External validation of a nomogram for outcome prediction in management of medium-sized (1-2 cm) kidney stones.

BACKGROUND: Stone nomogram by Micali et al., able topredict treatment failure of shock-wave lithotripsy (SWL), retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PNL) in the management of single 1-2 cm renal stones, was developed on 2605 patients and showed a high predictive accuracy, with an area under ROC curve of 0.793 at internal validation. The aim of the present study is to externally validate the model to assess whether it displayed a satisfactory predictive performance if applied to different populations. METHODS: External validation was retrospectively performed on 3025 patients who underwent an active stone treatment from December 2010 to June 2021 in 26 centers from four countries (Italy, USA, Spain, Argentina). Collected variables included: age, gender, previous renal surgery, preoperative urine culture, hydronephrosis, stone side, site, density, skin-to-stone distance. Treatment failure was the defined outcome (residual fragments >4 mm at three months CT-scan). RESULTS: Model discrimination in external validation datasets showed an area under ROC curve of 0.66 (95% 0.59-0.68) with adequate calibration. The retrospective fashion of the study and the lack of generalizability of the tool towards populations from Asia, Africa or Oceania represent limitations of the current analysis. CONCLUSIONS: According to the current findings, Micali's nomogram can be used for treatment prediction after SWL, RIRS and PNL; however, a lower discrimination performance than the one at internal validation should be acknowledged, reflecting geographical, temporal and domain limitation of external validation studies. Further prospective evaluation is required to refine and improve the nomogram findings and to validate its clinical value.

Open versus Robot-Assisted Radical Cystectomy for the Treatment of pT4a Bladder Cancer: Comparison of Perioperative Outcomes.

We compared the perioperative outcomes of open (ORC) vs. robot-assisted (RARC) radical cystectomy in the treatment of pT4a MIBC. In total, 212 patients underwent ORC (102 patients, Group A) vs. RARC (110 patients, Group B) for pT4a bladder cancer. Patients were prospectively followed and retrospectively reviewed. We assessed operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of stay, transfusion rate, and oncological outcomes. Preoperative features were comparable. The mean operative time was 232.8 vs. 189.2 min (p = 0.04), and mean EBL was 832.8 vs. 523.7 mL in Group A vs. B (p = 0.04). An intraoperative transfusion was performed in 32 (31.4%) vs. 11 (10.0%) cases during ORC vs. RARC (p = 0.03). The intraoperative complications rate was comparable. The mean length of stay was shorter after RARC (12.6 vs. 7.2 days, p = 0.02). Postoperative transfusions were performed in 36 (35.3%) vs. 13 (11.8%) cases (p = 0.03), and postoperative complications occurred in 37 (36.3%) vs. 29 (26.4%) patients in Groups A vs. B (p = 0.05). The positive surgical margin (PSM) rate was lower after RARC. No differences were recorded according to the oncological outcomes. ORC and RARC are feasible treatments for the management of pT4a bladder tumors. Minimally invasive surgery provides shorter operative time, bleeding, transfusion rate, postoperative complications, length of stay, and PSM rate.

Percutaneous Ablation of T1 Renal Masses: Comparative Local Control and Complications after Radiofrequency and Cryoablation.

The efficacy and complication rates of percutaneous radiofrequency ablation (RFA) and cryoablation (CA) in the treatment of T1 renal masses in two Northern Italy hospitals were retrospectively investigated. Eighty-two patients with 80 T1a tumors and 10 T1b tumors treated with thermal ablation from 2015 through 2020 were included. A total of 43 tumors in 38 patients were treated with RFA (2.3 ± 0.9 cm), and 47 tumors in 44 patients were treated with CA (2.1 ± 0.8 cm). The mean follow-up observation period was 26 ± 19 months. The major complications and efficacy, as measured using the technical success and local tumor recurrence rates, were recorded. There were three (6.9%) technical failures with RFA and one (2.1%) with cryoablation (p = 0.30). Among the 40 tumors that were successfully treated with RFA, 1 tumor (2.5%) developed local tumor recurrence; 5/46 tumors that were treated with cryoablation (10.8%) developed local tumor recurrence (p = 0.17). T1b lesions (4.0 ± 0.7 cm) resulted in 1/6 technically unsuccessful cases with RFA and 0/4 with CA. No recurrent disease was detected in the T1b lesions. Major complications occurred after 2.3% (1/43) of RFAs and 0/47 of cryoablation procedures. RFA and cryoablation are both effective in the treatment of renal masses. Major complications with either procedure are uncommon.

Stone-scoring systems for predicting complications in percutaneous nephrolithotomy: A systematic review of the literature.

Objective: Percutaneous nephrolithotomy is a treatment of choice for larger stones of the upper urinary tract. Currently, several nephrolithometric nomograms for prediction of post-operative surgical outcomes have been proposed, although uncertainties still exist regarding their roles in the estimation of complications. Methods: We conducted a systematic review on PubMed and Web of Sciences databases including English studies with at least 100 cases and published between January 2010 and December 2021. We identified original articles evaluating correlations between the Guy's stone score, the stone size (S), tract length (T), obstruction (O), number of involved calices (N), and essence or stone density (E) (S.T.O.N.E.), Clinical Research Office of the Endourological Society (CROES), and Seoul National University Renal Stone Complexity (S-ReSC) scores and post-operative complications in adult patients. We also included newly designed nomograms for prediction of specific complications. Results: After an initial search of 549 abstracts, we finally included a total of 18 papers. Of them, 11 investigated traditional nephrolithometric nomograms, while seven newly designed nomograms were used to predict specific complications. Overall, 7316 patients have been involved. In total, 14 out of 18 papers are derived from retrospective single-center studies. Guy's stone score obtained correlation with complications in five, S.T.O.N.E. nephrolithometry score in four, while CROES score and S-ReSC score in three and two, respectively. None of the studies investigated minimally invasive percutaneous nephrolithotomy (PCNL) and all cases have been conducted in prone position. Considering newly designed nomograms, none of them is currently externally validated; five of them predict post-operative infections; the remaining two have been designed for thromboembolic events and urinary leakage. Conclusion: This review presents all nomograms currently available in the PCNL field and highlights a certain number of concerns. Published data have appeared contradictory; more recent tools for prediction of post-operative complications are frequently based on small retrospective cohorts and lack external validations. Heterogeneity among studies has also been noticed. More rigorous validations are advisable in the future, involving larger prospective patients' series and with the comparison of different tools.

The role of warm ischemia time on functional outcomes after robotic partial nephrectomy: a radionuclide renal scan study from the clock randomized trial.

PURPOSE: To evaluate the relationship between warm ischemia time (WIT) duration and renal function after robot-assisted partial nephrectomy (RAPN). METHODS: The CLOCK trial is a phase 3 randomized controlled trial comparing on- vs off-clamp RAPN. All patients underwent pre- and postoperative renal scintigraphy. Six-month absolute variation of eGFR (AV-GFR), rate of relative variation in eGFR over 25% (RV-GFR > 25), absolute variation of split renal function (SRF) at scintigraphy (AV-SRF). The relationships WIT/outcomes were assessed by correlation graphs and then modeled by uni- and multivariable regression. RESULTS: 324 patients were included (206 on-clamp, 118 off-clamp RAPN). Correlation graphs showed a threshold on WIT equal to 10 min. The differences in outcome measures between cases with WIT < vs ≥ 10 min were: AV-GFR - 3.7 vs - 7.5 ml/min (p < 0.001); AV-SRF - 1% vs - 3.6% (p < 0.001); RV-GFR > 25 9.3% vs 17.8% (p = 0.008). Multivariable models found that AV-GFR was related to WIT ≥ 10 min (regression coefficient [RC] - 0.52, p = 0.019), age (RC - 0.35, p = 0.001) and baseline eGFR (RC - 0.30, p < 0.001); RV-GFR > 25 to WIT ≥ 10 min (odds ratio [OR] 1.11, p = 0.007) and acute kidney injury defined as > 50% increase in serum creatinine (OR 19.7, p = 0.009); AV-SRF to WIT ≥ 10 min (RC - 0.30, p = 0.018), baseline SRF (RC - 0.76, p < 0.001) and RENAL score (RC - 0.60. p = 0.028). The main limitation was that the CLOCK trial was designed on a different endpoint and therefore the present analysis could be underpowered. CONCLUSIONS: Up to 10 min WIT had no consequences on functional outcomes. Above the 10-min threshold, a statistically significant, but clinically negligible impact was found.

Corrigendum to "Rectal Perforation During Pelvic Surgery" [Eur Urol Open Sci 44 (2022) 54-59].

[This corrects the article DOI: 10.1016/j.euros.2022.04.006.].

Inguinal lymphadenectomy in penile cancer patients: a comparison between open and video endoscopic approach in a multicenter setting.

OBJECTIVES: To compare differences of operative outcomes, post-operative complications and survival outcomes between open and laparoscopic cases in a multicenter study. METHODS: This was a retrospective cohort study performed at three European centers from September 2011 to January 2019. The surgeon decision to perform open inguinal lymphadenectomy (OIL) or video endoscopic inguinal lymphadenectomy (VEIL) was done in each hospital after patient counselling. Inclusion criteria regarded a minimum follow-up of 9 months since the inguinal lymphadenectomy. RESULTS: A total of 55 patients with proven squamous cell penile cancer underwent inguinal lymphadenectomy. 26 of them underwent OIL, while 29 patients underwent VEIL. For the OIL and VEIL groups, the mean operative time was 2.5 vs. 3.4 h (p=0.129), respectively. Hospital stays were lower in the VEIL group with 4 vs. 8 days in OIL patients (p=0.053) while number of days requiring drains to remain in situ was 3 vs. 6 days (p=0.024). The VEIL group reported a lower incidence of major complications compared to the OIL group (2 vs. 17%, p=0.0067) while minor complications were comparable in both groups. In a median follow-up period of 60 months, the overall survival was 65.5 and 84.6% in OIL and VEIL groups, respectively (p=0.105). CONCLUSIONS: VEIL is comparable to OIL regarding safety, overall survival and post-operative outcomes.

The Therapeutic Intensity Score as Predictor of Clinical Outcomes after Total and Partial Adrenalectomy for Unilateral Primary Aldosteronism: Results of a Multicentric Series.

BACKGROUND: To evaluate the ability of therapeutic intensity score (TIS) in predicting the clinical outcomes of partial (PA) and total adrenalectomy (TA) for UPA. METHODS: Between 2011 and 2022, a four-center adrenalectomy dataset was queried for "unilateral adrenal mass" and "UPA" (n = 90). Preoperative TIS of each antihypertensive medication were individually calculated and merged to create a single, cumulative variable. Probability of complete clinical, partial, and absent pooled success rates according to TIS were assessed for the overall cohort by Kaplan-Meier. Cox analyses were used to identify predictors of complete clinical and partial/absent success, respectively. For all analyses, a two-sided p < 0.05 was considered significant. RESULTS: At a median follow-up of 42 months (IQR 27-54) complete partial, and absent clinical success were observed in 60%, 17.7%, and 22.3%, respectively. On Kaplan-Meier analysis, TIS < 1 predicted higher complete success rates (p < 0.001), while TIS ≥ 1 was predictor of either partial and absent clinical success (p = 0.008). On multivariable analysis, TIS < 1 (HR 0.25; 95% CI 0.11-0.57; p = 0.001) and adenoma size (HR 1.11; 95% CI 1-1.23; p = 0.0049) were independent predictors of complete clinical success, while TIS ≥ 1 (HR 2.84; 95% CI 1.32-6.1; p = 0.007) was the only independent predictor of absent clinical success. CONCLUSIONS: TIS score and adenoma size may help to identify patients who are likely to be at risk of persistent hypertension after surgery.

Reliability of nephrolithometric nomograms in patients treated with minimally invasive percutaneous nephrolithotomy: A precision study.

Objectives: The study aimed to evaluate quality of nephrolithometric nomograms to predict stone-free rates (SFRs) and complication rates (CRs) in case of minimally invasive percutaneous nephrolithotomy (PNL). In the last decade, nomograms have been introduced to estimate the SFRs and CRs of PNL. However, no data are available regarding their reliability in case of utilization of miniaturized devices. Herein we present a prospective multicentric study to evaluate reliability of Guy's stone score (GSS), the stone size, tract length, obstruction, number of involved calyces, and essence of stone (S.T.O.N.E.) nephrolithometry score and Clinical Research Office of the Endourological Society (CROES) score in patients treated with minimally invasive PNL. Methods: We evaluated SFRs and CRs of 222 adult patients treated with miniaturized PNL. Patients were considered stone-free if no residual fragments of any size at post-operative unenhanced computed tomography scan. Patients demographics, SFRs, and CRs were reported and analyzed. Performances of nomograms were evaluated with the area under the curve (AUC). Results: We included 222 patients, the AUCs of GSS, CROES score, and S.T.O.N.E. nephrolithometry score were 0.69 (95% confidence interval [CI] 0.61-0.78), 0.64 (95% CI 0.56-0.73), and 0.62 (95% CI 0.52-0.71), respectively. Regarding SFRs, at multivariate binomial logistic regression, only the GSS had significance with an odds ratio of 0.53 (95% CI 0.31-0.95, p=0.04). We did not find significant correlation with complications, with only a trend for GSS. Conclusion: This is the first study evaluating nomograms in miniaturized PNL. They still show good reliability; however, our data showed lower performances compared to standard PNL. We emphasize the need of further studies to confirm this trend. A dedicated nomogram for minimally invasive PNL may be necessary.

Learning Curve for Endoscopic Combined Intra-Renal Surgery Using Vacuum-Assisted Device.

INTRODUCTION: The aim of the study was to provide data related to endoscopic combined intra-renal surgery learning curve using minimally invasive techniques with vacuum-assisted devices. Minimal data exist on the learning curve for these techniques. METHODS: We conducted a prospective study monitoring the training of a mentored surgeon learning ECIRS with vacuum assistance. We use varied parameters for improvements. After collection of peri-operative data, tendency lines and CUSUM analysis were used to investigate the learning curves. RESULTS: 111 patients have been included. Guy's Stone Score 3 and 4 stones 51.3% of all cases. The mostly used percutaneous sheath was 16 Fr (87.3%). SFR was 78.4%. 52.3% patients were tubeless, and 38.7% achieved trifecta. High-degree complication rate was 3.6%. Operative time improved after 72 cases. We observed a decrease of complications throughout the case series, with improvement after 17 cases. In terms of trifecta, proficiency was reached after 53 cases. Proficiency seems achievable in a limited number of procedures, but results did not plateau. Higher number of cases might be necessary for excellence. DISCUSSION: A surgeon learning ECIRS with vacuum assistance can obtain proficiency in 17-50 cases. The number of procedures required for excellence remains unclear. Exclusion of more complex cases might positively affect the training, reducing unnecessary complications.

Percutaneous Ablation vs Robot-Assisted Partial Nephrectomy for Completely Endophytic Renal Masses: A Multicenter Trifecta Analysis with a Minimum 3-Year Follow-Up.

Purpose: To compare outcomes of robot-assisted partial nephrectomy (RAPN) and percutaneous tumor ablation (PTA) for completely endophytic renal masses. Methods: Data of patients who underwent RAPN or PTA for treatment of completely endophytic (three points for "E" domain of R.E.N.A.L. score) were collected from seven high-volume U.S. and European centers. PTA included cryoablation, radiofrequency, or microwave ablation. Baseline characteristics, clinical, surgical, and postoperative outcomes were compared. Recurrence-free survival (RFS) was calculated with Kaplan-Meier analysis. Trifecta was used as arbitrary combined outcome parameter as proxy for treatment "quality." Multivariable logistic regression model assessed predictors of trifecta failure. Results: One hundred fifty-two patients (RAPN, n = 60; PTA, n = 92) were included in the analysis. RAPN group was younger (p < 0.001), had lower American Society of Anesthesiologists score (p = 0.002), and higher baseline estimated glomerular filtration rate (p < 0.001). There was no difference in clinical tumor size, clinical T stage, and tumor complexity scores. PTA had significantly lower rate of overall (p < 0.001) and minor (p < 0.001) complications. ΔeGFR at 1 year was statistically higher for RAPN (-15.5 mL/min vs -3.1 mL/min; p = 0.005), no difference in ΔeGFR at last follow-up (p = 0.22) was observed. No difference in recurrences (RAPN, n = 2; PTA, n = 6) and RFS was found (p = 0.154). Trifecta achievement was higher for RAPN but not statistically different (65.3% vs 58.8%; p = 0.477). R.E.N.A.L. Nephrometry Score resulted predictive of trifecta failure (odds ratio = 1.47; confidence interval = 1.13-1.90; p = 0.004). Conclusions: PTA confirms to be an effective treatment for completely endophytic renal masses, offering low complications and good mid-term functional and oncologic outcomes. These outcomes compare favorably with those of RAPN, which seem to be the preferred option for younger and less comorbid patients.

Percutaneous thermal ablation for cT1 renal mass in solitary kidney: A multicenter trifecta comparative analysis versus robot-assisted partial nephrectomy.

INTRODUCTION: Renal cell carcinoma (RCC) in solitary kidney (SK) represents a challenging scenario. We sought to compare outcomes of robot-assisted partial nephrectomy (RAPN) versus percutaneous thermal ablation (PTA) in SK patients with renal tumors cT1. MATERIALS AND METHODS: We performed a multicenter retrospective analysis of SK patients treated for RCC. The PTA group included cryoablation or radiofrequency ablation. We collected baseline characteristics, intraoperative, pathological, and post-operative data. We applied an arbitrary composite "trifecta" to assess surgical, functional, and oncological outcomes, only for malignant histology. RFS analysis was performed using the Kaplan-Meier method. Multivariable regression analysis was performed to determine independent predictors of "trifecta" achievement. RESULTS: We included 198 SK patients (RAPN, n = 50; PTA n = 119). Mean clinical tumor size was not significantly different while R.E.N.A.L. score was higher for RAPN (p < 0.001). No differences in intra and major post-procedural complications. Recurrence rate was higher in PTA group but not statistically significant (p < 0.328). No difference in metastasis rate was found (p = 0.435). RFS was 96.1% in RAPN and 86.8% in PTA cohort (p = 0.003) while no difference in PFS was detected (p = 0.1). Trifecta was achieved in 72.5% of RAPN vs 77.3% of PTA (p = 0.481). Multivariable analysis has not detected predictors for Trifecta achievement. CONCLUSION: PTA offers good outcomes in the management of SK patients with RCC. Compared with RAPN, it might carry a higher risk of recurrence; on the other hand, re-treatment is possible. Overall, PTA can be safely offered to treat SK patients presenting RCC. In general, it should be preferred in more frail patients to minimize the risk of complications.

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

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

External validation of yonsei nomogram predicting chronic kidney disease development after partial nephrectomy: An international, multicenter study.

OBJECTIVE: To externally validate Yonsei nomogram. METHODS: From 2000 through 2018, 3526 consecutive patients underwent on-clamp PN for cT1 renal masses at 23 centers were included. All patients had two kidneys, preoperative eGFR ≥60 ml/min/1.73 m2, and a minimum follow-up of 12 months. New-onset CKD was defined as upgrading from CKD stage I or II into CKD stage ≥III. We obtained the CKD-free progression probabilities at 1, 3, 5, and 10 years for all patients by applying the nomogram found at https://eservices.ksmc.med.sa/ckd/. Thereafter, external validation of Yonsei nomogram for estimating new-onset CKD stage ≥III was assessed by calibration and discrimination analysis. RESULTS AND LIMITATION: Median values of patients' age, tumor size, eGFR and follow-up period were 47 years (IQR: 47-62), 3.3 cm (IQR: 2.5-4.2), 90.5 ml/min/1.73 m2 (IQR: 82.8-98), and 47 months (IQR: 27-65), respectively. A total of 683 patients (19.4%) developed new-onset CKD. The 5-year CKD-free progression rate was 77.9%. Yonsei nomogram demonstrated an AUC of 0.69, 0.72, 0.77, and 0.78 for the prediction of CKD stage ≥III at 1, 3, 5, and 10 years, respectively. The calibration plots at 1, 3, 5, and 10 years showed that the model was well calibrated with calibration slope values of 0.77, 0.83, 0.76, and 0.75, respectively. Retrospective database collection is a limitation of our study. CONCLUSIONS: The largest external validation of Yonsei nomogram showed good calibration properties. The nomogram can provide an accurate estimate of the individual risk of CKD-free progression on long-term follow-up.

Microwave versus cryoablation and radiofrequency ablation for small renal mass: a multicenter comparative analysis.

BACKGROUND: Ablative techniques emerged as effective alternative to nephron-sparing surgery for treatment of small renal masses. Radiofrequency ablation (RFA) and cryoablation (CRYO) are the two guidelines-recommended techniques. Microwave ablation (MWA) represents a newer technology, less described. The aim of the study was to compare outcomes of MWA to those of CRYO and RFA. METHODS: Retrospective investigation of patients who underwent MWA, CRYO, or RFA from seven high-volume US and European centers was performed. The first group included patients who underwent CRYO or RFA; the second MWA. We collected baseline characteristics, clinical, intraoperative, and postoperative data. Oncological data included technical success, local recurrence, and progression to metastasis. Multivariate analysis was performed to find predictors for postoperative complications. A composite outcome of "trifecta" was used to assess surgical, functional, and oncological outcomes. RESULTS: 739 patients underwent CRYO or RFA and 50 MWA. CRYO/RFA group had significantly longer operative time (P<0.001), but no difference in LOS, postprocedural Hb mean, intraprocedural complications (P=0.180), overall postprocedural complication rates (P=0.126), and in the 30-day re-admission rate (P=0.853) were detected. No predictive parameter of postprocedural complications was found. Concerning functional outcome, no differences were detected in terms of eGFR at 1 year (P=0.182), ΔeGFR at 1 year (P=0.825) and eGFR at latest follow-up (P=0.070). "Technical success" was achieved in 98.6% of the cases (MWA=100%, CRYO/RFA=98.5%; P=0.775), and there was no significant difference in terms of 2-year recurrence rate (P=0.114) and metastatic progression (P=0.203). Trifecta was achieved in 73.0% of CRYO/RFA vs. 69.6% of MWA cases (P=0.719). CONCLUSIONS: MWA is a safe and effective treatment option for small renal masses. Compared with CRYO/RFA, it seems to offer low complication rates, shorter operation time, and equivalent surgical and functional outcomes.

ProACT in the management of stress urinary incontinence after radical prostatectomy. What happens after 8 years of follow up? monocentric analysis in 42 patients.

OBJECTIVES: Stress urinary incontinence is defined by a complaint of any involuntary loss of urine on effort or physical exertion or on sneezing or coughing and represents a major complication after radical prostatectomy. According to surgical technique, incidence of post-prostatectomy incontinence varies from open (7-39.5%), laparoscopic (5-33.3%) or robotic-assisted (4-31%) approaches. The ProACT® device (Uromedica, Inc., MN) is a possible surgical option for the treatment of this condition. METHODS: We retrospectively analyzed surgical records of consecutive patients underwent ProACT® implantation in our department between January 2006 to November 2010. We collected data at 6 and 12 months after surgical approach about the daily pad use, International Prostatic Symptoms Score and its quality of life domain. RESULTS: 42 patients were included in the final analysis. Most patients (92.9%) received minimally invasive surgery for treating prostate cancer. During the follow up after 6 and 12 months, the daily pad, International Prostatic Symptom Score and its quality of life domain significantly improved compared to preoperative outcomes. The logistic regression analysis found that presence of comorbidities was the only predictive factor of low satisfaction rate (PGE-I > 2) in patients who underwent ProACT® implant. CONCLUSIONS: ProACT® implant represents an effective and safe treatment for post-prostatectomy stress urinary incontinence with a high satisfaction degree and a low rate of complications.

The role of the general practictioner in the management of urinary calculi.

BACKGROUND: The prevalence of kidney stones tends to increase worldwide due to dietary and climate changes. Disease management involves a high consumption of healthcare system resources which can be reduced with primary prevention measures and prophylaxis of recurrences. In this field, collaboration between general practitioners (GPs) and hospitals is crucial. METHODS: a panel composed of general practitioners and academic and hospital clinicians expert in the treatment of urinary stones met with the aim of identifying the activities that require the participation of the GP in the management process of the kidney stone patient. RESULTS: Collaboration between GP and hospital was found crucial in the treatment of renal colic and its infectious complications, expulsive treatment of ureteral stones, chemolysis of uric acid stones, long-term follow-up after active treatment of urinary stones, prevention of recurrence and primary prevention in the general population. CONCLUSIONS: The role of the GP is crucial in the management and prevention of urinary stones. Community hospitals which are normally led by GPs in liaison with consultants and other health professional can have a role in assisting multidisciplinary working as extended primary care.

Validation of the Italian version of wisconsin stone quality of life (WISQOL): a prospective Italian multicenter study.

Urolithiasis is a worldwide spread condition that affects patients' Health-Related Quality of Life (HRQOL), which measurement is an important tool for routine clinical and research practice. Disease-specific HRQOL measures demonstrated to perform better in assessing the effects of specific conditions. A disease-specific questionnaire for kidney stones, the WISQOL, has been validated in different languages, but an Italian version is still missing. Our aim is to produce and validate the Italian version of WISQOL (IT-WISQOL). Patients undergoing any elective treatment for upper urinary tract stones were enrolled. A multi-step process with forward- and back-translation was used to translate WISQOL into Italian. Patients were evaluated within 15 days pre-operatively and then at 30-, 90 days post-operatively and administered both IT-WISQOL and SF-36v2. Post-operative data such as 30 days postoperative complications, late stone-related events, successful status, and stone complexity were collected. Cronbach's α was used to evaluate the internal consistency of IT-WISQOL, while Spearman's rho was used for item and inter-domain correlations and IT-WISQOL with SF-36v2 correlation. We found excellent internal consistency across all domains (α ≥ 0.88), particularly when the total score is considered (α = 0.960). Test-retest reliability showed excellent results for the total questionnaire (Pearson correlation value: 0.85). The Inter-domain association ranged from 0.497 to 0.786. Convergent validity was confirmed by a good correlation with subdomains of the SF-36v2 measures. IT-WISQOL is a reliable tool to measure HRQOL in stone patients. It shows analog characteristics if compared to English WISQOL.

Randomized Clinical Trial Comparing On-clamp Versus Off-clamp Laparoscopic Partial Nephrectomy for Small Renal Masses (CLOCK II Laparoscopic Study): A Intention-to-treat Analysis of Perioperative Outcomes.

Background: Recent randomized trials (RCTs) in the field of robotic partial nephrectomy (PN) showed no significant differences in perioperative outcomes between the off- and on-clamp approaches. Objective: To compare the perioperative outcomes of on- versus off-clamp pure laparoscopic PN (LPN). Design setting and participants: A multi-institutional analysis of the on- versus off-clamp approach during LPN in the setting of an RCT (CLOCK II trial; ClinicalTrials.gov NCT02287987) was performed. Intervention: Off- versus on-clamp LPN. Outcome measurements and statistical analysis: Baseline patient and tumor variables, and peri- and postoperative data were collected. Randomized allocation with a 1:1 ratio was assigned. Surgical strategy for managing the renal pedicle was dictated by the study protocol. In the off-clamp arm, the renal artery had to remain unclamped for the duration of the whole procedure. Reporting the intention-to-treat analysis is the purpose of the study. Results and limitations: The study recruited 249 patients. Of them, 123 and 126 were randomized and allocated into the on- and off-clamp treatment groups, respectively. Treatment groups were comparable at baseline after randomization with respect to patients' demographics, comorbidities, renal function, and tumor size and complexity. A univariable analysis found no differences in the perioperative outcomes between the groups, including median (interquartile range) estimated blood loss (150 [100-200] vs 150 [100-250] ml, p = 0.2), grade ≥2 complication rate as classified according to the Clavien-Dindo system (5.7% vs 4.8%, p = 0.6), and positive surgical margin rate (8.2% vs 3.5% for the on- vs off-clamp group, p = 0.1). No differences were found in terms of the 1st (81.3 [66.7-94.3] vs 85.3 [71.0-97.7] ml/min, p = 0.2) and 5th postoperative days estimated glomerular filtration rate (83.3 [70.5-93.7] vs 83.4 [68.6-139.3] ml/min, p = 0.2). A multivariable analysis found each +1 increase in RENAL score corresponded to an increase in the protection from the occurrence of complications (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.54-0.97, p = 0.034), while each +1 cm increase in tumor size corresponded to an increase in the risk of blood transfusion (OR 1.39, 95% CI 1.14-1.70, p = 0.001). Conclusions: In the setting of an RCT, no differences were found in the perioperative and early functional outcomes between on- and off-clamp LPN. Patient summary: In this study, we investigated, by means of a randomized trial, whether avoiding the clamping of renal artery during laparoscopic resection of renal mass is able to translate into benefits. We found no differences in terms of safety, efficacy, and renal function from the standard approach, which includes arterial clamping.

Rectal Perforation During Pelvic Surgery.

Rectal perforations during pelvic surgery are rare but serious complications. The occurrence of rectal involvement is generally lower than that of the involvement of other portions of the bowel. The urologic field is responsible for the majority of iatrogenic rectal injuries from pelvic surgery; general and gynecologic surgeries are prone to the occurrence as well, the latter especially in the case of rectal shaving for deep infiltrating endometriosis. Attention should be posed to the prevention of rectal injuries, especially in case of challenging or salvage procedures; some tricks may be recommended to avoid thermal and mechanical damages and to realize a safe dissection. Intraoperative detection of rectal injuries is of paramount importance; once confirmed, immediate management with the closure of the defect is recommended. In general, rectal injuries diagnosed after surgery are liable to significantly worse outcomes than those detected and managed intraoperatively. Patient summary: Rectal perforation is a rare but possible complication of pelvic surgeries. The more challenging the procedure (ie, surgery for locally advanced tumors or after radiation therapy), the higher the risk of rectal lesion. Intraoperative management of the injury should be attempted, with direct repair of the defect with or without fecal diversion.