A proposed mathematical model to help preoperative planning between RIRS and MiniPerc for renal stones between 10 and 20 mm using holmium:Yag laser (Cyber Ho): the stone management according to size-hardness (SMASH) score.

To evaluate the performance of a mathematical model to drive preoperative planning between RIRS and MiniPerc (MP) for the treatment of renal stones between 10 and 20 mm. Patients with a renal stone between 10 and 20 mm were enrolled. A mathematical model named Stone Management According to Size-Hardness (SMASH) score was calculated: hounsfield units (HU) χ stone maximum size (cm)/100. Patients were divided into 4 groups: RIRS with score < 15 (Group A), RIRS with score ≥ 15 (Group B), MP with score < 15 (Group C), MP with score ≥ 15 (Group D). Cyber Ho device was always used. Stone free rate (SFR) was assessed after 3 months. Complication rate and need for auxiliary procedures were evaluated. Between January 2019 and December 2021, 350 patients were enrolled (87, 88, 82 and 93 in Groups A, B, C and D). Mean stone size was 13.1 vs 13.3 mm in Group A vs B (p = 0.18) and 16.2 vs 18.1 mm in Group C vs D (p = 0.12). SFR was 82%, 61%, 75% and 85% for Groups A, B, C and D. SFR was comparable between Groups C and D (p = 0.32) and Groups A and C (p = 0.22). SFR was significantly higher in Group A over B (p = 0.03) and in Group D over B (p = 0.02). Complication rate was 2.2%, 3.4%, 12.1%, 12.9% for Groups A, B, C, D. RIRS and MP are both safe and effective. The mathematical model with the proposed cut-off allowed a proper allocation of patients between endoscopic and percutaneous approaches.Registration number of the study ISRCTN55546280.

A comparison between vapor tunnel and virtual basket for the treatment of proximal ureteral stones using holmium:YAG laser (Cyber Ho): which is the best tool to reduce retropulsion?

PURPOSE: To compare vapor tunnel (VT) and virtual basket (VB) tools to reduce retropulsion in the treatment of proximal ureteral stones. METHODS: Patients with a single proximal ureteral stone were randomly assigned to holmium laser lithotripsy with the use of VT (Group A) or VB (Group B) tool. The 150W holmium:YAG cyber Ho generator was used. We compared operative time, dusting time, need for flexible ureteroscopy due to stone push-up and occurrence of ureteral lesions. The stone-free rate (SFR) and the occurrence of postoperative ureteral strictures were assessed. RESULTS: 186 patients were treated, of which 92 with the VT (49.5%, Group A) and 94 with the VB (50.5%, Group B). Mean stone size was 0.92 vs. 0.91 cm in Groups A vs. B (p = 0.32). Mean total operative time and dusting time were comparable between groups. 7 (7.6%) vs. 6 (6.4%) patients in Groups A vs. B required a flexible ureteroscope because of stone push-up (p = 0.12). Ureteral mucosa lesions were observed in 15 (16.3%) vs. 18 (19.1%) cases in the VT vs. VB group (p = 0.09). 1-Month SFR was comparable (97.8% vs. 95.7%, p = 0.41). We observed one case (1.1%) of postoperative ureteral stricture in the VT group vs. two cases (2.1%) in the VB group (p = 0.19). CONCLUSIONS: VT and VB are equally safe and effective tools in reducing retropulsion of ureteral stones. Operative time, dusting time and SFR were comparable. They also equally avoided stone push-up and prevented ureteral lesions, which may later occur in ureteral strictures.

Evaluation of the learning curve for Thulium laser enucleation of the prostate in a contemporary cohort.

PURPOSE: To assess the learning curve of Thulium laser enucleation of the prostate (ThuLEP) of a single surgeon. METHODS: Hundred patients suffering from benign prostatic hyperplasia were treated by the same surgeon. In all cases, a well-trained urologist was present in the operating room. Patients urinary function was assessed preoperatively using the International Prostate Symptoms Score (IPSS), maximum flow rate and Post-Void Residual volume. Preoperative prostate volume was recorded. Enucleation and morcellation efficiency and complication rate were evaluated. Patients were divided into 5 cohorts of 20 consecutive cases to assess changes in outcomes through time. RESULTS: Mean age of patients was 73.1 years (SD 17.5) and mean prostate volume was 89.7 ml (SD 55.1). Overall, mean enucleation and morcellation efficiency were 1.7 (SD 2.9) and 5.1 (SD 2.7) g/min. A statistically significant increase in enucleation efficiency was observed when comparing cohort 1 vs 2 (0.9 vs 1.3 g/min, p = 0.03) and cohort 2 vs 3 (1.3 vs 1.7 g/min, p = 0.02). A statistically significant increase in morcellation efficiency was observed when comparing cohort 1 vs 2 (2.8 vs 3.7 g/min, p = 0.02) and cohort 2 vs 3 (3.7 vs 4.9 g/min, p = 0.03). In both cases, no significant differences were observed when comparing the following cohorts. Complication rate showed no significant differences throughout the caseload. CONCLUSIONS: In our single-surgeon experience, we observed a learning curve of nearly 60 cases for the ThuLEP procedure in presence of a well-trained surgeon. Complication rate was low from the beginning of surgical experience.

Pulsed-wave vs Continuous-wave Thulium Fiber Laser Enucleation of the Prostate (ThuFLEP): A Comparison of Perioperative Outcomes.

OBJECTIVE: To compare intra and early postoperative outcomes between pulsed-wave and continuous-wave Thulium Fiber Laser Enucleation of the Prostate (PW-ThuFLEP vs CW-ThuFLEP) for the treatment of benign prostatic hyperplasia. METHODS: 238 patients with lower urinary tract symptoms due to benign prostatic hyperplasia underwent PW-ThuFLEP (118 patients) vs CW-ThuFLEP (120 patients). Preoperative prostate volume, adenoma volume, prostate-specific antigen (PSA), and hemoglobin values were recorded. International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), post-void residual volume, and International Index of Erectile Function-5 score (IIEF-5) were assessed. Operative time, enucleation time, enucleation efficiency, catheterization time, irrigation volume, hospital stay, hemoglobin drop, and postoperative complications were recorded. Micturition improvements and sexual outcomes were evaluated 3months after surgery. RESULTS: CW-ThuFLEP showed shorter operative time (61.5 vs 67.4 minutes, P = .04). Enucleation time (50.2 vs 53.3 minutes, P = .12), enucleation efficiency (0.8 vs 0.7 g/min, P = .38), catheterization time (2.2 vs 2.1days, P = .29), irrigation volume (32.9 vs 32.8L, P = .71), hospital stay (2.8 vs 2.6days, P = .29) and hemoglobin drop (0.38 vs 0.39 g/dL, P = .53) were comparable. No significant difference in complication rate was observed. At 3-month follow-up, the procedures did not show any significant difference in IPSS, Qmax, post-void residual volume, IIEF-5, and PSA value. CONCLUSION: PW-ThuFLEP and CW-ThuFLEP both relieve lower urinary tract symptoms equally, with high efficacy and safety. Operative time was significantly shorter with CW-ThuFLEP, but with a small difference with low clinical impact. Enucleation time, enucleation efficiency, catheterization time, irrigation volume, hospital stay, hemoglobin and PSA drop, complication rate, and sexual outcomes showed no differences.

Trends in the use of partial nephrectomy for cT1 renal tumors: Analysis of a 10-yr European multicenter dataset.

AIM: Although extensively addressed in US registries, the utilization rate of Partial Nephrectomy has been poorly addressed in European settings. Our aim is to evaluate the impact of hospital volume on the use of PN for cT1 renal tumors. METHODS: 2526 patients with cT1N0M0 renal tumors treated with either PN or radical nephrectomy at 10 European centres in the last decade were included in the analysis. Joinpoint regression analysis was used to identify significant changes over time in linear slope of the trend for each center. The correlation between yearly caseload and the slopes was assessed with the non-parametric Spearman test. Coincident pairwise tests and regression analyses were used to generate and compare the trends of high-volume (HV), mid-volume (MV) and low-volume (LV) groups. RESULTS: Yearly caseload was significantly associated with increased use of PN (R = 0.69, p = 0.028). The utilization rate of PN was stable at LV centres (p = 0.67, p = 0.7, p = 0.76, for cT1, cT1a, and cT1b tumors, respectively), while increased significantly at MV (p = 0.002, 0.0005 and 0.007, respectively) and HV centers (all p < 0.0001). Regression analysis confirmed the trends for HV and MV as significantly different from those observed in LV centres (all p ≤ 0.002) and highlighted significant differences also between MV and HV centres (all p ≤ 0.03). CONCLUSIONS: We confirmed the association between caseload and the use of PN for cT1 tumors. Our findings suggest that a minimum caseload might turn the tide also in LV centres while a selective referral to HV centers for cT1b tumors should be considered.

Conventional testicular sperm extraction (TESE) and non-obstructive azoospermia: is there still a chance in the era of microdissection TESE? Results from a single non-academic community hospital.

Spermatozoa can be retrieved in non-obstructive azoospermia (NOA) patients despite the absence of ejaculated spermatozoa in their semen because of the presence of isolated foci with active spermatogenesis. Conventional testicular sperm extraction (c-TESE) in patients with NOA has been partially replaced by micro-TESE. It is still under debate the problem regarding the higher costs related to micro-TESE when compared with c-TESE. In this study, we evaluated sperm retrieval rate (SRR) of c-TESE in naive NOA patients. Sixty-three NOA patients were referred to our centre for a c-TESE. For every subject, we collected demographic data, cause of infertility, time to first infertility diagnosis, serum levels of LH, FSH, total testosterone and prolactin. A statistical analysis was conducted to correlate all the clinical variables, the histology and the Johnsen score with the SRR. Sixty-three consecutive NOA patients with a mean age of 37.3 years were included. The positive SRR was 47.6%. No statistical differences were observed between positive vs. negative SRR regarding mean FSH (17.12 vs. 19.03 mUI/mL; p = 0.72), and LH (9.72 vs. 6.92 mUI/mL; p = 0.39) values. Interestingly, we found a statistically significant difference in terms of time to first infertility diagnosis (+SRR vs. -SRR; 44.5 vs. 57 months; p = 0.02) and regarding to age (+SSR vs. -SRR; 40.1 vs. 35.3; p = 0.04). There was a statistically significant decrease in SRRs with the decline in testicular histopathology from hypospermatogenesis to maturation arrest, and SCO. The mean Johnsen score was 5.9 with a mean percentage of Johnsen score ≥8 tubules equal to 19%. The overall pregnancy rate was 26.6%. In our prospective cohort of patients successful SRR with c-TESE was 47.6%. Lower costs and high reproducibility of this technique still support this procedure as an actual reliable option in NOA patients for sperm retrieval.

Serum and urine biomarkers for human renal cell carcinoma.

Renal cell carcinoma (RCC) diagnosis is mostly achieved incidentally by imaging provided for unrelated clinical reasons. The surgical management of localized tumors has reported excellent results. The therapy of advanced RCC has evolved considerably over recent years with the widespread use of the so-called "targeted therapies." The identification of molecular markers in body fluids (e.g., sera and urine), which can be used for screening, diagnosis, follow-up, and monitoring of drug-based therapy in RCC patients, is one of the most ambitious challenges in oncologic research. Although there are some promising reports about potential biomarkers in sera, there is limited available data regarding urine markers for RCC. The following review reports some of the most promising biomarkers identified in the biological fluids of RCC patients.

A prospective study to evaluate the efficacy of Cistiquer in improving lower urinary tract symptoms in females with urethral syndrome.

AIM: The aim of the study was to compare Cistiquer, a new phytotherapeutic product developed for chronic bladder inflammatory diseases, and intra-vesical administration of gentamicin plus betametasone, in females with urethral syndrome. METHODS: Between september 2013 and may 2014, 60 women with urethral syndrome and trigonitis were incuded in this study. Patients were randomly assigned to treatment with intra-vesical administration of betametasone 8 mg plus gentamicin 80 mg (group A), and oral administration of Cistiquer (group B) for 7 weeks. Before and after the therapeutic protocol, symptoms were assessed by three days voiding diary, the overactive bladder questionnaire short form and a ten points visual analogic scale adopted to assess the micturition discomfort. Histologic findings were assessed by the examination of specimens obtained by cold bladder biopsies of the bladder trigone at baseline in all the subjects. RESULTS: The two groups had significant and comparable symptoms improvement. However, the score obtained from the visual analogic scale decreased significantly only in the group submitted to oral therapy. Furthermore, in the group treated with endovesical approach, higher drop out rate and higher incidence of urinary infection were observed. CONCLUSION: Patients with urethral syndrome and trigonitis improved symptoms either with oral therapy with Cistiquer and with intra-vesical administration of gentamicin plus betametasone. However, treatment adherence resulted higher for patients treated by oral therapy and rate of adverse events resulted higher for those submitted to endovesical treatment.

Severe obstructive sleep apnoea syndrome and erectile dysfunction: a prospective randomised study to compare sildenafil vs. nasal continuous positive airway pressure.

BACKGROUND: A high incidence of erectile dysfunction (ED) among patients with obstructive sleep apnoea syndrome (OSAS) has been reported, with a strong correlation between obstructive sleep apnoea, ED, and quality of life (QOL), and it has been estimated that 10-60% of patients with OSAS suffer from ED. In this prospective randomised controlled trial, we investigated 82 men with ED consecutively who were referred to the outpatient clinic for sleep disorders and had severe OSAS (AHI> 30 events/h) without any other comorbidities as a possible cause of ED. The aim of this study was to evaluate and compare the efficacy of sildenafil vs. continuous positive airway pressure (CPAP) in men with ED and severe OSAS. METHODS: Eighty-two patients were randomised to two main treatment groups: group 1 patients (n = 41) were treated with 100-mg sildenafil 1 h before sexual intercourse without CPAP, and group 2 patients (n = 41 men) were treated with only nasal CPAP during night time sleep. Both groups were evaluated with the same questionnaires (International Index of Erectile Function-EF domain; Sex Encounter Profile; Erectile Dysfunction Inventory Treatment Satisfaction) 12 weeks after treatment. RESULTS: In patients receiving sildenafil treatment, 58.2% of those who attempted sexual intercourses were successful compared to 30.4% in the CPAP group. The mean number of successful attempts per week was significantly higher in the sildenafil group compared with the CPAP group (2.9 vs. 1.7, respectively; p < 0.0001). The mean IIEF-EF domain scores were significantly higher in the sildenafil group compared with the CPAP group (p < 0.0001). The overall satisfaction rate was 68% with sildenafil treatment and 29% with CPAP treatment. CONCLUSIONS: This study confirms that severe OSAS is strongly associated with erectile dysfunction. CPAP and sildenafil (100 mg) are safe and effective therapies for OSAS-related ED patients. In the present study sildenafil was more effective than CPAP in treating ED associated with OSAS, as indicated by a significantly higher rate of successful attempts at intercourse and higher IIEF-EF domain scores. Our study, to date, is the only that has investigated sildenafil in patients with severe OSAS.

A prospective randomized study to compare pelvic floor rehabilitation and dapoxetine for treatment of lifelong premature ejaculation.

Premature ejaculation (PE) is the most common male sexual disorder. We compared pelvic floor muscle rehabilitation to on-demand treatment with the selective serotonin reuptake inhibitor dapoxetine in 40 men with lifelong PE (baseline intra-vaginal ejaculatory latency time (IELT) ≤1 min). Subjects were randomized into the following two treatment groups: (1) PFM rehabilitation or (2) 30 or 60 mg of on-demand dapoxetine. Total treatment time for both groups was 12 weeks, at the end of which, IELT mean values were calculated to compare the effectiveness of the two different therapeutic approaches. At the end of treatment, 11 of the 19 patients (57%) treated with rehabilitation were able to control the ejaculation reflex, with a mean IELT of 126.6 sec (range: 123.6-152.4 sec). In the dapoxetine group, after 12 weeks of therapy, 5 of 8 (62.5%) patients in the 30 mg subgroup and five of seven (72%) in the 60 mg subgroup had an IELT >180 sec (mean: 178.2 and 202.8 sec, respectively). The results obtained in the group treated with pelvic floor rehabilitation are promising, and this treatment represents an important cost reduction if compared to dapoxetine on-demand treatment. The present study confirms the data that are previously available in the literature on the efficacy and safety of the new inhibitor of serotonin reuptake, dapoxetine, as well as proposes and evaluates a new type of physical treatment that may be a viable therapeutic option for treatment of PE.

Synchronous urinary tract metastases from breast cancer.

Breast carcinoma has a metastatic potential to any organ system. However, breast carcinoma metastases to the urinary tract have very rarely been described. The authors present the case of a patient with a synchronous right ureteral and vesical metastasis of a breast cancer. This is the unique case reported in Literature of synchronous urinary metastatic localization from breast invasive lobular carcinoma.

Early echographical assessment of minimal lesions of cavernosum corpora and tunica albuginea in subjects with erectile dysfunction, suggestive of La Peyronie's disease.

The aim of the study is to evaluate the incidence and the echographic characteristics of minimal lesions of cavernosum corpora and tunica albuginea (TA) in subjects reporting erectile dysfunction (ED), which could suggest the suspicious of La Peyronie's disease (LPD). In total, 185 patients (pts) underwent dynamic penile Ultrasound Color Doppler (USCD) for ED. None of the pts presented any clinical symptoms or any clinical findings for LPD. In this study we evaluated, using USCD, thickness, echogenicity, regularity of the surface profile of the dorsal TA, the intercavernous and the intercaverno-spongeous septa, and the extension of the eventual pathologic lesions. In all, 16 pts (8.7%) presented minimal lesions at the ultrasound examinations. In nine of these pts (56%) the lesion was localized at the dorsal position, in six (38%) on the intercavernous septum and in one patient (6%) in both positions. The dorsal lesions were represented in nodular form in four pts (4%), and in diffuse form in five pts (55%). The nodular form was present in all the intercavernous septal lesions observed. As reported in the literature, USCD represents the investigative technique of choice in the study of LPD and in ED. Furthermore, the results of this study suggest that this technique could allow the localization of minimal lesions attributable to LPD during a preclinical phase of this disease. The localization of these lesions could permit to start a therapeutic approach during an early phase of the disease.

Benign prostatic hyperplasia: what about a campaign for prevention?

OBJECTIVES: In an era when prevention is considered better than cure, is there a rationale for benign prostatic hyperplasia (BPH) prevention? MATERIALS AND METHODS: Medline and Current Content databases were searched for studies conduced in the last 10 years on BPH and the feasibility of prevention program. RESULTS: Some important criteria for promoting prevention can be found in BPH disease. The significant impact of BPH on the male population and on its quality of life is well established. Knowledge of the etiopathogenesis of this disease is rapidly improving. However, the use of PSA or other markers to select a population at higher risk for developing BPH and its clinical manifestations needs to be better established. More data are available for secondary prevention against BPH progression. Although the action of some natural and nutritional agents on BPH tissue has been demonstrated experimentally, data from prospective clinical trials are not available. Synthetic agents such as 5alpha-reductase inhibitors or COX-2 inhibitors may be effective, but clinical results for primary prevention of BPH have not been reported. CONCLUSION: At present, we propose a BPH prevention program as a basis for discussion and future work.

[Heredity and urologic tumors]. / Ereditarietà e tumori di interesse urologica.

Most human malignant tumours derive from a series of several mutations in cell growth regulatory genes. Neoplastic transformation is a multistep, or at times multigenic event where several mutations must intervene. Hereditary forms have been identified for a number of human neoplasias. In hereditary forms, the individual already inherits one or more of these mutations and assumes an increased risk of developing a specific carcinoma and at an earlier age. On the other hand, in sporadic forms, the risk is lower because the environmental factors must provoke in sequence all the mutations necessary for neoplastic transformation. These genic mutations are often associated with the deletion of oncosuppressor genes which negatively regulate cell proliferation and/or with the hyper-expression and activation of protoncogenes which favour cell proliferation. The products of these genes are often growth factors or receptors of growth factors. The present review analyses the definition and more or less proven identification of familial and hereditary forms in neoplasias of urological interest.

[Role of nitric oxide in the urogenital system: physiology and pathology]. / Ruolo dell'ossido nitrico nell'apparato genito-urinario: fisiologia e patologia.

A review has been made on the role of nitric oxide in the physiology and pathophysiology of penis, bladder, prostate and the nervous structures involved in the urinary control. NO is an essential mediator in penile erection and his action can be modulated by sildenafil. Nitric oxide could be involved in bladder detrusor relaxation and in the development of interstitial cystitis. Little is known about the role of nitric oxide in the physiology and pathophysiology of the prostate: this molecule is released by the epithelial and stromal cells of the prostate, and by the prostatic nerves. Actually some studies hypothesize a role played by nitric oxide in benign prostatic hyperplasia development.

Intermittent androgen deprivation (IAD) in patients with localized prostate cancer and a biochemical progression after radical prostatectomy.

BACKGROUND: To analyze the modifications in serum PSA levels during IAD in patients with an initial PSA progression after radical retropubic prostatectomy (RRP). METHODS: Between February 1994 and May 1996, 34 consecutive patients with an initial PSA progression (> 0.4 ng/ml) after RRP were selected. All men had localized adenocarcinoma of the prostate, stage pT2 pN0 M0. Patients were offered IAD when PSA progressed over 0.4 ng/ml. The initial treatment period with complete androgen deprivation (CAD) lasted 24 weeks in all cases. After, an acceptable nadir PSA level was considered to be a value < or = 0.4 ng/ml. CAD was then with held until serum PSA increased to a value over 0.4 ng/ml. RESULTS: Follow-up ranges from 144 to 228 weeks. The median time for the first 5 treatment cycles was 32, 24, 28, 32 and 32 weeks respectively, with a median time "off" therapy that increased from 8 weeks (first cycle) to 22 weeks (fifth cycle). The median nadir PSA value during "on" treatment period was 0.20 ng/ml in all 5 cycles. So far, in none of the patients did a serum PSA fail to decrease during "on" treatment period. CONCLUSIONS: We suggest that IAD may be an effective therapy in patients with an initial PSA progression after RRP. However, large prospective studies are needed to confirm these results and to better understand the meaning of PSA variations.

Elucidation of the structure of constrained bicyclopeptides in solution by two-dimensional cross-relaxation spectroscopy: amatoxin analogues.

The evaluation of peptide structures in solution is made feasible by the combined use of two-dimensional NMR in the laboratory (NOESY) and rotating frames (ROESY), and by the use of molecular dynamics calculations. The present paper describes how both the NMR method and molecular dynamics calculations were applied to very rigid synthetic bicycle peptides that are analogues of natural amatoxins. The NMR theory, which allows the estimate of interatomic distances between interacting nuclei, is briefly discussed. The experimental data were compared with those of known solid-state structures. Three amatoxin analogues have been examined. Of these, one is biologically active (S-deoxo gamma[R] OH-Ile3-amaninamide) and its structure in the solid state has recently been worked out. The second and third analogues (S-dexo-Ile3-Ala5-amaninamide and S-deoxo-D-Ile3-amaninamide, respectively) are inactive and their solid-state structures are unknown. The data presented confirm the authors previous hypothesis that lack of biological activity of S-deoxo-Ile3-Ala5-amaninamide is due to the masking of the tryptophan ring by the methyl group of L-Ala and not to massive conformational changes of the analogue.