Ejaculatory function following transperineal laser ablation vs TURP for benign prostatic obstruction: a randomized trial.

OBJECTIVES: To evaluate the reliability of transperineal interstitial laser ablation of the prostate (TPLA) in preserving antegrade ejaculation compared to transurethral resection of the prostate (TURP). PATIENTS AND METHODS: In this single-centre, prospective, randomized, open-label study, consecutive patients with indication for surgical treatment for benign prostatic obstruction (BPO) were enrolled between January 2020 and September 2021 (NCT04781049). Patients were randomized to one of two treatment arms: Group A: TPLA (experimental group) and Group B: TURP (reference standard group). The primary endpoint was change in ejaculatory function (assessed by the Male Sexual Health Questionnaire - Ejaculatory function domain [EJ-MSHQ]) at 1 month after surgery. Secondary endpoints included comparison of visual analogue scale (VAS) scores, changes in sexual function (assessed using the five-item International Index of Erectile Function [IIEF-5]), change in International Prostate Symptom Score [IPSS], change in quality of life score, and maximum urinary flow rate [Qmax ] improvement at 1-6 months, as appropriate. RESULTS: Fifty-one patients (26 TPLA vs 25 TURP) were analysed. No differences in the perception of pain assessed by VAS and no differences in IIEF-5 score were found between the groups. The distribution of ejaculatory function assessed by the EJ-MSHQ remained unmodified after TPLA (P = 0.2), while a median 30% decrease in EJ-MSHQ score was observed after TURP (P = 0.01). Absence of antegrade ejaculation was reported in one patient in the TPLA group (vs 18 patients in the TURP group). A statistically significant difference between the treatment groups was found in terms of postoperative Qmax (TPLA vs TURP: 15.2 [interquartile range 13.5-18.3] mL/s vs 26.0 [interquartile range 22.0-48.0] mL/s; P < 0.001). Both treatments significantly improved Qmax , with a mean 23.9 mL/s improvement after TURP (95% confidence interval [CI] 17.1-30.7) vs 6.0 mL/s after TPLA (95% CI 5.0-7.0), and IPSS, with a mean decrease of 11.6 (95% CI 9.7-13.5) vs 5.8 after TPLA (95% CI.2-9.6) with respect to baseline. CONCLUSION: In our study, TPLA preserved ejaculatory function in 96% of cases in addition to providing significant relief from BPO.

"Single-Surgeon" versus "Dual-Surgeon" Robot-Assisted Radical Prostatectomy and Pelvic Lymph-nodes Dissection: Comparative Analysis of Perioperative Outcomes.

PURPOSE: To compare the perioperative outcomes of robot-assisted radical prostatectomy (RARP) with pelvic lymph-nodes dissection (PLND) when the same surgeon performs RARP and PLND versus one surgeon performs RARP and another surgeon performs PLND. MATERIALS AND METHODS: From January 2022 to March 2023, data of consecutive patients who underwent RARP with PLND were prospectively collected. The surgeries were performed by two "young" surgeons with detailed profile. Specifically for the study purpose, one surgeon performed RARP, and the other surgeon performed PLND. A set of surgeries performed according to the standard setup (i.e., the same surgeon performing both RARP and PLND) was retrieved from the institutional database and used as comparator arm. To test the study hypothesis, patients were divided into two groups: "dual-surgeon" versus "single-surgeon". RESULTS: Fifty patients underwent RARP and PLND performed according to dual-surgeon setup and were compared to the last 50 procedures performed according to the standard single-surgeon setup. Patients in the groups had comparable baseline characteristics. Dual-surgeon interventions had significantly shorter median total operative (194 [IQR 178-215] versus 174 [IQR 146-195] minutes, p<0.001) and console time (173 [IQR 158-194] versus 154 [IQR 129-170] minutes, p<0.001). No significant differences were found in terms of blood loss, intraoperative complications, postoperative outcomes, and final pathology results. CONCLUSIONS: The present analysis found that when RARP and PLND are split onto two surgeons, the operative time is shorter by 20 minutes compared to when a single surgeon performs RARP and PLND. This is an interesting finding that could sponsor further studies.

The efficacy of a suppository based on Phenolmicin P3 and Bosexil (Mictalase®) in control of irritative symptoms in patients undergoing thulium laser enucleation of prostate: a single-center, randomized, controlled, open label, phase III study.

BACKGROUND: Several studies described post-operative irritative symptoms after laser enucleation of prostate, sometimes associated with urge incontinence, probably linked to laser-induced prostatic capsule irritation, and potential for lower urinary tract infections We aimed to evaluate the efficacy of a suppository based on Phenolmicin P3 and Bosexil (Mictalase®) in control of irritative symptoms in patients undergoing thulium laser enucleation of prostate (ThuLEP). METHODS: In this single-center, prospective, randomized, open label, phase-III study, patients with indication to ThuLEP were enrolled (Dec2019-Feb2021-Institutional ethics committee STS CE Lazio approval no.1/N-726-ClinicalTrials.gov NCT05130918). The report conformed to CONSORT 2010 guidelines. Eligible patients were 1:1 randomized. Randomization defined Group A: patients who were administered Mictalase® suppositories twice a day for 5 days, then once a day for other 10 days; Group B: patients who did not receive Mictalase® ("controls"). Study endpoints were evaluated at 15 and 30 days postoperation. Primary endpoint included evaluation of effects of the suppository on irritative symptoms by administering IPSS + QoL questionnaire. Secondary endpoint included evaluation of effects on urinary tract infections by performance of urinalysis with urine culture. RESULTS: 111 patients were randomized: 56 in Group A received Mictalase®. Baseline and perioperative data were comparable. At 15-days, no significant differences were found in terms of IPSS + QoL scores and urinalysis parameters. A significant difference in the rate of positive urine cultures favored Group A (p = 0.04). At 30-days follow-up, significant differences were found in median IPSS score (6 [IQR 3-11] versus 10 [5-13], Group A vs B, respectively, p = 0.02). Urinalysis parameters and rate of positive urine cultures were not significantly different. CONCLUSIONS: The present randomized trial investigated the efficacy of Mictalase® in control of irritative symptoms and prevention of lower urinary tract infections in patients undergoing ThuLEP. IPSS improvement 30-days postoperation was more pronounced in patients who received Mictalase®. Lower rate of positive urine culture favored Mictalase® group 15-days postoperatively. TRIAL REGISTRATION: The clinical trial has been registered on ClinicalTrials.gov on November 23rd, 2021-Registration number NCT05130918.

Urethral and bladder neck stenosis after thulium laser enucleation of the prostate: Analysis of risk factors in a series of 1003 patients.

We assessed the incidence and risks factors of bladder neck and urethral stenosis after Thulium laser enucleation of the prostate. Patients who underwent surgery at two centres were retrospectively reviewed (December 2014-June 2020). Exclusion criteria: previous urethral/prostatic surgery, pelvic irradiation, prostate cancer, neurogenic bladder, history of bladder neck and urethral stenosis, concomitant transurethral surgery, active urinary tract infection. Significant variables at univariate analysis (p < 0.05) were included in a multivariate logistic regression analysis to establish their association with bladder neck/urethral stenosis. One thousand and three patients were included. Median age was 69.0 (63.0-75.0) years. Median prostate volume was 65.0 (46.3-82.0) ml. Median follow-up was 31 (25-75) months. Thirty patients (2.99%) developed bladder neck stenosis [median time after surgery: 15 (11-17.75) months], 50 patients (4.98%) urethral stenosis [median time after surgery: 9 (7-11) months]. Men with bladder neck and urethral stenosis had significantly smaller prostate volume (median volume 43.5 ml vs. 66.0 ml, p = 0.008, and 52.0 ml vs. 66.0 ml, p = 0.009, respectively). At multivariable analysis, short surgical time predicted for bladder neck stenosis (OR 0.973; 95% CI 0.957-0.994, p = 0.002), and re-catheterization (OR 3.956; 95% CI 1.867-8.382, p < 0.001) for urethral stenosis, whereas prostate volume was significantly associated with a lower incidence of US (OR 0.984, 95% CI 0.972-0.998, p = 0.03).

Thulium laser enucleation of prostate versus laparoscopic trans-vesical simple prostatectomy in the treatment of large benign prostatic hyperplasia: head-to-head comparison.

OBJECTIVES: To compare thulium laser enucleation of prostate (ThuLEP) versus laparoscopic trans-vesical simple prostatectomy (LSP) in the treatment of benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Data of patients who underwent surgery for "large" BPH (>80mL) at three Institutions were collected and analyzed. Two institutions performed ThuLEP only; the third institution performed LSP only. Preoperative (indwelling catheter status, prostate volume (PVol), hemoglobin (Hb), Qmax, post-voiding residual volume (PVR), IPSS, QoL, IIEF-5) and perioperative data (operative time, enucleated adenoma, catheterization time, length of stay, Hb-drop, complications) were compared. Functional (Qmax, PVR, %ΔQmax) and patient-reported outcomes (IPSS, QoL, IIEF-5, %ΔIPSS, %ΔQoL) were compared at last follow-up. RESULTS: 80 and 115 patients underwent LSP and ThuLEP, respectively. At baseline, median PVol was 130 versus 120mL, p <0.001; Qmax 9.6 vs. 7.1mL/s, p=0.005; IPSS 21 versus 25, p <0.001. Groups were comparable in terms of intraoperative complications (1 during LSP vs. 3 during ThuLEP) and transfusions (1 per group). Differences in terms of operative time (156 vs. 92 minutes, p <0.001), Hb-drop (-2.5 vs. -0.9g/dL, p <0.001), catheterization time (5 vs. 2 days, p <0.001) and postoperative complications (13.8% vs. 0, p <0.001) favored ThuLEP. At median follow-up of 40 months after LSP versus 30 after ThuLEP (p <0.001), Qmax improved by 226% vs. 205% (p=0.5), IPSS decreased by 88% versus 85% (p=0.9), QoL decreased by 80% with IIEF-5 remaining almost unmodified for both the approaches. CONCLUSIONS: Our analysis showed that LSP and ThuLEP are comparable in relieving from BPO and improving the patient-reported outcomes. Invasiveness of LSP is more significant.

An Italian multicenter analysis of emergency admissions and treatment of upper tract urolithiasis during the lockdown and reopening phases of the COVID-19 pandemic: Are we ready for a second wave of the outbreak?

OBJECTIVES: To assess if the lockdown period (March-April 2020) during the coronavirus disease-19 outbreak in Italy influenced the number, presentation, and treatment of urgent admissions to the emergency department for ureteral lithiasis, and to evaluate the same variables during the reopening phase (May-June 2020). METHODS: We performed a retrospective analysis of patients admitted to the emergency department of three different hospitals (two coronavirus disease-19 hubs). Demographics and data on acute pyelonephritis, acute kidney injury, urinoma, hematuria, inpatient admission/discharge home, and type of treatment were gathered and compared with the same periods in 2019. RESULTS: A total of 516 patients were admitted during the study period, of whom 62.4% were male. Their mean age was 58.86 ± 16.24 years. The number of admissions decreased significantly, by 51.25% (P = 0.003), during lockdown compared to 2019 (78 vs 160 admissions). The number of admissions in the reopening phase (May-June 2020) was in line with that in 2019 (n = 138). The number of hospitalizations (P = 0.005), acute obstructive pyelonephritis (P = 0.019), and complications (P = 0.02) was statistically significantly higher during lockdown compared to 2019. The increase in the rate of surgical procedures nearly reached significance (P = 0.059). The odds of having complications and being hospitalized were almost fivefold (odds ratio 4.68, 95% confidence interval 1.98-11.07) and twofold greater (odds ratio 2.39, 95% confidence interval 1.29-4.43) compared to the same period in 2019. No difference was noted between May-June 2020 and 2019. CONCLUSION: The coronavirus disease-19 lockdown period provoked a meaningful reduction in symptomatic ureteral lithiasis admission. Most patients presented with complicated disease, which required an increased rate of interventional procedures compared to the equivalent period in 2019. Admissions reverted to normal levels during the reopening phase.

Male sexual dysfunction in patients with chronic end-stage renal insufficiency and in renal transplant recipients.

MATERIALS AND METHODS: The study was conducted from December 2011 to December 2012 on 95 patients between the ages of 20 and 65 years: 44 of which had been undergoing dialysis for over a year and 51 of whom had undergone kidney transplants more than 6 months before. Comorbidities were carefully recorded, erectile function was evaluated the with IIEF5 questionnaire and serum levels of total testosterone / free and prolactin were tested at early morning (7 AM). To assess the relationship between erectile dysfunction (ED) and clinical laboratory tests, Student's t-test statistical (quantitative variables), chi-square (qualitative variables), the uni and multivariate analysis were used. RESULTS: In patients undergoing dialysis and in recently transplanted patients a higher instance of ED was found (70% and 65% of cases respectively). Amongst dialyzed patients, patients aged over 50 suffer from ED more frequently. Patients aged over 50s represent 61% of the total number of patients suffering from ED, and just 31% of patients not suffering from ED, (p = 0.006); Hyperprolactinemia was found in 23% and 20% of both groups respectively. Fifty nine % of the dialyzed patients presented values of testosterone serum levels of less than 250 ng/dl with a significant difference between those who were suffering from ED and those who were not (65% of ED patients vs. 46%,of patients not affected from ED p = 0.019). This was found in only 37% of transplanted patients and there does not appear to be a statistically significant correlation with the onset of ED (p = 0.12). In patients over the age of 50, diabetes and a condition of hypotestosteronemia were significantly correlated with ED at univariate and multivariate analyses. CONCLUSIONS: The ED in patients with end stage chronic kidney failure (CKF) continues to have a strong prevalence, either in the patients who are undergoing dialysis or in those who have received transplants. In literature this issue is not sufficiently considered if not at all. Hypotestosteronemia is a risk factor for the onset of ED in end stage CKF patients. A significantly lower prevalence of hypogonadism among dialyzed patents and transplant recipients suggests that renal transplantation may be protective for the sexual capabilities of these patients.

Oral supplementation with probiotics, potassium citrate, and magnesium in reducing crystalluria in stone formers: A phase II study.

INTRODUCTION: Crystalluria is an important indicator of renal stone recurrence. Mechanisms underlying urinary stone formation are still not fully understood and raising interests has been giving to intestinal commensal bacteria for their contribute in maintaining urinary solutes equilibrium. The aim of our phase II study was to examine the administration of potassium citrate, magnesium and probiotics in order to reduce crystalluria. MATERIALS AND METHODS: Since May 2021, we enrolled 23 patients candidates for ureterorenolithotripsy for calcium oxalate kidney stones with crystalluria and a normal metabolic profile. The analysis was validated by the Institution's Ethical Committee (no. approval STS CE Lazio 1/N-823). At discharge, patients were provided with daily food supplementation for 20 days of 1 billion Lactobacillus paracasei LPC09, 1 billion Lactobacillus plantarum LP01, 1 billion Bifidobacterium breve BR03, potassium (520 mg), citrate (1400 mg), and magnesium (80 mg). Crystalluria was re-assessed at 1, 3, 6, and 12-months follow-up by polarized light microscopy. RESULTS: After one month from the oral supplementation, no patient reported crystalluria; at 3 months, among the 20 participants available for re-evaluation, still no patient reported crystalluria. Instead, crystalluria was reported in three patients (15%) at 6 months, and in five patients (25%) at 12 months follow-up. CONCLUSIONS: The oral supplementation with Lactobacillus spp. and Bifidobacterium spp. was found able to reduce the prevalence of crystalluria in a cohort of patients with diagnosis of calcium oxalate kidney stones with crystalluria candidate to ureterorenolithotripsy.

Transperineal Laser Ablation for Focal Therapy of Localized Prostate Cancer: 12-Month Follow-up Outcomes from a Single Prospective Cohort Study.

INTRODUCTION AND OBJECTIVES: To evaluate the oncological and functional outcomes of transperineal laser ablation (TPLA) as the focal therapy for localized prostate cancer (PCa) after a 12-month follow-up. MATERIALS AND METHODS: Patients with low- and intermediate-risk localized PCa were prospectively treated with focal TPLA between July 2021 and December 2022. The inclusion criteria were the following: clinical stage < T2b; PSA < 20 ng/mL; International Society of Urological Pathology (ISUP) grade ≤ 2; MRI-fusion biopsy-confirmed lesion classified as PI-RADS v2.1 ≥ 3. Intra-, peri-, and post-operative data were collected. Variables including age, PSA, prostate volume (PVol), Charlson's Comorbidity Index (CCI), International Prostate Symptom Score (IPSS) with QoL score, International Index of Erectile Function (IIEF-5), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), and Male Sexual Health Questionnaire-Ejaculatory Dysfunction Short Form (MSHQ-EjD) were collected at baseline and at 3, 6 and 12 months after TPLA. Post-operative mpMRI was performed at 3 and 12 months. Finally, all patients underwent prostatic re-biopsy under fusion guidance at 12 months. The success of this technique was defined as no recurrence in the target treated lesion at the 12-month follow up. RESULTS: Twenty-four patients underwent focal TPLA. Baseline features were age [median 67 years (IQR 12)], PSA [5.7 ng/mL (3.9)], PVol [49 mL (27)], CCI [0 (0)], IPSS [11 (9)], IPSS-QoL [2 (2)], IIEF-5 [21 (6)], ICIQ-SF [0 (7)], MSHQ-EjD ejaculation domain [14 (4)] and bother score [0 (2)]. Median operative time was 34 min (IQR 12). Median visual analogue scale (VAS) 6 h after TPLA was 0 (IQR 1). The post-operative course was regular for all patients, who were discharged on the second post-operative day and underwent catheter removal on the seventh post-operative day. No patient had incontinence at catheter removal. A significant reduction in PSA (p = 0.01) and an improvement in IPSS (p = 0.009), IPSS-QoL (p = 0.02) and ICIQ-SF scores (p = 0.04) compared to baseline were observed at the 3-month follow-up. Erectile and ejaculatory functions did not show any significant variation during the follow-up. No intra- and peri-operative complications were recorded. Three Clavien-Dindo post-operative complications were recorded (12%): grade 1 (two cases of urinary retention) and grade 2 (one case of urinary tract infection). At the 12-month follow-up, eight patients showed mpMRI images referable to suspicious recurrent disease (PIRADS v2.1 ≥ 3). After re-biopsy, 7/24 patients' (29%) results were histologically confirmed as PCa, 3 of which were recurrences in the treated lesion (12.5%). The success rate was 87.5%. CONCLUSIONS: The focal TPLA oncological and functional results seemed to be encouraging. TPLA is a safe, painless, and effective technique with a good preservation of continence and sexual outcomes. Recurrence rate at 12 months was about 12.5%.

Sexual outcomes after organ potency-sparing surgery and glans reconstruction in patients with penile carcinoma.

INTRODUCTION: Radical surgery is the "gold standard" for treatment of invasive penile carcinoma but very poor aesthetic, functional and psychological outcomes have been reported. Our purpose was to assess the impact of organ potency-sparing surgery in locally confined carcinoma of the penis. MATERIALS AND METHODS: We evaluated retrospectively 42 patients with early penile cancer (Ta,T1,T2), treated with glandulectomy and glanduloplasty with urethral mucosa and sparing of cavernosal apexes, or glandulectomy and limited apical resection in cases of Stage T2. Sexual function, ejaculation and libido were evaluated with an IIEF-15 questionnaire before the appearance of neoplasia (about three months before the surgery) and six months after surgery. Quality of life was evaluated by the Bigelow-Young questionnaire. The scores relating to two weeks prior to the surgery have been compared to those obtained six months after surgery. The statistical analysis was conducted using t-Student for repeated measures and analysis of variance. RESULTS: Six months after surgery 73% of patients reported spontaneous rigid erections, 60% coital activity while 76% of the group treated with urethral glanduloplasty reported normal ejaculation and orgasm, regained an average of 35 days after surgery. The average IIEF-15 scores reported in the entire series in the domains of erection, libido and coital activity of the pre-cancer period were not statistically different than those recorded six months after surgery. In the group treated with glandular reconstruction, pre-and postoperative IIEF-15 mean scores related to ejaculation and orgasm domains were not significantly different. Mean scores of Bigelow-Young questionnaires related to sexual pleasure, familial, social and professional relationships showed significant improvement after surgery. CONCLUSIONS: Potency sparing-sparing surgical treatments have a positive impact on a wide spectrum of the patient's life including family relationships, and social and working conditions.

Urological complications following inguinal hernioplasty.

Aim of this paper is to report a systematic review of the literature about the incidence and putative mechanisms of genital tract injuries following open and laparoscopic herniorraphy and their effects on sexual function and fertility and to point out the measures of prevention and of treatment. The most frequently described events have been intraoperative complications as bladder or spermatic cord structure damage, immediate postoperative complications as ischaemic orchitis, urinary retention, urinary tract infection, hydrocele or scrotal haematoma and bacterial orchitis, or long-term complications as chronic orchialgia, testis atrophy, sexual dysfunction and infertility. The evidence of literature shows that urological complication after hernioplasty are under-reported. Only a small number of studies to date have essentially dealt with sexual quality of life after inguinal hernia surgical repair. The sexual needs of patients with groin hernias are rarely discussed. Extensive laparoscopic procedures, due to the need of learning curve, have increased the risk of vas damage and infertility in young patients candidate to hernioplasty. Early diagnosis prevents urological complication as well as possible legal claims after hernia repair: it should be include careful history, objective and subjective symptoms and signs of uro-genital pathologies, lab data when necessary, immediate eco-color-Doppler imaging and urgent urological consultation. Despite the lack of prospective randomized trials, there is a growing evidence in literature about positive impact of hernioplasty on sexual function, encouraging future studies on this issue.

Standardization of retrograde intrarenal surgery with "gravity irrigation" technique leads to low postoperative infection rate regardless of surgeon experience.

OBJECTIVES: We aimed to evaluate the prevalence and predictive factors of postoperative infections after a standardized low-pressure RIRS technique. The secondary outcome was comparing surgeons' experience in terms of infective complication and stone-free rate. METHODS: A single-center retrospective analysis was conducted on all patients who underwent RIRS for kidney stones between January 2018 and February 2019. INCLUSION CRITERIA: adults, stone ≤ 20 mm (unless percutaneous nephrolithotomy contraindica-tions). Concomitant ureteral lithotripsy was allowed. EXCLUSION CRITERIA: bilateral surgery, active urinary tract infections (UTI), pregnancy, fever at surgery. Low-pressure RIRS and ureteroscopy was achieved with gravity irrigation, a 5 Ch open-ended urethral catheter (ureteral lithotripsy), intravenous furosemide (20 mg), and ureteral access sheath above the ureteral-pelvic junction (RIRS). RESULTS: 236 patients were included in the analysis. Mean age was 55.89±13.96 years. Mean stone diameter was 14.28±5.81mm. 43 (18.2%) patients underwent concomitant ureteral lithotripsy. Mean operative time was 61.10 ± 31.36 minutes. Infective complications occurred in 13 (5.5%) patients. Sepsis occurred in 10 (4.2%) patients and septic shock occurred in 1 (0.4%). One patient (0.4%) required stent substitution. Multivariate logistic regression analysis showed that history of UTI predicted for higher risk of postoperative infections (OR 8.434, CI 95% 2.36-29.46). Outcomes comparison of surgical expertise did not statistically differ in terms of stone-free rate and infective complications. CONCLUSION: Our standardized RIRS technique achieved a low postoperative infective complication rate. History of UTI was the strongest predictor of postoperative infections.

Is microsurgical technique really necessary in inguinal or sub-inguinal surgical treatment of varicocele?

The ideal method for treatment of varicocele is still controversial. The techniques of inguinal and sub-inguinal ligation, although less invasive than "high" abdominal ligations (Palomo, Ivanissevich), have been less popular than the former ones. Up to now most authors have considered as mandatory microsurgical techniques for the ligation of spermatic veins at inguinal or sub-inguinal level, or at least instruments of optical magnification in order to preserve testicular arterial supply of the spermatic and cremasteric artery at groin and to prevent testicular atrophia or gonadic ischemia. The aim of this study was to assess clinical outcomes of open surgical technique of varicocele repair compared to results derived from microsurgical series. A retrospective study included 45 patients of mean age 31 years (range 18-39) that underwent open surgical technique of inguinal ligation of spermatic veins in the period 2004-2009; clinical results of this series were compared with those obtained in five relevant studies derived from systematic review of the literature on microsurgical techniques. The pre-operatory evaluation in our series included a physical examination, a minimum of two semen analysis and scrotal color Doppler ultrasound. Post-operative pain, complication rates, days of hospitalization and time to return to work were considered as main outcomes. All patients were evaluated at 1 week, at 3 and 6 months after the operation by means of a physical examination, scrotal Doppler ultrasound and sperm analysis. Most patients (39/45) presented no pain in the first week, 6/45 mild to moderate pain (mean VAS score 2). None of the patients reported pain in the weeks thereafter The hospitalization (1.8 +/- 0.7 days) and the time for return to work (7.2 +/- 3.2 days) were not significantly different in microsurgical and open groups. During follow-up no complications like hydrocele or testicular atrophy were observed. Doppler ultrasound carried out 3 and 6 months after surgery, pointed out no reflux in testicular veins in 41/45 cases while in 4/45 it showed a persistence of reflux grade I, less than the grade before the treatment. Comparing pre-and post-operatory sperm analysis allowed us to observe a significant improvement either in spermatozoa concentration (22 +/- 4 40_+/- 6 millions/ml, p < 0.01), either in motility (33 +/- 4% and 48 +/- 4%, p < 0.05), without significant changes in morphology. No significant differences were recorded comparing these data with those coming from microsurgical series. Our study reported positive clinical outcomes using the technique of sub-inguinal surgical ligature of varicocele without using microsurgical techniques or instruments of optical magnification. The operative time, complication and relapse rates, Doppler flow parameters and semen parameters were not significantly different from those reported in the literature of microsurgical techniques, with the advantage of such a simple surgical technique combined with cost savings and patient's comfort.

Transurethral Resection of Bladder Tumor: Electrosurgical and Laser.

Transurethral resection of bladder tumor (TURBT) is still the gold standard for the diagnosis, treatment, and staging of nonmuscle invasive bladder cancer. En bloc resection of bladder tumor (EBRT) has been recently introduced to overcome the limitations of conventional TURBT. EBRT potential advantages are (1) complete resection, (2) a more precise and controlled resection (potentially fewer complications), (3) better sample orientation for histopathology analysis, (4) presence of detrusor in the specimen, and (5) less tumor seeding on normal urothelium by tumor fragments. This article aimed to present a step-by-step technique of conventional TURBT and EBRT with thulium laser support. We also aimed to provide tips and tricks for a correct surgical procedure and postoperative patient care. Finally, clinical outcomes of TURBT versus EBRT were reviewed.

Utility of Preoperative Neutrophil/Lymphocyte Ratio as a New Objective Prognostic Tool in Endoscopically Treated Upper Tract Urothelial Carcinoma: A Retrospective Evaluation.

Introduction: This exploratory retrospective analysis examined any potential prognostic role of preoperative neutrophil lymphocyte ratio (NLR) for progression-free survival (PFS) and time to endoscopically verified upper tract or bladder recurrence-free survival (RFS) in upper tract urothelial cancer (UTUC) patients selected for endoscopic treatment with subsequent endosurveillance. Patients and Methods: Eligibility criteria were natural orifice endoscopically retrogradely treated low-risk and imperative UTUC patients treated between 2005 and 2019, with biopsy confirmed diagnosis and 12 months minimum follow-up. For PFS, optimal NLR cutoff value was derived by log-rank test. Subsequently, both PFS and RFS were assessed for differences using Kaplan-Meier survival curves and log-rank test. Multivariate proportional Cox regression analysis adjusted for clinicopathologic variables was performed to examine end points for NLR-independent prognostic significance. Results: There were 100 eligible patients (63 truly low risk and 37 imperative cases). The optimal PFS log-rank test NLR cutoff value was 2.7. NLR ≥2.7 was significantly associated with shorter PFS (p = 0.01), and shorter upper tract RFS (p = 0.03), but not with bladder RFS (p = 0.90). Only positive high-grade cytology (hazard ratio [HR] 5.92, 95% confidence interval [CI] 2.140-16.35, p = 0.002) and NLR ≥2.7 (HR 4.28, 95% CI 1.34-13.72, p = 0.014) independently predicted PFS in multivariate analysis. Recurrence and progression were not significantly linked in the low-risk subset. Conclusions: This exploratory analysis showed that baseline NLR evaluation before first endoscopic UTUC treatment may be a valuable predictor and prognosticator of defined disease progression and of upper tract recurrence risk. In conjunction with high-grade urine cytology, NLR may improve risk stratification to optimize future individualized management.

Thulium-Holmium:YAG Duo Laser in Conservative Upper Tract Urothelial Cancer Treatment: 13 Years Experience from a Tertiary National Referral Center.

Introduction and Objectives: To evaluate ablative safety and efficacy of thulium-holmium:YAG (TL-HL:YAG) duo laser in renal conserving retrograde intrarenal surgery (RC-RIRS) in upper tract urothelial carcinoma (UTUC). Materials and Methods: A retrospective study was performed on 178 consecutive patients referred for consideration of RC-RIRS UTUC-eLA (endoscopic laser ablation) in a tertiary center (January 2005 to December 2018). Key data were recorded using a standardized study proforma. Results: After endodiagnostic procedure, 42 declined rigorous endosurveillance protocol and went elsewhere for alternative treatment, leaving 136 patients, of whom 35 patients dropped out (25.7%) after undergoing primary radical nephroureterectomy (RNU) (unsuitable for renal preservation). This was left with 101 candidates who continued UTUC conservative management (intention-to-treat [ITT] population). Mean follow-up (FU) for these 101 patients was 28.7 months. At last FU (range 3-144 months), 70 patients (69.3%) were recurrence free, 22 (21.8%) had endoscopically treated recurrences, and a further 9 (8.9%) had undergone RNU. In the ITT population, kidney-preserving rate was 91%, whereas in imperative indications, it was 87.5%. Clavien-Dindo grade I complications only (self-limiting hematuria) were reported in 10%. Conclusions: Over a 13-year period, RC-RIRS UTUC treatment with the TL-HL:YAG duo laser was safe and oncologically noninferior to alternative combination laser energy technologies used for this indication.

"Single-Surgeon" versus "Dual-Surgeon" Robot-Assisted Radical Prostatectomy and Pelvic Lymph-nodes Dissection: Comparative Analysis of Perioperative Outcomes

ABSTRACT Purpose: To compare the perioperative outcomes of robot-assisted radical prostatectomy (RARP) with pelvic lymph-nodes dissection (PLND) when the same surgeon performs RARP and PLND versus one surgeon performs RARP and another surgeon performs PLND. Materials and Methods: From January 2022 to March 2023, data of consecutive patients who underwent RARP with PLND were prospectively collected. The surgeries were performed by two "young" surgeons with detailed profile. Specifically for the study purpose, one surgeon performed RARP, and the other surgeon performed PLND. A set of surgeries performed according to the standard setup (i.e., the same surgeon performing both RARP and PLND) was retrieved from the institutional database and used as comparator arm. To test the study hypothesis, patients were divided into two groups: "dual-surgeon" versus "single-surgeon". Results: Fifty patients underwent RARP and PLND performed according to dual-surgeon setup and were compared to the last 50 procedures performed according to the standard single-surgeon setup. Patients in the groups had comparable baseline characteristics. Dual-surgeon interventions had significantly shorter median total operative (194 [IQR 178-215] versus 174 [IQR 146-195] minutes, p<0.001) and console time (173 [IQR 158-194] versus 154 [IQR 129-170] minutes, p<0.001). No significant differences were found in terms of blood loss, intraoperative complications, postoperative outcomes, and final pathology results. Conclusions: The present analysis found that when RARP and PLND are split onto two surgeons, the operative time is shorter by 20 minutes compared to when a single surgeon performs RARP and PLND. This is an interesting finding that could sponsor further studies.