course of a combination of Curcuma Longa, Boswellia, Pinus pinaster and Urtica dioica seems to be an interesting tool to avoid unnecessary prostate biopsies among men with higher-than-normal PSA levels.

Plication surgery does not produce additional loss of length in Peyronie's disease patients.

Nesbit's procedure remains a cornerstone in surgical management of Peyronie's disease, despite the subjective loss of penile length. This retrospective study demonstrates that the perceived length loss has already occurred prior to surgery and that the Nesbit's procedure does not produce additional loss of length. Ninety-one patients who had undergone Nesbit's procedure between 2017 and 2022 at the Department of Urology of the University of Trieste were enrolled in the study. Preoperative stretched penile length and postoperative stretched penile length were measured. The curvature was uniplanar in 78 patients and biplanar in the remainder. Mean degree of the main curvature was 52.58° ± 14.13° and mean number of plications was 2.42 ± 1.07. Analysis revealed that the median of the differences between preoperative stretched penile length and postoperative stretched penile length was not significant (p = 0.466). According to our results, no significant penile shortening occurs as immediate consequence of Nesbit's procedure, as length is defined by the shorter side of the shaft affected by Peyronie's disease. Hence the length loss should have to be attributed to Peyronie's disease itself and could have been accurately predicted preoperatively allowing for a more accurate counseling of patients. Further studies are pending to assess potential postoperative loss of length due to scarring contracture.

Advanced Age Impacts Survival After Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma.

INTRODUCTION: Upper tract urothelial carcinoma is rare but has a poor prognosis. Prognostic factors have been extensively studied in order to provide the best possible management for patients. We have aimed to investigate commonly available factors predictive of recurrence and survival in this patient population at high risk of death and recurrence, with an emphasis on the effects of age (using a cutoff of 70 years) on survival outcomes. PATIENTS AND METHODS: From 1387 patients with clinically nonmetastatic upper tract urothelial carcinoma treated with radical nephroureterectomy at 21 academic hospital centers between 2005 and 2021, 776 patients were eligible and included in the study. Univariable and multivariable Cox regression models were built to evaluate the independent prognosticators for intravesical and extravesical recurrence, overall survival, and cancer-specific survival according to age groups. A P value of <.05 was considered statistically significant. RESULTS: We did not find an association between groups aged <70 and >70 years old and preoperatively clinical or histopathological characteristics. Kaplan-Meier analysis was found no statistical significance between the 2 age groups in terms of intravesical or extravesical recurrence (P = .09 and P = .57). Overall survival (P = .0001) and cancer-specific survival (P = .0001) have been found to be statistically significantly associated with age as independent predictors (confounding factors: gender, tumor size, tumor side, clinical T stage, localization, preoperative hydronephrosis, tumor localization, type of surgery, multifocality of the tumor, pathological grade, lymphovascular invasion, concomitant CIS, lymph node status, necrosis, or history of previous bladder cancer). CONCLUSION: This research confirms that patients aged 70 and above who undergo radical nephroureterectomy may have worse outcomes compared to younger patients, older patients needing an improved care and management of UTUC to improve their outcomes in the setting of an increase in this aged population group.

Fluorescence Confocal Microscopy in Urological Malignancies: Current Applications and Future Perspectives.

Fluorescence confocal microscopy (FCM) represents a novel diagnostic technique able to provide real-time histological images from non-fixed specimens. As a consequence of its recent developments, FCM is gaining growing popularity in urological practice. Nevertheless, evidence is still sparse, and, at the moment, its applications are heterogeneous. We performed a narrative review of the current literature on this topic. Papers were selected from the Pubmed, Embase, and Medline archives. We focused on FCM applications in prostate cancer (PCa), urothelial carcinoma (UC), and renal cell carcinoma (RCC). Articles investigating both office and intraoperative settings were included. The review of the literature showed that FCM displays promising accuracy as compared to conventional histopathology. These results represent significant steps along the path of FCM's formal validation as an innovative ready-to-use diagnostic support in urological practice. Instant access to a reliable histological evaluation may indeed significantly influence physicians' decision-making process. In this regard, FCM addresses this still unmet clinical need and introduces intriguing perspectives into future diagnostic pathways. Further studies are required to thoroughly assess the whole potential of this technique.

Validation of the Italian version of the Peyronie's Disease Questionnaire (PDQ).

Peyronie's disease (PD) is a connective tissue disorder characterized by the formation of fibrous plaques in the tunica albuginea of the penis which can result in pain, deformity and erectile dysfunction (ED). The Peyronie's Disease Questionnaire (PDQ) assesses the severity of symptoms, including pain, penile curvature and ED, as well as the impact on sexual function, emotional well-being, and overall quality of life of PD patients. Previous studies validated the PDQ in languages other than English and confirmed its test-retest reliability and clinical utility. Despite this, in many countries the unavailability of an adequate PDQ validation in native language hampers its use in clinical practice. In the present non-interventional, observational study we aimed at validating the Italian version of the PDQ (PDQ-I). Between January 2019 and November 2021, 79 PD patients from 6 Italian high-volume centers were administrated the PDQ-I in two separated office visits distanced by a period of 6 months. Intraclass correlation coefficients (ICCs) were used to evaluate the association between the three PDQ scale scores at visit 1 and 2. Paired t-tests were used to evaluate significant score changes between the 2 visits. Cronbach's alpha was used to assess internal consistency reliability. PDQ-I demonstrated an excellent test-retest reliability in the Italian population (ICC 0.78-0.92) as well as a strong internal consistency, with all three scale scores showing a Cronbach's alpha coefficient above 0.70. PDQ-I proved to be a useful tool which allows to reliably evaluate Italian PD patients' quality of life in both everyday andrological practice and clinical research. External validation of our results is pending.

Penile revascularization using the descending branch of the lateral circumflex femoral artery: An alternative vascular graft.

INTRODUCTION AND RELEVANCE: Microsurgical revascularization stands as the preferred method for addressing erectile dysfunction (ED) resulting from traumatic penile arterial insufficiency. Traditional microarterial bypass surgery (MABS) techniques have typically relied on utilizing the inferior epigastric artery (IEA) as the graft vessel. However, issues such as endothelial dysfunction in the vessel and alterations in abdominal tissue can negatively impact surgical outcomes. MABS using the descending branch of the lateral circumflex artery of the femur (DLCFA) should be proposed as a surgical option for penile arterial revascularization. CASE PRESENTATION: A 29-year-old who experienced ED after a pelvic bone fracture with hypogastric vascular injury was referred to our center. Preoperatory penile Doppler ultrasound (PDU) examination documented the presence of arterial insufficiency. Selective hypogastric angiography pointed out the interruption of arterial blood flow at the level of the distal right internal pudendal artery. CASE DISCUSSION: Access to the dorsal penile artery was gained through an infrapubic incision, the DLCFA pedicle was isolated through an incision along the anterolateral right thigh. After its transposition, the arterial bundle was anastomosed to the dorsal penile artery in an end-to-end fashion. Intraoperative PDU has been used to verify the patency of the anastomosis. At 6 months follow-up, optimal flow parameters on PDU were persistently registered, and the patient had consistent clinical improvement on the IIEF-5 score. CONCLUSION: DLCFA grafting for penile revascularization is a suitable therapeutic option in traumatic ED due to its size and accessibility. Further experience is necessary to compare clinical outcomes among different revascularization techniques.

Neoclitoral location may affect sexual function in transgender women: a preliminary pelvic MRI study.

Assigned female at birth with anorgasmia possess a smaller clitoral glans and clitoral components farther from the vagina lumen than women with normal orgasmic function. There are no studies evaluating this correlation in operated transgender women. We evaluated whether differences in MRI measurements of neoclitoris volume and distance between the neoclitoris and the neovagina were correlated with differences in sexual function. We recruited for a prospective survey study 40 operated male to female patients (oMtF) who had undergone genital gender affirming surgery and postoperative pelvic MRI. Individual pelvic MRIs were reviewed by two blinded investigators, the three axes of the neoclitoris were measured and the volume was calculated using the ellipsoid formula. The distance between the neoclitoris and the neovagina was also measured. Sexual functioning was assessed using the Female Sexual Function Index (FSFI) and the operated Male to Female Sexual Function Index (oMtFSFI). Mean scores differences in FSFI, oMtFSFI were examined; associations with clitoral size, location, sexual functioning and demographical variables were investigated as well. The response rate was 55%, 11 MtFs operated with pubic neoclitoris technique (PNT) and 11 with neo-urethroclitoroplasty according to Petrovic (NCP). The NCP group presented a neoclitoris mean volume of 1.04 (SD 0.39) cc vs 1.31 (SD 0.78) cc of the other group (p = 0.55). The mean distance between neoclitoris and neovagina was 4.20 (SD 0.57) cm in the PNT group and 2.55 (SD 0.45) in the NCP group (p < 0.001). Patients who had undergone NCP achieved a higher FSFI and oMtFSFI mean Total Score than those operated with the previous technique (FSFI 25.81 SD 3.02 vs 18.62 SD 9.92 p = 0.08; oMtFSFI 37.63 SD 8.28 vs 43.36 SD 13.02 p = 0.23). According to pelvic MRI measurements, this study suggests a correlation between neoclitoral location and oMtF sexual satisfaction.

The Utility of Inflammatory Serum Markers in the Assessment of Perioperative Morbidity after Radical Cystectomy for Bladder Cancer.

Background and Objectives: To date, sparse evidence exists about the impact of inflammatory serum markers in predicting perioperative complications after radical cystectomy (RC) for bladder cancer (BC). Here, we evaluated the role of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), systemic immune-inflammation index (SII), C-reactive protein (CRP), and plasma fibrinogen in predicting perioperative morbidity and unplanned 30-days readmission after RC for BC. Materials and methods: We relied on a collaborative database of 271 patients who underwent open RC for cT1-4a N0 M0 BC between January 2012 and December 2022. Univariable and multivariable binomial logistic regression analyses were performed to assess the odds ratio (OR) with 95% confidence intervals (CI) testing the ability of each serum marker to predict postoperative complications (any-grade and major complications), and 30-days unplanned readmission. Results: The median age at RC was 73 yr (IQR 67-79). A total of 182 (67.2%) patients were male and the median BMI was 25.2 (IQR 23.2-28.4). Overall, 172 (63.5%) patients had a Charlson Comorbidity Index (CCI) greater than 2 points and 98 (36.2%) were current smokers at the time of RC. Overall, 233 (86.0%) patients experienced at least one complication after RC. Of these, 171 (63.1%) patients had minor complications (Clavien-Dindo grade 1-2) while 100 (36.9%) experienced major complications (Clavien-Dindo grade ≥ 3). According to multivariable analysis, current smoking status, high plasma fibrinogen, and preoperative anemia were independently associated with major complications (OR 2.10, 95%CI 1.15-4.90, p = 0.02), (OR 1.51, 95%CI 1.26-1.98, p = 0.09), and (OR 1.35, 95%CI 1.17-2.57, p = 0.03), respectively. Overall, 56 (20.7%) patients experienced a 30-days unplanned readmission. According to univariable analysis, high preoperative CRP and hyperfibrinogenemia were significantly associated with an increased risk of unplanned readmission (OR 2.15, 95%CI 1.15-4.16, p = 0.02; OR 2.18, 95%CI 1.13-4.44, p = 0.02, respectively). Conclusions: In our study, the preoperative immune-inflammation signature described by NLR, PLR, LMR, SII, and CRP showed a low reliability in predicting perioperative course after RC. Preoperative anemia and hyperfibrinogenemia were independent predictors of major complications. Further studies are pending in order to draw definitive conclusions.

Intraoperative ventilatory leak: Real-time guidance for management of air leak in lung cancer patients undergoing VATS lobectomy.

BACKGROUND: Persistent air leak (PAL) is a common complication after video-assisted thoracoscopic surgery (VATS) lobectomy. We aimed to evaluate whether the intraoperative quantitative measurement of air leaks using a mechanical ventilation test could predict PAL and identify those patients needing additional treatment for the prevention of PAL. METHODS: This was an observational, retrospective, single-center study that included 82 patients who underwent VATS lobectomy with a mechanical ventilation test for VL. Only 2% of patients who underwent lobectomy surgery had persistent air leaks. RESULTS: At the end of lobectomy performed in patients with non-small cell lung cancer, the lung was reinflated at a 25-30 mmH2O pressure and ventilatory leaks (VL) were calculated and in relation to the entity of the air leaks, we evaluated the most suitable intraoperative treatment to prevent persistent air leaks. CONCLUSION: VL is an independent predictor of PAL after VATS lobectomy; it provides a real-time intraoperative guidance to identify those patients who can benefit from additional intraoperative preventive interventions to reduce PAL.

Artificial Intelligence Can Guide Antibiotic Choice in Recurrent UTIs and Become an Important Aid to Improve Antimicrobial Stewardship.

BACKGROUND: A correct approach to recurrent urinary tract infections (rUTIs) is an important pillar of antimicrobial stewardship. We aim to define an Artificial Neural Network (ANN) for predicting the clinical efficacy of the empiric antimicrobial treatment in women with rUTIs. METHODS: We extracted clinical and microbiological data from 1043 women. We trained an ANN on 725 patients and validated it on 318. RESULTS: The ANN showed a sensitivity of 87.8% and specificity of 97.3% in predicting the clinical efficacy of empirical therapy. The previous use of fluoroquinolones (HR = 4.23; p = 0.008) and cephalosporins (HR = 2.81; p = 0.003) as well as the presence of Escherichia coli with resistance against cotrimoxazole (HR = 3.54; p = 0.001) have been identified as the most important variables affecting the ANN output decision predicting the fluoroquinolones-based therapy failure. A previous isolation of Escherichia coli with resistance against fosfomycin (HR = 2.67; p = 0.001) and amoxicillin-clavulanic acid (HR = 1.94; p = 0.001) seems to be the most influential variable affecting the output decision predicting the cephalosporins- and cotrimoxazole-based therapy failure. The previously mentioned Escherichia coli with resistance against cotrimoxazole (HR = 2.35; p < 0.001) and amoxicillin-clavulanic acid (HR = 3.41; p = 0.007) seems to be the most influential variable affecting the output decision predicting the fosfomycin-based therapy failure. CONCLUSIONS: ANNs seem to be an interesting tool to guide the antimicrobial choice in the management of rUTIs at the point of care.

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.

Impact of the controlling nutritional status (CONUT) score on perioperative morbidity and oncological outcomes in patients with bladder cancer treated with radical cystectomy.

INTRODUCTION AND OBJECTIVES: To evaluate the impact of the Controlling Nutritional Status (CONUT) score on perioperative morbidity and oncological outcomes of bladder cancer (BC) patients treated with radical cystectomy (RC). MATERIALS AND METHODS: We retrospectively analyzed a multi-institutional cohort of 347 patients treated with RC for clinical-localized BC between 2005 and 2019. The CONUT-score was defined as an algorithm including serum albumin, total lymphocyte count, and cholesterol. Multivariable logistic regression analyses were performed to evaluate the ability of the CONUT-score to predict any-grade complications, major complications and 30 days readmission. Multivariable Cox' regression models were performed to evaluate the prognostic effect of the CONUT-score on recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS). RESULTS: A cut-off value to discriminate between low and high CONUT-score was determined by calculating the receiver operating characteristic (ROC) curve. The area under the curve was 0.72 hence high CONUT-score was defined as ≥3 points. Overall, 112 (32.3%) patients had a high CONUT. At multivariable logistic regression analyses, high CONUT was associated with any-grade complications (OR 3.58, P = 0.001), major complications (OR 2.56, P = 0.003) and 30 days readmission (OR 2.39, P = 0.01). On multivariable Cox' regression analyses, high CONUT remained associated with worse RFS (HR 2.57, P < 0.001), OS (HR 2.37, P < 0.001) and CSS (HR 3.52, P < 0.001). CONCLUSIONS: Poor nutritional status measured by the CONUT-score is independently associated with a poorer postoperative course after RC and is predictive of worse RFS, OS, and CSS. This simple index could serve as a comprehensive personalized risk-stratification tool identifying patients who may benefit from an intensified regimen of supportive cares.

Penile prosthesis impending erosion: Surgical technique for extracapsular re-implantation reconstruction.

INTRODUCTION AND OBJECTIVES: Impending erosion is an unusual complication of inflatable penile prosthesis that can strongly impact on patient's morbidity and quality of life. In this case report we present a salvage surgery technique for impending erosion performed in a 57-year-old man. MATERIALS AND METHODS: We present our surgical technique for cylinder reimplantation in an impending erosion of a three-component inflatable prosthesis with a peno-scrotal access and extracapsular reseating of the cylinder. RESULTS: No post-operative complication occurred, and the patient regained full function of the prosthesis after recovery. The surgical site healed well with no signs of infections. CONCLUSIONS: Impending erosion is a problematic complication of penile prosthesis; however, can be administered with a salvage technique avoiding the explant of the IPP.

One-lung ventilation in obese patients undergoing thoracoscopic lobectomy for lung cancer.

BACKGROUND: We evaluated the safety and feasibility of one-lung ventilation in obese patients undergoing thoracoscopic lobectomy and whether obesity affected peri- and postoperative outcomes. METHODS: This was a retrospective single center study including consecutive patients undergoing thoracoscopic lobectomy between October 2019 and February 2022. Obese patients were statistically compared to a control group to evaluate any differences in relation to one-lung ventilation and peri- and postoperative outcomes. RESULTS: Our study population included 111 patients; of these, 26 (23%) were included in the obese group, while 85 (77%) were included within the nonobese group. To obtain one-lung ventilation in nonobese patients, a double-lumen tube was more frequently used than a single-lumen tube with bronchial blocker (61% vs. 39%; p = 0.02), while in obese patients a single-lumen tube with bronchial blocker was used more than a double-lumen tube (81% vs. 19%, p = 0.001). Intergroup comparison showed that a double-lumen tube was the preferred method in nonobese patients, while a single-lumen tube with bronchial blockers was the strategy of choice in obese patients (p = 0.0002). Intubation time was longer in the obese group than in the nonobese group (94.0 ± 6.1 vs. 85.0 ± 7.0 s; p = 0.0004) and failure rate of first attempt at intubation was higher in the obese group (23% vs. 5%; p = 0.01). Obesity was not associated with increased intra-, peri- and postoperative complications and/or mortality. CONCLUSIONS: One-lung ventilation is a feasible and safe procedure also in obese patients and obesity did not negatively affect peri- and postoperative outcomes after lung resection.

Radical cystectomy and orthotopic neobladder in a patient with a preexisting three-components inflatable penile prosthesis.

INTRODUCTION AND OBJECTIVES: As erectile dysfunction is more commonly being diagnosed and treated with a preexisting inflatable penile prosthesis (IPP) insertion at younger ages, surgeons will increasingly encounter pre-placed abdominal reservoirs when performing pelvic surgery. MATERIALS AND METHODS: A 69-year-old Caucasian man with BCG refractory carcinoma-in-situ (CIS) and past history of non-invasive high-grade urothelial carcinoma of the bladder was a candidate for a radical cystectomy and an ileal-neobladder diversion. He had a three-components IPP inserted for the treatment of Peyronie disease and organic erectile dysfunction (ED). During the radical cystectomy the reservoir was encapsulated on the left lateral pelvic wall over the external iliac vessels. It was isolated and IPP was inflated to reduce the reservoir size. After accurate disinfection, the reservoir was removed from Retzius space without disconnecting it from the pump. Then, the radical cystectomy was carried out without any intraoperative complications and Studer ileal orthotopic neobladder was performed. At the end of the surgery, the reservoir was disinfected with the Mulcahy protocol and then placed in the same position. RESULTS: A week after catheter removal the IPP was successfully activated. The patient's postoperative recovery was uneventful and no postoperative complication occurred. Definitive histological examination described a multifocal urothelial carcinoma of the bladder: pG3Tis N0 R0. The patient reports excellent functionality of the penile prosthesis and is currently using it. CONCLUSIONS: Sexual functionality preservation in oncologic patients should be pursued when possible. In this report, the functionality of the IPP was preserved, while still performing oncologically radical procedures. A multicenter study is needed to assure more solid recommendations on this rare procedure that is surely burdened by a lot of risks.

A Proposal of a New Nomogram to Predict the Need for Testosterone ReplACEment (TRACE): A Simple Tool for Everyday Clinical Practice.

International guidelines suggest to use testosterone therapy (TTh) in hypogonadal men presenting symptoms of testosterone deficiency (TD), even if there is no fixed threshold level of T at which TTh should be started. We aimed to develop and validate a nomogram named TRACE (Testosterone ReplACEment) for predicting the need of TTh in patients with "low-normal" total testosterone levels. The following nomogram variables were used: serum T level; serum LH level; BMI; state of nocturnal erections; metabolic comorbidities; and IPSS total score. The nomogram has been tested by calculating concordance probabilities, as well as assaying the calibration of predicted probability of clinical testosterone deficiency and need for TTh, together with the clinical outcome of the TTh. A cohort of 141 patients was used for the development of the nomogram, while a cohort of 123 patients attending another institution was used to externally validate and calibrate it. Sixty-four patients (45.3%) received TTh. Among them, sixty patients (93.7%) reported a significant clinical improvement after TTh. The nomogram had a concordance index of 0.83 [area under the ROC curve 0.81 (95% CI 0.71-0.83)]. In conclusion, the TRACE nomogram accurately predicted the probability of clinical impairment related to TD, and resulted in a simple and reliable method to use to select hypogonadal patients with not clearly pathological testosterone values who will benefit from TTh.