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.

Laparoscopic Simple Prostatectomy: A Single Center Experience with A Long-Term Follow Up.

PURPOSE: The aim of this retrospective study is to assess the long-term outcomes and safety of laparoscopic simple prostatectomy. MATERIAL AND METHODS: Between 2012 and 2019 80 patients with prostates volumes ≥ 80 mL were treated with laparoscopic simple prostatectomy at our department. Uroflowmetry, post void residual volume and standardized questionnaires were assessed pre- and postoperatively. Perioperative complications were categorized using the Clavien-Dindo classification. RESULTS: The mean specimen weight was 83 grams, and the mean operation time was 156 minutes. At a mean follow-up time of 40 months patients showed a significant improvement of Qmax (P = .002), IPSS (P < .001) and QoL (P < .001). Post void residual volumes decreased significantly. Complications occurred in 11 patients (13.8%), nine had mild (grade 1 - 2) and two had severe (grade 3b - 4a) complications. One conversion to open surgery due to massive prostatic adherence from previous abscess formation was recorded and one patient needed blood transfusion intraoperatively. CONCLUSION: laparoscopic simple prostatectomy is an effective and safe procedure for large volume prostate glands with a significant and stable long term symptoms improvement.

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

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

The Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration Project: Development of Criteria for Reporting Adverse Events During Surgical Procedures and Evaluating Their Impact on the Postoperative Course.

BACKGROUND: Intraoperative adverse events (iAEs) are surgical and anesthesiologic complications. Despite the availability of grading criteria, iAEs are infrequently reported in the surgical literature and in cases for which iAEs are reported, these events are described with significant heterogeneity. OBJECTIVE: To develop Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration criteria to standardize the assessment, reporting, and grading of iAEs. The ultimate aim is to improve our understanding of the nature and frequency of iAEs and our ability to counsel patients regarding surgical procedures. DESIGN, SETTING, AND PARTICIPANTS: The present study involved the following steps: (1) collecting criteria for assessing, reporting, and grading of iAEs via a comprehensive umbrella review; (2) collecting additional criteria via a survey of a panel of experienced surgeons (first round of a modified Delphi survey); (3) creating a comprehensive list of reporting criteria; (4) combining criteria acquired in the first two steps; and (5) establishing a consensus on clinical and quality assessment utility as determined in the second round of the Delphi survey. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Panel inter-rater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α. RESULTS AND LIMITATIONS: The umbrella review led to nine common criteria for assessing, grading, and reporting iAEs, and review of iAE grading systems led to two additional criteria. In the first Delphi round, 35 surgeons responded and two criteria were added. In the second Delphi round, 13 common criteria met the threshold for final guideline inclusion. All 13 criteria achieved the consensus minimum of 70%, with agreement on the usefulness of the criteria for clinical and quality improvement ranging from 74% to 100%. The mean inter-rater agreement was 89.0% for clinical improvement and 88.6% for quality improvement. CONCLUSIONS: The ICARUS Global Collaboration criteria might aid in identifying important criteria when reporting iAEs, which will support all those involved in patient care and scientific publishing. PATIENT SUMMARY: We consulted a panel of experienced surgeons to develop a set of guidelines for academic surgeons to follow when publishing surgical studies. The surgeon panel proposed a list of 13 criteria that may improve global understanding of complications during specific procedures and thus improve the ability to counsel patients on surgical risk.

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

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

The dramatic COVID 19 outbreak in Italy is responsible of a huge drop of urological surgical activity: a multicenter observational study.

OBJECTIVE: To describe the trend in surgical volume in urology in Italy during the coronavirus disease 2019 (COVID-19) outbreak, as a result of the abrupt reorganisation of the Italian national health system to augment care provision to symptomatic patients with COVID-19. METHODS: A total of 33 urological units with physicians affiliated to the AGILE consortium (Italian Group for Advanced Laparo-Endoscopic Surgery; www.agilegroup.it) were surveyed. Urologists were asked to report the amount of surgical elective procedures week-by-week, from the beginning of the emergency to the following month. RESULTS: The 33 hospitals involved in the study account overall for 22 945 beds and are distributed in 13/20 Italian regions. Before the outbreak, the involved urology units performed overall 1213 procedures/week, half of which were oncological. A month later, the number of surgeries had declined by 78%. Lombardy, the first region with positive COVID-19 cases, experienced a 94% reduction. The decrease in oncological and non-oncological surgical activity was 35.9% and 89%, respectively. The trend of the decline showed a delay of roughly 2 weeks for the other regions. CONCLUSION: Italy, a country with a high fatality rate from COVID-19, experienced a sudden decline in surgical activity. This decline was inversely related to the increase in COVID-19 care, with potential harm particularly in the oncological field. The Italian experience may be helpful for future surgical pre-planning in other countries not so drastically affected by the disease to date.

Urology in the Time of Coronavirus: Reduced Access to Urgent and Emergent Urological Care during the Coronavirus Disease 2019 Outbreak in Italy.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has put a substantial burden on the Italian healthcare system, resulting in the restructuring of hospitals to care for COVID-19 patients. However, this has likely impacted access to care for patients experiencing other conditions. We aimed to quantify the impact of COVID-19 on access to care for patients with urgent/emergent urological conditions throughout Italy. MATERIALS AND METHODS: A questionnaire was sent to 33 urological units in the AGILE consortium, asking clinicians to report on the number of urgent/emergent urological patients seen and/or undergoing surgery over a 3-week period during the peak of the COVID-19 outbreak and a reference week prior to the outbreak. ANOVA and linear regression models were used to quantify these changes. RESULTS: Data from 27 urological centres in Italy showed a decrease from 956 patients/week seen just prior to the outbreak to 291 patients/week seen by the end of the study period. There was a difference in the number of patients with urgent/emergent urological disease seen within/during the different weeks (all p values < 0.05). A significant decrease in the number of patients presenting with haematuria, urinary retention, urinary tract infection, scrotal pain, renal colic, or trauma and urgent/emergent cases that required surgery was reported (all p values < 0.05). CONCLUSION: In Italy, during the COVID-19 outbreak there has been a decrease in patients seeking help for urgent/emergent urological conditions. Restructuring of hospitals and clinics is mandatory to cope with the COVID-19 pandemic; however, the healthcare system should continue to provide adequate levels of care also to patients with other conditions.

Male Slings for Postprostatectomy Incontinence: A Systematic Review and Meta-analysis.

CONTEXT: Male slings are recommended by the European Association of Urology guideline for the treatment of mild to moderate postprostatectomy incontinence. However, none of them has been proved to be superior to the others, and there are no defined guidelines to preference of a given sling model. OBJECTIVE: To evaluate and compare the efficacy and safety of the different types of male slings in the treatment of postprostatectomy incontinence. EVIDENCE ACQUISITION: This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. A systematic literature search in the databases of PubMed, Embase, and Cochrane using the keywords "incontinence," "prostatectomy," and "male sling/system" was conducted in June 2018. Studies in English with at least 15 patients and a minimum follow-up of 12 mo were included. As the primary endpoint, we assessed the cure rate of the different sling types. As secondary endpoints, we assessed the improvement rate, subjective cure rate, overall complication rate, explantation rate, risk factors for failure, and effect on patients' quality of life. EVIDENCE SYNTHESIS: The literature search identified 833 articles. A total of 64 studies with 72 patient cohorts were eligible for inclusion. Fixed slings were implanted in 55 (76.4%) of the patient cohorts. The objective cure rate varies between 8.3% and 87% (pooled estimate 0.50, 95% confidence interval [CI] 0.45-0.56, I2=82%). Subjective cure was achieved in 33-94.4%. Adjustable slings showed objective cure rates between 17% and 92% (pooled estimate 0.61, 95% CI 0.51-0.71, I2=88%). The subjective cure rate varies between 28% and 100%. In both types of slings, pain was the most common complication, but chronic painful conditions were really rare (1.3% in fixed slings and 1.5% in adjustable slings). The most common complication after pain was urinary retention in fixed slings, and infection and consequential explantation in adjustable slings. CONCLUSIONS: Both fixed and adjustable slings are beneficial for the treatment of postprostatectomy incontinence. Although adjustable slings might lead to higher objective cure rates, they might be associated with higher complication and explantation rates. However, at present, due to significant heterogeneity of the data, this cannot be said with certainty. More randomized controlled trials with long-term follow-up and the same definition for continence are needed. PATIENT SUMMARY: Fixed and adjustable slings are effective treatment options in mild to moderate postprostatectomy incontinence.

What is the standard surgical approach to large volume BPE? Systematic review of existing randomized clinical trials.

INTRODUCTION: In the past years several reviews have analysed different aspects of surgical techniques for patients with LUTS due to BPE however none of them have concentrated on large prostates treatment exclusively. Moreover, none of the reviews have focused on level 1 evidence which is essential to avoid bias and wrong conclusions. With this knowledge in mind, aim of the present review is to analyze the available randomized clinical trials assessing the management of patients with big prostates (>80 cc). EVIDENCE ACQUISITION: A systematic review of the literature using the Medline, Scopus and Web of Science databases for relevant articles published until January 2019 was performed using both the Medical Subjects Heading and free test protocols. The search was conducted by combining the following terms: "Enucleation," "Prostate," "Benign Prostatic Hyperplasia," "Holmium," "laser," "adenomectomy," "Randomized clinical trial," "Big" "large" "prostate," ">80," "≥80," "transurethral resection of prostate," "Thulium," "Diode," "laparoscopy," "robotic," "Plasmakinetic," "green light" "532 nm" "YAG" "Lower Urinary tract symptoms". Only randomized clinical trials were included in the analysis. EVIDENCE SYNTHESIS: Overall 9 RCTs were retrieved with most of them reporting data at 1 year. The present trials compared enucleation, vaporization and open techniques between each other. In terms of perioperative outcomes all the techniques had similar operative times and resected weight however catheterization time and hospital stay were better in endoscopic techniques when compared to open surgery. In terms of functional outcomes (IPSS, QMAX and PVR) none of the techniques was proven superior to the other. When considering complications open procedures carried a higher risk of transfusions while no technique was proven superior to the others in terms of transient urge urinary incontinence, bladder neck contracture and reintervention. Only one trial was retrieved reporting five years data confirming the safety, efficacy and durability of simple prostatectomy SP and holmium laser enucleation of the prostate at five years. CONCLUSIONS: According to our review no technique may be considered better than the other when treating large adenomas. Studies are still lacking to prove long term efficacy and future studies should clarify the role of prostatic artery embolization and minimally invasive simple prostatectomy in the management of prostates larger than 80 mL.

The fascial suspension of the prostate: A cadaveric study.

AIMS: Analysis and description of the supporting fascial structure around the prostate and urethra, which needs to be preserved or restored during radical prostatectomy (RP). METHODS: Anatomical dissection of 10 male cadavers was performed and the supporting fascial structures of bladder neck, prostate, and proximal urethra were investigated. The cadavers were embalmed according to Thiel's method, which preserves a natural texture and color of tissues. RESULTS: Anteriorly, the puboprostatic ligament (PL), the dorsal vein complex, and the urethropelvic ligament form an integral structure that suspends and stabilizes the prostatic apex. Laterally, the fascia originates from the fascial tendinous arch of the pelvis and stabilizes the prostate in the central position. In the posterolateral aspect, we could demonstrate a tendineous dorsal raphe, which represents an important stabilization structure of the urethra. CONCLUSIONS: The anterior and posterior pelvic fascial structure seems to be important stabilizer for the prostate and proximal urethra. Their preservation or reconstruction during RP is mandatory to restore the anatomic and functional continuity of the bladder neck and urethra. Neurourol. Urodynam. 36:1131-1135, 2017. © 2016 Wiley Periodicals, Inc.

Validation of the Preoperative Platelet-to-Lymphocyte Ratio as a Prognostic Factor in a European Cohort of Patients with Upper Tract Urothelial Carcinoma.

INTRODUCTION: This study is aimed at investigating the potential prognostic impact of the preoperatively assessed platelet-to-lymphocyte ratio (PLR) in a European cohort of patients with non-metastatic upper tract urothelial carcinoma (UTUC). MATERIALS AND METHODS: Clinicopathological data from 180 consecutive non-metastatic UTUC patients, operated between 1990 and 2012 at a single tertiary academic center, were evaluated retrospectively. The preoperative PLR was assessed one day before surgery. Patients were categorized using a PLR cut-off value according to receiver-operating curve analysis. Cancer-specific survival (CSS) and overall survival (OS) were assessed using the Kaplan-Meier method. Additionally, multivariate proportional Cox regression models were applied. RESULTS: In multivariate analyses, age at the date of surgery (<65 vs. ≥65 years, hazard ratio (HR) 1.827, 95% CI 1.051-3.175, p = 0.033), pathologic T-stage (pT1 vs. pT2-4, HR 1.873, 95% CI 1.066-3.292, p = 0.029), and pretreatment PLR (<150.0 vs. ≥150.0, HR 1.782, 95% CI 1.041-3.050, p = 0.035) were independent predictors of OS. Regarding CSS, pathologic T-stage (pT1 vs. pT2-4, HR 2.176, 95% CI 1.062-4.460, p = 0.034) and pretreatment PLR (<150.0 vs. ≥150.0, HR 2.026, 95% CI 1.045-3.930, p = 0.037) were considered independent predictors. CONCLUSIONS: In the cohort studied, patients with an elevated (≥150.0) preoperative PLR had a higher cancer-specific mortality and overall mortality after radical surgery for UTUC, compared with those with a low pretreatment PLR.

Critical evaluation of the potential prognostic value of the pretreatment-derived neutrophil-lymphocyte ratio under consideration of C-reactive protein levels in clear cell renal cell carcinoma.

BACKGROUND: We investigated the prognostic value of the pretreatment-derived neutrophil-lymphocyte ratio (dNLR) and original NLR in relation to the commonly used inflammation marker C-reactive protein (CRP) in a large cohort of patients with clear cell renal cell carcinoma (RCC). METHODS: Clinicopathological data from 587 consecutive non-metastatic clear cell RCC patients, operated between 2000 and 2010 at a single tertiary academic center, were evaluated retrospectively. Patients were categorised according to a cutoff value derived from receiver operating curve analysis. Overall (OS), cancer-specific (CSS) as well as metastasis-free survival (MFS) were assessed using the Kaplan-Meier method and multivariate Cox proportional models were applied. Spearman's rank correlation coefficient tested the association between dNLR and other markers of the systemic inflammatory response. RESULTS: The significant correlation between pretreatment NLR and dNLR was strong (ρ=0.84), whereas between dNLR and CRP it was weak (ρ=0.18). In multivariate analyses, dNLR achieved independent predictor status regarding CSS (P=0.037) and MFS (P=0.041), whereas CRP was confirmed as independent predictor of OS (P=0.010), CSS (P=0.039) and MFS (P=0.005), respectively. The NLR failed to reach independent predictor status regarding OS, CSS and MFS when CRP was included into the multivariate model. CONCLUSIONS: In the cohort studied, an elevated (⩾10.0) pretreatment CRP level and elevated dNLR (>2) were robust independent predictors of CSS and MFS. Our data suggest that CRP might be superior to both NLR and dNLR.

Infective complications after retrograde intrarenal surgery: a new standardized classification system.

PURPOSE: Retrograde intrarenal surgery (RIRS) is considered a safe procedure; however, infective complications are potentially serious postoperative complications. The aim of this multicentre study was to evaluate prospectively the prevalence of infective complications after RIRS and identify risk factors. METHODS: Baseline data were collected, and patients were questioned regarding postoperative infective complications following RIRS. The Fisher exact test, Student t test, Mann-Whitney U test, and multivariate regression analysis were used for data analysis. RESULTS: A total of 403 patients from five European centers were included. Antibiotic prophylaxis was administered prior to RIRS in 100 %. Infection complications were recorded in 31 patients (7.7 %), consisting of fever in 18 (4.4 %), SIRS in 7 (1.7), and sepsis in 3 (0.7 %). Three required hospitalization for non-obstructive pyelonephritis (0.7 %). Univariate analysis revealed that coronary heart disease, chronic kidney disease, alteration of lipid metabolism, anticoagulant therapy, past surgery for renal stone, presence of residual fragments were predictors of infective complications. Multivariate analysis did not identify any patient subgroups at a significantly higher risk of infection. The low rate of complications may have limited the conclusions from our study. CONCLUSION: Using a standardized method for the definition and classification of infective complication from a multicentre prospective large database, we find a prevalence of 7.7 % of infective complication among patients undergoing RIRS for renal stone. However, to predict which patients will develop infective complications still remains a clinical challenge.

A prospective multicenter European study on flexible ureterorenoscopy for the management of renal stone.

PURPOSE: The aim of this study was to describe the outcomes and the complications of retrograde intrarenal surgery (RIRS) for renal stones in a multi-institutional working group. MATERIALS AND METHODS: From 2012 to 2014, we conducted a prospective study including all RIRS performed for kidney stones in 4 European centers. Demographic information, disease characteristics, and perioperative and postoperative data were gathered. Patients and stone data, procedure characteristics, results and safety outcomes were analyzed and compared by descriptive statistics. Complications were reported using the standardized Clavien system. RESULTS: Three hundred and fifty-six patients underwent 377 RIRS with holmium laser lithotripsy for renal stones. The RIRS was completed in all patients with a mean operative time of 63.5 min. The stone-free status was confirmed endoscopically and through fluoroscopic imaging after the first procedure in 73.6%. The second procedure was performed in twenty patients (5.6%) achieving an overall stone free rate of 78.9%. The overall complication rate was 15.1%. Intra-operative and post-operative complications were seen in 24 (6.7%) and 30 (8.4%) cases, respectively. CONCLUSIONS: RIRS is a minimally invasive procedure with good results in terms of stone-free and complications rate.

A prospective multicenter European study on flexible ureterorenoscopy for the management of renal stone

ABSTRACT Purpose The aim of this study was to describe the outcomes and the complications of retrograde intrarenal surgery (RIRS) for renal stones in a multi-institutional working group. Materials and Methods From 2012 to 2014, we conducted a prospective study including all RIRS performed for kidney stones in 4 European centers. Demographic information, disease characteristics, and perioperative and postoperative data were gathered. Patients and stone data, procedure characteristics, results and safety outcomes were analyzed and compared by descriptive statistics. Complications were reported using the standardized Clavien system. Results Three hundred and fifty-six patients underwent 377 RIRS with holmium laser lithotripsy for renal stones. The RIRS was completed in all patients with a mean operative time of 63.5 min. The stone-free status was confirmed endoscopically and through fluoroscopic imaging after the first procedure in 73.6%. The second procedure was performed in twenty patients (5.6%) achieving an overall stone free rate of 78.9%. The overall complication rate was 15.1%. Intra-operative and post-operative complications were seen in 24 (6.7%) and 30 (8.4%) cases, respectively. Conclusions RIRS is a minimally invasive procedure with good results in terms of stone-free and complications rate.

Adjustable Continence Balloons in Men: Adjustments Do Not Translate Into Long-term Continence.

OBJECTIVE: To evaluate the functional results, morbidity, and quality of life of the adjustable continence balloons ProACT for the treatment of male stress urinary incontinence after prostate surgery considering both short- and long-term results. METHODS: Between 2002 and 2012, twenty-two consecutive male patients were implanted with the ProACT device. Continence was defined by the use of 0 pads daily, and the quality of life was assessed by validated questionnaires. RESULTS: Only 1 patient (4.5%) was immediately continent after ProACT implantation, and the other 21 men (95.5%) needed ≥1 balloon refillments postoperatively. The baseline daily pad number decreased from a mean of 5.9 pads (range, 3-12 pads) to a mean of 1.7 pads (range, 0-5 pads) per day after refilling but increased to a mean of 3.9 (range, 0-10) at the last follow-up visit. After balloon adjustments, 4 patients (18%) were continent and 18 patients (82%) showed an improvement with a 95% rate of subjective satisfaction. Revision and explantation rates were 73% and 55%, respectively. At a median follow-up of 57 months, only 1 patient (4.5%) remained dry, and only 10 patients (45%) remained satisfied with the procedure, whereas 12 patients (55%) were unchanged and dissatisfied. CONCLUSION: The ProACT device appears to be safe and efficacious in the short term. The postoperative readjustment allows the achievement of a short-term continence status. However, on the long term, the ProACT does not appear to be an ideal device for durable continence and patients' satisfaction.

Preoperative serum-gamma-glutamyltransferase (GGT) does not represent an independent prognostic factor in a European cohort of patients with non-metastatic renal cell carcinoma.

AIMS: Increasing evidence suggests that the serum-gamma-glutamyltransferase (GGT) might correlate with tumour development and growth rates in various human cancer types. Thus, we decided to investigate the potential prognostic impact of the preoperatively assessed serum-GGT in a European cohort of patients with non-metastatic renal cell carcinoma (RCC). METHODS: Clinicopathological data from 700 consecutive patients with non-metastatic RCC, operated between 2000 and 2010 at a single tertiary academic centre, were evaluated retrospectively. Preoperative serum-GGT was assessed 1 day before surgery. Patients were categorised using a serum-GGT cut-off value of 40 U/L according to a calculation by receiver operating curve analysis. Patients' cancer-specific survival (CSS), metastasis-free survival (MFS), as well as overall survival (OS) were assessed using the Kaplan-Meier method and Cox proportional models. RESULTS: In univariate analysis, an elevated preoperative serum-GGT level (<40 U/L vs ≥40 U/L) was statistically significantly associated with a shorter MFS (HR=1.517, 95% CI 1.047 to 2.197, p=0.027). In multivariate analyses, pathological T-Stage (pT-1 vs pT-2-4, HR=2.065, 95% CI 1.665 to 2.560), tumour grade (G-1+G-2 vs G-3+G-4, HR=1.671, 95% CI 1.261 to 2.213), as well as the presence of histological tumour necrosis (No vs Yes, HR=2.031, 95% CI 1.355 to 3.046) were independent predictors of MFS in patients with RCC, whereas the preoperative serum-GGT failed to reach independent predictor status (<40 U/L vs ≥40 U/L, HR=1.156, 95% CI 0.791 to 1.690). No prognostic role for GGT in OS or CSS could be identified. CONCLUSIONS: In the cohort studied, patients with an elevated (≥40 U/L) preoperative serum-GGT had a subsequently shorter MFS only in univariate analysis. In contrast to previous studies, our data failed to demonstrate preoperatively assessed serum-GGT as an independent prognostic factor in patients with non-metastatic RCC.

Pretreatment lymphocyte-monocyte ratio as a potential prognostic factor in a cohort of patients with upper tract urothelial carcinoma.

AIMS: To investigate the potential prognostic impact of the lymphocyte-monocyte ratio (LMR) in a large European cohort of patients with localised upper urinary tract urothelial carcinoma (UTUC). The LMR as an indicator of systemic inflammatory response has been shown to represent a potential prognostic factor in various types of human cancers. Up to date, the prognostic significance of the LMR in UTUC has not been evaluated. METHODS: Clinico-pathological data from 182 non-metastatic patients with UTUC, operated between 1990 and 2012 at a single tertiary academic centre, were evaluated retrospectively. Pretreatment LMR was assessed 1 day before surgery. Patients were categorised using an LMR cut-off value of 2.0 according to a calculation by receiver-operating curve analysis. Patients' overall survival (OS) was assessed using the Kaplan-Meier method. To evaluate the independent prognostic significance of the LMR, a multivariate proportional Cox regression model was applied for OS. RESULTS: In multivariate analyses, age on the date of surgery (<65 vs ≥65 years, HR=2.10, 95% CI 1.22 to 3.64), pathological T-stage (pT1 vs pT2-4, HR=2.15, 95% CI 1.26 to 3.67), as well as the LMR (<2 vs ≥2, HR=0.56, 95% CI 0.35 to 0.92) were independent predictors of OS of patients with UTUC. CONCLUSIONS: In the cohort studied, patients with an elevated (≥2) preoperative LMR had a subsequently longer OS after radical surgery for UTUC, compared with those with a low (<2) preoperative LMR. Thus, we believe this parameter might be considered an additional prognostic factor in UTUC in the future.

Evaluation of the prognostic significance of perirenal fat invasion and tumor size in patients with pT1-pT3a localized renal cell carcinoma in a comprehensive multicenter study of the CORONA project. Can we improve prognostic discrimination for patients with stage pT3a tumors?

BACKGROUND: The current TNM system for renal cell carcinoma (RCC) merges perirenal fat invasion (PFI) and renal vein invasion (RVI) as stage pT3a despite limited evidence concerning their prognostic equivalence. In addition, the prognostic value of PFI compared to pT1-pT2 tumors remains controversial. OBJECTIVE: To analyze the prognostic significance of PFI, RVI, and tumor size in pT1-pT3a RCC. DESIGN, SETTING, AND PARTICIPANTS: Data for 7384 pT1a-pT3a RCC patients were pooled from 12 centers. Patients were grouped according to stages and PFI/RVI presence as follows: pT1-2N0M0 (n=6137; 83.1%), pT3aN0M0 + PFI (n=1036; 14%), and pT3aN0M0 (RVI ± PFI; n=211; 2.9%). INTERVENTION: Radical nephrectomy or nephron-sparing surgery (NSS) (1992-2010). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Cancer-specific survival was estimated using the Kaplan-Meier method. Univariate and multivariate Cox proportional-hazards regression models, as well as sensitivity and discrimination analyses, were used to evaluate the impact of clinicopathologic parameters on cancer-specific mortality (CSM). RESULTS AND LIMITATIONS: Compared to stage pT1-2, patients with stage pT3a RCC were significantly more often male (59.4% vs 53.1%) and older (64.9 vs 62.1 yr), more often had clear cell RCC (85.2% vs 77.7%), Fuhrman grade 3-4 (29.4% vs 13.4%), and tumor size >7 cm (39.1% vs 13%), and underwent NSS less often (7.5% vs 36.6%; all p<0.001). According to multivariate analysis, CSM was significantly higher for the PFI and RVI ± PFI groups compared to pT1-2 patients (hazard ratio [HR] 1.94 and 2.12, respectively; p<0.001), whereas patients with PFI only and RVI ± PFI did not differ (HR 1.17; p=0.316). Tumor size instead enhanced CSM by 7% per cm in stage pT3a (HR 1.07; p<0.001) with a 7 cm cutoff yielding the highest prediction accuracy. CONCLUSIONS: Since the prognostic impact of PFI and RVI on CSM seems to be comparable, merging both as stage pT3a RCC might be justified. Enhanced prognostic discrimination of stage pT3a RCC appears to be possible by applying a tumor size cutoff of 7 cm within an alternative staging system. PATIENT SUMMARY: Prognosis prediction for patients with localized renal cell carcinoma up to stage pT3a can be enhanced by including tumor size with a cutoff of 7 cm as an additional parameter in the TNM classification system.