Visual extended reality tools in image-guided surgery in urology: a systematic review.

PURPOSE: The aim of this systematic review is to assess the clinical implications of employing various Extended Reality (XR) tools for image guidance in urological surgery. METHODS: In June 2023, a systematic electronic literature search was conducted using the Medline database (via PubMed), Embase (via Ovid), Scopus, and Web of Science. The search strategy was designed based on the PICO (Patients, Intervention, Comparison, Outcome) criteria. Study protocol was registered on PROSPERO (registry number CRD42023449025). We incorporated retrospective and prospective comparative studies, along with single-arm studies, which provided information on the use of XR, Mixed Reality (MR), Augmented Reality (AR), and Virtual Reality (VR) in urological surgical procedures. Studies that were not written in English, non-original investigations, and those involving experimental research on animals or cadavers were excluded from our analysis. The quality assessment of comparative and cohort studies was conducted utilizing the Newcastle-Ottawa scale, whilst for randomized controlled trials (RCTs), the Jadad scale was adopted. The level of evidence for each study was determined based on the guidelines provided by the Oxford Centre for Evidence-Based Medicine. RESULTS: The initial electronic search yielded 1,803 papers after removing duplicates. Among these, 58 publications underwent a comprehensive review, leading to the inclusion of 40 studies that met the specified criteria for analysis. 11, 20 and 9 studies tested XR on prostate cancer, kidney cancer and miscellaneous, including bladder cancer and lithiasis surgeries, respectively. Focusing on the different technologies 20, 15 and 5 explored the potential of VR, AR and MR. The majority of the included studies (i.e., 22) were prospective non-randomized, whilst 7 and 11 were RCT and retrospective studies respectively. The included studies that revealed how these new tools can be useful both in preoperative and intraoperative setting for a tailored surgical approach. CONCLUSIONS: AR, VR and MR techniques have emerged as highly effective new tools for image-guided surgery, especially for urologic oncology. Nevertheless, the complete clinical advantages of these innovations are still in the process of evaluation.

Automatic 3D Augmented-Reality Robot-Assisted Partial Nephrectomy Using Machine Learning: Our Pioneer Experience.

The aim of "Precision Surgery" is to reduce the impact of surgeries on patients' global health. In this context, over the last years, the use of three-dimensional virtual models (3DVMs) of organs has allowed for intraoperative guidance, showing hidden anatomical targets, thus limiting healthy-tissue dissections and subsequent damage during an operation. In order to provide an automatic 3DVM overlapping in the surgical field, we developed and tested a new software, called "ikidney", based on convolutional neural networks (CNNs). From January 2022 to April 2023, patients affected by organ-confined renal masses amenable to RAPN were enrolled. A bioengineer, a software developer, and a surgeon collaborated to create hyper-accurate 3D models for automatic 3D AR-guided RAPN, using CNNs. For each patient, demographic and clinical data were collected. A total of 13 patients were included in the present study. The average anchoring time was 11 (6-13) s. Unintended 3D-model automatic co-registration temporary failures happened in a static setting in one patient, while this happened in one patient in a dynamic setting. There was one failure; in this single case, an ultrasound drop-in probe was used to detect the neoplasm, and the surgery was performed under ultrasound guidance instead of AR guidance. No major intraoperative nor postoperative complications (i.e., Clavien Dindo > 2) were recorded. The employment of AI has unveiled several new scenarios in clinical practice, thanks to its ability to perform specific tasks autonomously. We employed CNNs for an automatic 3DVM overlapping during RAPN, thus improving the accuracy of the superimposition process.

Development of Bleeding Artificial Intelligence Detector (BLAIR) System for Robotic Radical Prostatectomy.

BACKGROUND: Addressing intraoperative bleeding remains a significant challenge in the field of robotic surgery. This research endeavors to pioneer a groundbreaking solution utilizing convolutional neural networks (CNNs). The objective is to establish a system capable of forecasting instances of intraoperative bleeding during robot-assisted radical prostatectomy (RARP) and promptly notify the surgeon about bleeding risks. METHODS: To achieve this, a multi-task learning (MTL) CNN was introduced, leveraging a modified version of the U-Net architecture. The aim was to categorize video input as either "absence of blood accumulation" (0) or "presence of blood accumulation" (1). To facilitate seamless interaction with the neural networks, the Bleeding Artificial Intelligence-based Detector (BLAIR) software was created using the Python Keras API and built upon the PyQT framework. A subsequent clinical assessment of BLAIR's efficacy was performed, comparing its bleeding identification performance against that of a urologist. Various perioperative variables were also gathered. For optimal MTL-CNN training parameterization, a multi-task loss function was adopted to enhance the accuracy of event detection by taking advantage of surgical tools' semantic segmentation. Additionally, the Multiple Correspondence Analysis (MCA) approach was employed to assess software performance. RESULTS: The MTL-CNN demonstrated a remarkable event recognition accuracy of 90.63%. When evaluating BLAIR's predictive ability and its capacity to pre-warn surgeons of potential bleeding incidents, the density plot highlighted a striking similarity between BLAIR and human assessments. In fact, BLAIR exhibited a faster response. Notably, the MCA analysis revealed no discernible distinction between the software and human performance in accurately identifying instances of bleeding. CONCLUSION: The BLAIR software proved its competence by achieving over 90% accuracy in predicting bleeding events during RARP. This accomplishment underscores the potential of AI to assist surgeons during interventions. This study exemplifies the positive impact AI applications can have on surgical procedures.

3D Model Artificial Intelligence-Guided Automatic Augmented Reality Images during Robotic Partial Nephrectomy.

More than ever, precision surgery is making its way into modern surgery for functional organ preservation. This is possible mainly due to the increasing number of technologies available, including 3D models, virtual reality, augmented reality, and artificial intelligence. Intraoperative surgical navigation represents an interesting application of these technologies, allowing to understand in detail the surgical anatomy, planning a patient-tailored approach. Automatic superimposition comes into this context to optimally perform surgery as accurately as possible. Through a dedicated software (the first version) called iKidney, it is possible to superimpose the images using 3D models and live endoscopic images during partial nephrectomy, targeting the renal mass only. The patient is 31 years old with a 28 mm totally endophytic right-sided renal mass, with a PADUA score of 9. Thanks to the automatic superimposition and selective clamping, an enucleoresection of the renal mass alone was performed with no major postoperative complication (i.e., Clavien-Dindo < 2). iKidney-guided partial nephrectomy is safe, feasible, and yields excellent results in terms of organ preservation and functional outcomes. Further validation studies are needed to improve the prototype software, particularly to improve the rotational axes and avoid human help. Furthermore, it is important to reduce the costs associated with these technologies to increase its use in smaller hospitals.

Robot-Assisted Extraperitoneal Radical Prostatectomy for Giant Multilocular Prostatic Cystadenoma: A Case Report and Literature Review.

A 48-year-old man with a medical history of hypertension and no family history of prostate cancer presented with abdominal distension, lower abdominal pain, and lower urinary symptoms. Physical examination revealed a palpable mass in the lower abdomen, and a digital rectal examination detected a firm mass on the anterior side of the rectum. Laboratory tests showed an elevated PSA level (7.9 ng/mL). Imaging studies indicated a solid mass connected to the prostate's posterior and rectum's anterior walls, along with bladder compression. Transperitoneal biopsy and histological analysis led to a diagnosis of a stromal tumor with uncertain potential malignancy. Considering the absence of apparent malignancy signs and the smooth outer wall of the tumor, the patient underwent, for the first time in the literature, a robot-assisted radical extraperitoneal prostatectomy for complete macroscopic resection. The surgery involved excision of the bulky pelvic mass, preservation of the urethra, and anatomical reconstruction. The postoperative course was uneventful, and we discharged the patient with no complications. The pathological examination documented the diagnosis of multilocular prostatic cystadenoma. Post-surgery follow-up examinations, including PSA levels and imaging scans, showed no signs of tumor recurrence. At the 3-, 6-, and 9-month follow-ups, the patient was asymptomatic and had fully recovered, with no urinary or sexual dysfunction reported.

Development of a predictive model to distinguish prostate cancer from benign prostatic hyperplasia by integrating serum glycoproteomics and clinical variables.

BACKGROUND: Prostate Cancer (PCa) represents the second leading cause of cancer-related death in men. Prostate-specific antigen (PSA) serum testing, currently used for PCa screening, lacks the necessary sensitivity and specificity. New non-invasive diagnostic tools able to discriminate tumoral from benign conditions and aggressive (AG-PCa) from indolent forms of PCa (NAG-PCa) are required to avoid unnecessary biopsies. METHODS: In this work, 32 formerly N-glycosylated peptides were quantified by PRM (parallel reaction monitoring) in 163 serum samples (79 from PCa patients and 84 from individuals affected by benign prostatic hyperplasia (BPH)) in two technical replicates. These potential biomarker candidates were prioritized through a multi-stage biomarker discovery pipeline articulated in: discovery, LC-PRM assay development and verification phases. Because of the well-established involvement of glycoproteins in cancer development and progression, the proteomic analysis was focused on glycoproteins enriched by TiO2 (titanium dioxide) strategy. RESULTS: Machine learning algorithms have been applied to the combined matrix comprising proteomic and clinical variables, resulting in a predictive model based on six proteomic variables (RNASE1, LAMP2, LUM, MASP1, NCAM1, GPLD1) and five clinical variables (prostate dimension, proPSA, free-PSA, total-PSA, free/total-PSA) able to distinguish PCa from BPH with an area under the Receiver Operating Characteristic (ROC) curve of 0.93. This model outperformed PSA alone which, on the same sample set, was able to discriminate PCa from BPH with an AUC of 0.79. To improve the clinical managing of PCa patients, an explorative small-scale analysis (79 samples) aimed at distinguishing AG-PCa from NAG-PCa was conducted. A predictor of PCa aggressiveness based on the combination of 7 proteomic variables (FCN3, LGALS3BP, AZU1, C6, LAMB1, CHL1, POSTN) and proPSA was developed (AUC of 0.69). CONCLUSIONS: To address the impelling need of more sensitive and specific serum diagnostic tests, a predictive model combining proteomic and clinical variables was developed. A preliminary evaluation to build a new tool able to discriminate aggressive presentations of PCa from tumors with benign behavior was exploited. This predictor displayed moderate performances, but no conclusions can be drawn due to the limited number of the sample cohort. Data are available via ProteomeXchange with identifier PXD035935.

A New Concept for Minimally Invasive Surgical Treatment in Renal Cancer: The Use of Neuroaxial Anesthesia During Laparoscopic Partial Nephrectomy.

A new concept for minimally invasive treatment involves abdominal laparoscopic surgery performed while the patient breathes independently without losing consciousness. Here we report the first series of laparoscopic partial nephrectomy (LPN) performed under neuroaxial anesthesia (NA). From May 2021 to September 2022 we prospectively enrolled selected patients with an organ-confined single renal mass to undergo LPN under NA. Anesthesia was administered using an epidural catheter placed at the level of T7, with additional anesthesia at the level of T10. The rationale was to avoid use of a tracheal tube and the side effects of general anesthesia. Ten patients were enrolled in the study. Targeted sedation was achieved in all cases. In one case, a switch to general anesthesia was needed because of patient anxiety. Food intake started at 12 h after surgery in 9/10 cases; mobilization started from 3 h after surgery. The length of hospital stay was 3 d in 4/10 cases and 4 d in 3/10 cases. This first experience worldwide of LPN performed under NA demonstrates the feasibility and safety of the procedure.

Neuraxial anesthesia versus general anesthesia in patients undergoing three-dimensional laparoscopic radical prostatectomy: Preliminary results of a prospective comparative study.

Objective: Neuraxial anesthesia (NA) showed to reduce both morbidity and mortality in patients undergoing laparoscopic surgery. We aimed to investigate the use of NA in patients undergoing transperitoneal three-dimensional laparoscopic radical prostatectomy (t-3DLRP) and compare the intraoperative and postoperative outcomes with a control group of patients undergoing t-3DLRP under general anesthesia (GA). Methods: A prospective, double-center, double-surgeon study cohort of 84 consecutive patients undergoing t-3DLRP between June 2019 and June 2021 was analyzed. A study group of 42 patients undergoing t-3DLRP under NA was compared with a control group of 42 patients undergoing t-3DLRP under GA. Results: The two group were similar in all demographic, clinical, and pathological variables. Postoperative blood gas parameters were within physiologic limits in both groups. Muscle relaxation was adequate for surgery during both NA and GA. Median length of stay was 1 day shorter for NA group than GA group (5 days vs. 6 days, p=0.05). t-3DLRP under NA had a statistically lower rate of minor complications (4.8% vs. 19.0%, p=0.03) and less postoperative pain (median numeric rating scale 3 vs. 4, p=0.01) compared to GA. No major complications were observed in both groups. Significantly more patients were willing to undergo a similar intervention under NA than GA (p=0.04). Conclusion: t-3DLRP under NA is a feasible and safe procedure, with less postoperative pain and fewer minor complications than the same procedure under GA. NA allows the maintenance of muscle relaxation and respiratory excursions without interfering with surgery.

Artificial Intelligence-Based Hyper Accuracy Three-Dimensional (HA3D®) Models in Surgical Planning of Challenging Robotic Nephron-Sparing Surgery: A Case Report and Snapshot of the State-of-the-Art with Possible Future Implications.

Recently, 3D models (3DM) gained popularity in urology, especially in nephron-sparing interventions (NSI). Up to now, the application of artificial intelligence (AI) techniques alone does not allow us to obtain a 3DM adequate to plan a robot-assisted partial nephrectomy (RAPN). Integration of AI with computer vision algorithms seems promising as it allows to speed up the process. Herein, we present a 3DM realized with the integration of AI and a computer vision approach (CVA), displaying the utility of AI-based Hyper Accuracy Three-dimensional (HA3D®) models in preoperative planning and intraoperative decision-making process of challenging robotic NSI. A 54-year-old Caucasian female with no past medical history was referred to the urologist for incidental detection of the right renal mass. Preoperative contrast-enhanced abdominal CT confirmed a 35 × 25 mm lesion on the anterior surface of the upper pole (PADUA 7), with no signs of distant metastasis. CT images in DICOM format were processed to obtain a HA3D® model. RAPN was performed using Da Vinci Xi surgical system in a three-arm configuration. The enucleation strategy was achieved after selective clamping of the tumor-feeding artery. Overall operative time was 85 min (14 min of warm ischemia time). No intra-, peri- and post-operative complications were recorded. Histopathological examination revealed a ccRCC (stage pT1aNxMx). AI is breaking new ground in medical image analysis panorama, with enormous potential in organ/tissue classification and segmentation, thus obtaining 3DM automatically and repetitively. Realized with the integration of AI and CVA, the results of our 3DM were accurate as demonstrated during NSI, proving the potentialities of this approach for HA3D® models' reconstruction.

Data-Independent Acquisition Mass Spectrometry of EPS-Urine Coupled to Machine Learning: A Predictive Model for Prostate Cancer.

Prostate cancer (PCa) is annually the most frequently diagnosed cancer in the male population. To date, the diagnostic path for PCa detection includes the dosage of serum prostate-specific antigen (PSA) and the digital rectal exam (DRE). However, PSA-based screening has insufficient specificity and sensitivity; besides, it cannot discriminate between the aggressive and indolent types of PCa. For this reason, the improvement of new clinical approaches and the discovery of new biomarkers are necessary. In this work, expressed prostatic secretion (EPS)-urine samples from PCa patients and benign prostatic hyperplasia (BPH) patients were analyzed with the aim of detecting differentially expressed proteins between the two analyzed groups. To map the urinary proteome, EPS-urine samples were analyzed by data-independent acquisition (DIA), a high-sensitivity method particularly suitable for detecting proteins at low abundance. Overall, in our analysis, 2615 proteins were identified in 133 EPS-urine specimens obtaining the highest proteomic coverage for this type of sample; of these 2615 proteins, 1670 were consistently identified across the entire data set. The matrix containing the quantified proteins in each patient was integrated with clinical parameters such as the PSA level and gland size, and the complete matrix was analyzed by machine learning algorithms (by exploiting 90% of samples for training/testing using a 10-fold cross-validation approach, and 10% of samples for validation). The best predictive model was based on the following components: semaphorin-7A (sema7A), secreted protein acidic and rich in cysteine (SPARC), FT ratio, and prostate gland size. The classifier could predict disease conditions (BPH, PCa) correctly in 83% of samples in the validation set. Data are available via ProteomeXchange with the identifier PXD035942.

Multiparametric Magnetic Resonance Imaging-Ultrasound Fusion Transperineal Prostate Biopsy: Diagnostic Accuracy from a Single Center Retrospective Study.

The management of prostate biopsy in men with clinical suspicion of prostate cancer has changed in the last few years, especially with the introduction of imaging techniques, to overcome the low efficacy of risk stratification based on PSA levels. Here, we aimed to compare the diagnostic accuracy of multiparametric MRI with fusion ultrasound-guided prostate biopsy and standard biopsy, both performed through the transperineal route. To this end, we retrospectively analyzed 272 patients who underwent combined transperineal targeted and standard biopsy during the same session. The primary outcome was to compare the cancer detection rate between targeted and standard biopsy. The secondary outcome was to evaluate the added value of combined targeted and standard biopsy approach as compared to only targeted or standard biopsy. Results showed that a rate of 16.7% clinically significant tumors (International Society of Urological Pathology (ISUP) grade ≥ 2) would have been lost if only the standard biopsy had been used. The combined targeted and standard biopsy showed an added value of 10.3% and 9.9% in reducing the risk of prostate cancer missing after targeted or standard biopsy alone, respectively. The combined targeted and standard biopsy pathway is recommended to reduce the risk of missing clinically significant prostate cancer.

Proteomic Profile of EPS-Urine through FASP Digestion and Data-Independent Analysis.

Filter-aided sample protocol (FASP) is widely used for proteomics sample preparation because it allows to concentrate diluted samples and it is compatible with a wide variety of detergents. Bottom-up proteomics workflows like FASP increasingly rely on LC-MS/MS methods performed in data-independent analysis (DIA) mode, a scanning method that allows deep proteome coverage and low incidence of missing values. In this report, we will provide the details of a workflow that combines a FASP protocol, a double StageTip purification step and LC-MS/MS in DIA mode for urinary proteome mapping. As a model sample, we analyzed expressed prostatic secretions (EPS)-urine, a sample collected after a digital rectal exam (DRE), which is of interest in prostate cancer biomarker discovery studies.

Athermal versus ultrasonic nerve-sparing laparoscopic radical prostatectomy: a comparison of functional and oncological outcomes.

PURPOSE: Many urologists emphasize the concept of heat-related damage suggesting the avoidance of any energy to perform nerve-sparing radical prostatectomy. At our institution, both athermal and ultrasonic dissection have been used over the last years to perform a nerve-sparing laparoscopic radical prostatectomy (NSLRP). In this study, we compare functional and oncological outcomes of the two procedures. METHODS: All charts from patients undergoing NSLRP between January 2009 and June 2015 were reviewed. The International Index of Erectile Function (IIEF-5) was recorded preoperatively and 3, 12 and 24 months after surgery; continence was recorded at 3 and 12 months; PSA was recorded at last follow-up. Uni- and multivariate analyses were performed to assess the association of variables with functional and oncological outcomes. RESULTS: Ultrasonic NSLRP was used for 120 patients, while athermal NSLRP on 111. The impact of the cutting technique on erection recovery was different at 3 months, favoring athermal dissection (p = 0.002); however, significance was lost at 12 (p = 0.09) and 24 (p = 0.14) months. Continence recovery was comparable at 3 (p = 0.1) and 12 (p = 0.2) months; the rate of positive surgical margins and PSA recurrence were also similar (p = 0.2 and p = 0.06, respectively). At univariate analysis, age, Gleason sum, nerve-sparing laterality, and extension (intra- vs interfascial) were associated with overall erection recovery; only age and nerve-sparing laterality were independent predictors. Age and preoperative TRUS prostate volume were associated with continence recovery, both at uni- and multivariate analysis. CONCLUSIONS: The use of an ultrasonic device compared to athermal dissection during NSLRP does not affect long-term potency, nor continence and early biochemical recurrence.

Diagnostic Accuracy of Hexaminolevulinate in a Cohort of Patients Undergoing Radical Cystectomy.

PURPOSE: To compare the accuracy of white light cystoscopy (WLC) and blue light cystoscopy (BLC) in a cohort of patients undergoing radical cystectomy (RC) for previously resected urothelial bladder cancer. PATIENTS AND METHODS: A cohort of patients undergoing RC received WLC and BLC prior radical surgery. To evaluate the residual tumor rate, the bladder was inspected after its removal and normal appearing mucosa sampled for histologic analysis. Lesions detected under WLC, BLC, or both, and biopsy samples from normal appearing mucosa, were all recorded separately. RESULTS: Starting 2011, 64 patients underwent WLC and BLC prior cystectomy. Overall, 540 tissue samples were collected during cystoscopy and from normal appearing mucosa. Residual disease was found in 31/64 (48.4%) patients, including 27 (42.1%) cases of carcinoma in situ (CIS). The accuracy of BLC was much higher than WLC, both in the diagnosis of any residual disease (87.1% vs 32.3%, and 87.9% vs 51.5%, for sensitivity and specificity, respectively), as of CIS only (92.6% vs 29.6% and 83.8% vs 51.4%). We further evaluated the diagnostic accuracy as a result of the analysis on all specimens collected during the study. A total of 535 specimens were analyzed, and 58 specimens with residual disease were found, including 48 CIS foci. Again, detection rates and measures of accuracy were much better for BLC vs WLC, both overall (86.2% vs 31%, and 98.3% vs 93.3%, for sensitivity and specificity, respectively), and when CIS only was considered (89.6% vs 31.2% and 96.9% vs 92.8%). CONCLUSIONS: Although BLC missed 12.9% of positive patients, and 7.4% of those with CIS, the agreement between BLC diagnostic accuracy and the definitive pathology was very robust.

Renal transplantation: technical aspects, diagnosis and management of early and late urological complications.

INTRODUCTION: Renal transplantation (RT) represents actually the most effective therapy in patients with end-stage renal failure as it is cost effective, allows for a normal life style and reduces the risk of mortality from dialysis related complications. The purpose of the present review is to update the recent published literature regarding the technical aspects, diagnosis and the urological complications associated with renal transplantation. EVIDENCE ACQUISITION: A comprehensive literature review was performed using PubMed and Thomson-Reuters Web of Science between February 2014 and June 2016. Using free-text protocol, the following terms were applied: "chronic kidney failure", "renal transplantation", "robot-assisted surgery", "laparoscopy", "living donor nephrectomy", "surgical techniques", "urological complications". EVIDENCE SYNTHESIS: RT represents actually the most effective therapy in patients with end-stage renal failure as it is cost effective, allows for a normal life style and reduces the risk of mortality from dialysis related complications. In the last 2 years, an increased number of published studies on the use of robot-assisted surgery for RT has been presented. CONCLUSIONS: We could expect that in the next future RKT and LDN are both destined to replace open surgery also in a special field as RT.

Leydig cell tumour and giant adrenal myelolipoma associated with adrenogenital syndrome: a case report with a review of the literature.

CONTEXT: Male patients with congenital adrenal hyperplasia (CAH) may develop bilateral testicular adrenal rest tumours (TARTs). These tumours, in most cases, regress with glucocorticoid therapy and their histological differentiation from Leydig-cell tumors is quite difficult. OBJECTIVE: The aim of this study was to differentiate the histological and clinical features of the TARTs from those of the Leydig-cell tumours. METHODS: The authors report a case of bilateral Leydig-cell tumour associated with giant bilateral adrenal myelolipoma in a male with adrenogenital syndrome who was submitted to a bilateral orchiectomy. RESULTS: Testicular neoplasia continue to grow despite adequate hormonal treatment and a bilateral orchiectomy was performed. The histopathological examination of the specimen ultimately confirmed the diagnosis of bilateral Leydig-cell tumour. CONCLUSIONS: This case shows the importance of all the relevant examinations, blood chemistry analysis, and instrumental tests in the differential diagnosis of TARTs and other testicular tumours.

Minilaparoendoscopic Single-site Pyeloplasty: The Best Compromise Between Surgeon's Ergonomy and Patient's Cosmesis (IDEAL Phase 2a).

BACKGROUND: Laparoendoscopic single-site (LESS) surgery and minilaparoscopy (ML) represent the evolution of laparoscopy for the treatment of urologic diseases. OBJECTIVE: To describe the technique and report the surgical outcomes of minilaparoendoscopic single-site dismembered pyeloplasty (MILESS-DP), a new technique overcoming the technical limitations of LESS and ML, and equally combining the advantages of both these surgical procedures. DESIGN, SETTING, AND PARTICIPANTS: Twenty consecutive patients underwent MILESS-DP for ureteropelvic junction obstruction. SURGICAL PROCEDURE: The SILS port was inserted through a transumbilical incision and two 3-mm trocars were inserted in the ipsilateral midclavicular line. The sequence of steps of MILESS-DP is comparable to standard laparoscopic dismembered pyeloplasty. MEASUREMENTS: The end points of this study were: (1) feasibility; (2) safety; (3) efficacy; and (4) cosmesis, evaluated using a body image questionnaire. RESULTS AND LIMITATIONS: All patients were symptomatic (100%) and three (15%) had concomitant kidney stones. (1) Feasibility: a conversion to either standard laparoscopic technique or open technique did not occur in any case. Median operative time was 147.3min (interquartile range [IQR]: 110-195min); (2) safety: no intraoperative complications were reported. Only in two patients (10%), a urinoma was postoperatively identified and conservatively treated with an ureteral stent. The median difference in post- and preoperative creatinine and haemoglobin was +0.55mg/dl and -0.76mg/dl (IQR: -0.20/-1.20mg/dl); (3) efficacy: the median postoperative hospital stay was 4.4 d (IQR: 4-9 d). The overall success rate was 95% at the follow-up; (4) cosmesis: all patients were enthusiastic with the appearance of the scars; the median body image score and the median cosmesis score were 19.95 (IQR 19-20) and 23.95 (IQR 23-24), respectively. The limitations of this study are the limited series and short follow-up. CONCLUSIONS: Our phase 2a studies demonstrate that MILESS-DP is a safe and reproducible procedure with excellent cosmetic outcomes and short-term clinical outcomes in the hands of a surgical team with experience in laparoscopy. PATIENT SUMMARY: Minilaparoscopy using 3-mm instruments and laparoendoscopic single-site using a single abdominal incision, still present several technical drawbacks which limit their reproducibility in urology. In order to overcome these technical limitations and equally combining the advantages of both these surgical procedures, we ideated a hybrid technique which we defined minilaparoendoscopic single-site. This study aims to demonstrate that minilaparoendoscopic single-site pyeloplasty is a safe and reproducible procedure with excellent cosmetic outcomes and short-term clinical outcomes in the hands of a surgical team with experience in mini-invasive surgery.

Celecoxib for the prevention of nonmuscle invasive bladder cancer: results from a matched control study.

OBJECTIVES: New targets and approaches are under investigation for the treatment of nonmuscle invasive bladder cancer (NMIBC). Preclinical data suggest cyclooxygenase-2 (COX-2) as a promising target. Celecoxib, a COX-2 selective inhibitor, inhibits tumor development and enhances survival, both in vitro and in vivo models of bladder cancer. Therefore, we conducted a pilot study of celecoxib to prevent recurrence in patients with intermediate risk NMIBC. METHODS: Treatment with celecoxib was administered orally for 12 months and compared with a contemporary series of patients treated with intravesical mitomycin C (MMC), given weekly for 4 weeks and then monthly for 11 months. Primary endpoints were time to first recurrence and adverse events. RESULTS: From 2003 through 2006, 58 patients were treated with celecoxib and compared with 66 patients receiving MMC. After a median follow up of 75 months, 49 patients were disease free, including 23 (34.85%) in the MMC group and 26 (44.8%) in the celecoxib group. Median disease-free interval was 67 months [95% confidence interval (CI) 35.8 to NA] versus 41 months (95% CI 27.1-67.1; log-rank p = 0.25) for patients treated with MMC and celecoxib, respectively. In the multivariate analysis, treatment was not found to be an independent predictor for recurrence [hazard ratio (HR) 0.76, 95% CI 0.47-1.22, p = 0.25). Overall, 45 AEs were recorded in 35/124 patients. There were no differences between the two groups. CONCLUSIONS: Our data support a clinical benefit of celecoxib and encourage future trials in which COX-2 inhibitors may be tested in selected patients with NMIBC.

Laparoscopic radical cystectomy with extracorporeal ileal neobladder for muscle-invasive urothelial carcinoma of the bladder: technique and short-term outcomes.

OBJECTIVES: To report the surgical outcomes of laparoscopic radical cystectomy (LRC) with extracorporeal orthotopic ileal neobladder (OIN) in patients with muscle-invasive urothelial carcinoma of the bladder (UCB). MATERIALS AND METHODS: Between October 2009 and December 2011, 37 patients with muscle-invasive UCB underwent a LRC with OIN. Indications included (a) muscle-invasive UCB T2-4a, N0-Nx, M0; (b) high-risk and recurrent non-muscle-invasive tumors; (c) T1G3 plus CIS; and (d) extensive non-muscle-invasive disease that could not be controlled by transurethral resection and intravesical therapy. Demographic data, perioperative, and postoperative variables were recorded and analyzed. RESULTS: The median operating time was 330 min, with a median estimated blood loss of 410 ml. Median length of stay was 12 days, and the mean length of the skin incision to extract the specimen and for the configuration of the neobladder was 7 ± 1 cm. The complication rate was 21.6 % (Clavien II). No Clavien III-V complications were reported. Daytime and nocturnal continence were preserved in 95 and 78 %, respectively. No local recurrence or port site metastasis occurred. Median time to disease recurrence was 14 months (IQR 9-24), and 1-year cancer-specific survival was 91.9 %. CONCLUSIONS: Laparoscopic radical cystectomy with extracorporeal ileal neobladder is a challenging procedure but technically feasible, allowing low morbidity and oncological safety. Long-term oncological results are required to definitely recognize this procedure as a standard treatment for bladder cancer.