Three-Dimensional Customized Imaging Reconstruction for Urological Surgery: Diffusion and Role in Real-Life Practice from an International Survey.

Despite the arising interest in three-dimensional (3D) reconstruction models from 2D imaging, their diffusion and perception among urologists have been scarcely explored. The aim of the study is to report the results of an international survey investigating the use of such tools among urologists of different backgrounds and origins. Beyond demographics, the survey explored the degree to which 3D models are perceived to improve surgical outcomes, the procedures mostly making use of them, the settings in which those tools are mostly applied, the surgical steps benefiting from 3D reconstructions and future perspectives of improvement. One hundred responders fully completed the survey. All levels of expertise were allowed; more than half (53%) were first surgeons, and 59% had already completed their training. Their main application was partial nephrectomy (85%), followed by radical nephrectomy and radical prostatectomy. Three-dimensional models are mostly used for preoperative planning (75%), intraoperative consultation and tailoring. More than half recognized that 3D models may highly improve surgical outcomes. Despite their recognized usefulness, 77% of responders use 3D models in less than 25% of their major operations due to costs or the extra time taken to perform the reconstruction. Technical improvements and a higher availability of the 3D models will further increase their role in surgical and clinical daily practice.

Correlation Between Long-Term Acetylsalicylic Acid Use and Prostate Cancer Screening with PSA. Should We Reduce the PSA Cut-off for Patients in Chronic Therapy? A Multicenter Study.

Purpose: To evaluate the prostate cancer (PCa) detection rate in men with chronic use of Aspirin and to compare it with the detection rate of non-users. Patients and Methods: Prospectively maintained database regarding patients undergoing prostate biopsy over the last 10 years in five institutions. Patients were divided into two groups according to their exposure to Aspirin. We relied on multivariable linear and logistic regression models to test whether Aspirin administration was associated with lower PSA values at prostate biopsy, higher PCa diagnosis, and higher Gleason Grade Grouping (GGG) at biopsy. Results: Were identified 1059 patients, of whom 803 (76%) did not take Aspirin vs 256 (24%) were taking it. In multivariable log-linear regression analysis, Aspirin administration was associated with lower PSA levels (OR 0.83, 95% CI 0.71-0.97, p = 0.01), after controlling for age, prostate volume, smoking history, associated inflammation at prostate biopsy, presence of PCa at biopsy, and GGG. In multivariable logistic regression analysis, Aspirin administration was not found to be a predictor of PCa at prostate biopsy (OR 1.40, 95% CI 0.82-2.40, p = 0.21) after controlling for age, PSA, smoking history, prostate volume, findings at digital rectal examination and the number of biopsy cores. In patients with PCa at prostate biopsy (n = 516), Aspirin administration was found to predict higher GGG (OR 2.24, 95% CI 1.01-4.87, p = 0.04). Conclusion: Aspirin administration was found to be a predictor of more aggressive GGG. These findings suggest that a lower PSA threshold should be considered in patients taking Aspirin, as, despite low PSA levels, they might harbour aggressive PCa.

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.

Segmental Ureterectomy Versus Radical Nephroureterectomy in Older Patients Treated for Upper Tract Urothelial Carcinoma.

INTRODUCTION: The world population is ageing and surgical procedures for older patients are associated with higher perioperative morbidity and mortality rates than in younger patients. Segmental ureterectomy (SU) has been proposed as an alternative to radical nephroureterectomy (RNU) for selected upper tract urothelial carcinomas (UTUC), to reduce post-operative morbidity, and preserve renal function. The aim of this study was to compare RNU and SU in terms of post-operative complications, functional outcomes, and overall survival (OS) in older patients treated for UTUC. MATERIALS AND METHODS: Data of patients aged 75 years or older and treated for UTUC were included. The primary outcome was to compare RNU versus SU according to post-operative complications, the estimated glomerular filtration rate (eGFR) variation, and OS. Complications were defined according to the Clavien-Dindo classification. eGFR was calculated according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. Un-adjusted OS curves were plotted using the Kaplan-Meier method. RESULTS: Overall, 177 patients (150 RNU and 27 SU) were eligible for the analysis. Pre- and post-operative characteristics were similar between the 2 groups. RNU patients showed higher incidence of post-operative complications (34.0% vs. 7.4%, P = .011). The mean post-operative serum creatinine was lower in SU patients in comparison with the RNU ones (1.23 vs. 1.69 mg/dL, P = .046), but no differences were found in terms of eGFR variation (P = .258). At 3 years of follow-up, the OS was comparable between the two surgical techniques (P = .129). CONCLUSION: In older patients diagnosed with UTUC, SU could offer lower rates of post-operative complications without affecting survival.

Perioperative outcomes of patients undergoing urological elective surgery during the COVID-19 pandemic: a national overview across 28 Italian institutions.

INTRODUCTION: The aim of this study was to assess the safety of elective urological surgery performed during the pandemic by estimating the prevalence of COVID-19-like symptoms in the postoperative period and its correlation with perioperative and clinical factors. MATERIAL AND METHODS: In this multicenter, observational study we recorded clinical, surgical and postoperative data of consecutive patients undergoing elective urological surgery in 28 different institutions across Italy during initial stage of the COVID-19 pandemic (between February 24 and March 30, 2020, inclusive). RESULTS: A total of 1943 patients were enrolled. In 12%, 7.1%, 21.3%, 56.7% and 2.6% of cases an open, laparoscopic, robotic, endoscopic or percutaneous surgical approach was performed, respectively. Overall, 166 (8.5%) postoperative complications were registered, 77 (3.9%) surgical and 89 (4.6%) medical. Twenty-eight (1.4%) patients were readmitted to hospital after discharge and 13 (0.7%) died. In the 30 days following discharge, fever and respiratory symptoms were recorded in 101 (5.2%) and 60 (3.1%) patients. At multivariable analysis, not performing nasopharyngeal swab at hospital admission (HR 2.3; CI 95% 1.01-5.19; p = 0.04) was independently associated with risk of developing postoperative medical complications. Number of patients in the facility was confirmed as an independent predictor of experiencing postoperative respiratory symptoms (p = 0.047, HR:1.12; CI95% 1.00-1.05), while COVID-19-free type of hospitalization facility was a strong independent protective factor (p = 0.02, HR:0.23, CI95% 0.07-0.79). CONCLUSIONS: Performing elective surgery during the COVID-19 pandemic does not seem to affect perioperative outcomes as long as proper preventive measures are adopted, including nasopharyngeal swab before hospital admission and hospitalization in dedicated COVID-19-free facilities.

Original Observation of Primary Bladder Histiocytic Sarcoma: First Case Report.

Histiocytic sarcoma (HS) is a rare malignant lymphohematopoietic neoplasm; it has been cited in the recent World Health Organization (WHO) classification as a malignant proliferation of cells exhibiting morphological and immunophenotypic features of mature histiocytes. To our knowledge, the present case is the first to be described in the bladder of a patient without a history of lymphoma. Only one case has been reported so far regarding a secondary bladder presentation in the setting of a previous diffuse large B-cell lymphoma. We discuss the case of a 68-year-old male who presented with hematuria and dysuria. CT scan revealed a 4-cm intravesical mass that histological examination defined as HS. Our objective was to describe the clinical, histological, immunophenotypical, molecular characteristics and discuss the differential diagnoses of this first case of primary bladder HS. Our research was based on a review of selected articles obtained via the PubMed database. This extremely rare experience provided us with the opportunity to depict an interesting case, highlight its uniqueness, and build up new pathological evidence.

The role of MRI/TRUS fusion biopsy in the diagnosis of clinically significant prostate cancer.

BACKGROUND: The aim of this work is to evaluate the detection rate of magnetic resonance imaging/transrectal ultrasound (MRI/TRUS) fusion-guided biopsy for clinically significant prostate cancers (Cs PCas), with particular interest in biopsy-naive patients and patients in active surveillance. MRI-targeted biopsy improves cancer detection rate (DR) in patients with prior negative biopsies; the current literature focuses on biopsy naive patients. We also evaluated the pathologic concordance between biopsies and surgical specimens. METHODS: MRI/TRUS fusion-guided biopsies were performed between February 2016 and February 2019. Patients with previous negative biopsies, biopsy-naive or in active surveillance (AS) were included. Cs PCas were defined through Epstein's criteria. RESULTS: A total of 416 men were enrolled. The overall DRs and Cs PCa DRs were 49% and 34.3%, respectively. Cs PCas were 17.2%, 44.9% and 73.4%, respectively for PI-RADS 3, 4 or 5. Among biopsy-naive patients, 34.8% were found to have a Cs PCa, while a 43.6% tumour upgrading was achieved in men with a low risk of PCa. In patients who underwent radical prostatectomy (RP), the concordance between biopsy Gleason score (GS) (bGS) and pathological GS (pGS) was 90.8%. CONCLUSION: Our study highlights the role of MRI/TRUS fusion prostate biopsy in the detection of PCa in patients with previous negative biopsies focusing on Cs PCa diagnosis. The MRI/TRUS fusion biopsy is also emerging as a diagnostic tool in biopsy-naïve patients and deserves a fundamental role in AS protocols. A greater concordance between bGS and pGS can be achieved with targeted biopsies.

Second-look TURBT: evaluation of anatomopatological and oncologic results in a single center.

INTRODUCTION: T1 bladder cancer is associated with a high risk of recurrence and progression; concomitant carcinoma in situ and/or multifocality are negative prognostic factors. Persistent disease after resection of T1 tumours has been observed in 33-55% of patients, and after resection of High-grade (HG) Ta tumour in 41,4%. It has been demonstrated that a second TURB can increase recurrence-free survival and it can make a restaging of the cancer. PATIENTS AND METHODS: From January 2011 to December 2016, 87 patients with superficial bladder tumor (Ta-T1), undergoing TURB and routine repeat TURB (Re-TURB) 4-6 weeks after the initial resection, were included in the study. Re-TURB was applied to the scar of the first resection and other suspicious lesions in the bladder. After the second-look, we studied the follow-up of each patient. RESULTS: Specimens obtained during the second TURBT showed no tumor in 47 (54,02%) patients; 40 (45,98%) patients had residual cancer: 34 of them had cancer of the same stage, 6 patients of pT1 had a lower stage, and 3 had a higher stage. 5 patient underwent radical cistectomy immediatly after re-TURBT. During the first year of follow up, 15 patients had a recurrent bladder cancer; 2 of them underwent radical cistectomy. CONCLUSIONS: T1 bladder cancer is an high risk tumor, so that second-look TURBT is a valuable procedure for accurate staging of nonmuscle-invasive bladder cancer and it can guarantee a better eradication of the neoplasm.

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.

Segmental ureterectomy vs. radical nephroureterectomy for ureteral carcinoma in patients with a preoperative glomerular filtration rate less than 90 ml/min/1.73 m2: A multicenter study.

OBJECTIVES: To compare segmental ureterectomy (SU) and radical nephroureterectomy (RNU) in terms of overall survival (OS) and impact on postoperative renal function in patients treated for upper tract urothelial carcinoma (UTUC) of the ureter with preoperatively reduced estimated glomerular filtration rate (eGFR). MATERIALS AND METHODS: We retrospectively collected the data of consecutive patients treated for UTUC, in 6 Italian tertiary referral centers, from 2003 to 2013, and analyzed those treated with RNU or SU for ureteral cancer and with a preoperative eGFR <90 ml/min/1.73m2. The primary outcome was to compare the postoperative eGFR variation and the OS according to the surgical technique chosen. RESULTS: Out of 521 patients with UTUC, 228 patients had preoperative reduced eGFR. Out of these patients, 93 had ureteral cancer and were included in the primary analyses - 67 (72.0%) treated with RNU and 26 (28.0%) with SU. Preoperative characteristics were similar in the 2 groups. The overall median follow-up period was 26.5 months. A nonsignificant postoperative eGFR decrease of 3.0 ml/min/1.73m2 was found overall (P = 0.094), with nonsignificant difference between the 2 groups (P = 0.735). A comparable 5-year OS was calculated for RNU and SU patients (P = 0.99). CONCLUSIONS: The type of surgery (SU vs. RNU) has a low impact on postoperative renal function and OS in patients with ureteral cancer and preoperative eGFR <90 ml/min/1.73m2. The indications for kidney sparing surgery for UTUC should be based on the surgical and oncological risks in these patients.

The Predictive Role of Biomarkers for the Detection of Acute Kidney Injury After Partial or Radical Nephrectomy: A Systematic Review of the Literature.

CONTEXT: Postoperative acute kidney injury (AKI) is a serious complication after kidney surgery, associated with prolonged hospital stay, high morbidity, and mortality. Biomarkers represent a tool of increasing importance to identify renal impairment after partial nephrectomy (PN) or radical nephrectomy (RN) in order to optimize and anticipate the diagnosis of AKI. OBJECTIVE: The goal of this systematic review is to investigate current insights on the role of biomarkers in predicting renal impairment in patients undergoing PN or RN. EVIDENCE ACQUISITION: A systematic review was conducted up to November 30, 2017 through PubMed, Scopus, and Embase databases, to identify eligible studies evaluating the role of biomarkers for the prediction of AKI after PN or RN. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria were applied to select articles. EVIDENCE SYNTHESIS: According to the study selection criteria, 10 publications were included with a total number of 728 patients. Incidence of AKI was 26.7% (range: 9-58%). Based on the evidence reviewed, serum cystatin C and urinary neutrophil gelatinase-associated lipocalin (NGAL) showed a significant correlation with serum creatinine rise postoperatively, emerging as potential noninvasive and early biomarkers of AKI in patients undergoing renal surgery. In this setting, serum cystatin C and urinary NGAL have preceded the rise in serum creatinine peak from 3 up to 24h, even in case of mild renal damage. CONCLUSIONS: The literature underlines the potential usefulness of biomarkers such as cystatin C and NGAL as promising and early tools to predict AKI after PN or RN. However, no strong evidence in support of their use is available to date and further investigations are awaited. PATIENT SUMMARY: We looked at the role of biomarkers in predicting renal injury in patients undergoing partial or radical nephrectomy. Serum cystatin C and urinary neutrophil gelatinase-associated lipocalin have emerged as promising noninvasive, accurate, and early biomarkers.

Keratinizing squamous metaplasia of the bladder: Our experience and current approaches.

INTRODUCTION: Bladder mucosa is anatomically covered by urothelial epithelium. The replacement of the urothelium with stratified squamous cells is defined as squamous metaplasia which can be keratinizing or non-keratinizing. Clinically, it is also known as leukoplakia or keratinizing cystitis of the bladder. Although several etiologic factors have been proposed such as chronic inflammation, irritative stimuli and infection, its pathogenesis is not clearly understood. The natural history of squamous metaplasia and clinical treatment are controversial. Many authors consider squamous metaplasia as a premalignant lesion, so it is fundamental to find an effective treatment to reduce the risk of developing bladder squamous carcinoma. CASE DESCRIPTION: We report our management of a 58-year-old man with histological evidence of keratinizing squamous metaplasia and severe lower urinary tract symptoms. After repeated transurethral resections, the patient was treated with intravesical instillation of hyaluronic acid showing the regression of the lesion with an improvement of macroscopic appearance followed by the resolution of clinical symptoms. CONCLUSION: The therapeutic management of keratinizing squamous metaplasia is controversial, and currently no effective medical therapy is available for its treatment. Actually, patients undergo transurethral resections and a multidisciplinary approach is required to avoid cystectomy. Annual cystoscopy with multiple biopsies should be performed to determine the presence of dysplasia. Moreover, the therapeutic treatment with hyaluronic acid instillations could be the starting point and the gold standard in the follow-up of our patient. However, at present, further studies are required to formulate an adequate policy for therapeutic management of this unusual lesion of the bladder mucosa.

Efficacy and safety of adjustable balloons (Proact™) to treat male stress urinary incontinence after prostate surgery: Medium and long-term follow-up data of a national multicentric retrospective study.

AIMS: Male stress urinary incontinence (SUI) represents a complication after radical prostatectomy or benign prostatic obstruction surgery. The artificial urinary sphincter is considered the standard treatment but interest on minimally invasive devices, such as adjustable balloons, has recently increased. Aim of this study is to evaluate the efficacy and safety of the ProACT system. METHODS: In this multicentric retrospective study, we reported the data from nine centers. Patients with SUI who underwent a ProACT device implantation for postoperative SUI and had a minimum follow-up of 24 months were included. Efficacy was evaluated at the maximum available follow-up and was assessed utilizing a 24-hour pad test. Patients were considered: "Dry" if presenting a urine leak weight lower than 8 g at the 24-hour pad test; "Improved" if presenting a reduction of urine leak higher than 50% (but >8 g/24 hours); "Failure" if presenting a reduction in urine leak lower than 50%. The evaluation included a record of intraoperative and long-term complications. RESULTS: Safety and efficacy results are reported on 240 patients. 29.6% of patients were dry at 24 months, 37.5% were improved and 32.9% of patients were considered failures. The baseline mean pad weight of 367 g was reduced to 123 g at 24 months. Five-year follow-up on 152 patients showed similar efficacy. The complication rate was 22.5%, with the top complication being long-term balloon failure. CONCLUSIONS: ProACT implantation represents a safe and efficacious treatment for male postoperative SUI at both medium and long-term follow up. 67.1% of patients were dry or improved at 24 months. The majority of complications are low grade.

Segmental resection of distal ureter with termino-terminal ureteric anastomosis vs bladder cuff removal and ureteric re-implantation for upper tract urothelial carcinoma: results of a multicentre study.

OBJECTIVES: To compare overall (OS), cancer-specific (CSS), recurrence-free survival (RFS) and postoperative renal function amongst patients with upper tract urothelial carcinoma (UTUC) of the distal (lower lumbar and pelvic) ureter, electively treated with segmental resection and termino-terminal anastomosis (TT) vs bladder cuff removal and ureteric re-implantation (RR). PATIENTS AND METHODS: A multicentre retrospective study, including 84 patients diagnosed with UTUC of the distal ureter and treated with TT or RR, is presented. The primary endpoint was to compare TT and RR in terms of OS, CSS and RFS. As a secondary outcome, we compared the postoperative creatinine values as an index of renal function in the two groups. RESULTS: Of 521 patients with UTUC, 65 (77.4%) and 19 (22.6%) patients underwent RR and TT, respectively. Pre- and postoperative characteristics were not statistically different between the two groups. The median follow-up period was 22.7 months. Patients treated with TT and those treated with RR did not have significantly different 5-year OS, CSS or RFS (73.7% vs 92.3%, P = 0.052; 94.7% vs 95.4%, P = 0.970: and 63.2% vs 53.9%, P = 0.489, respectively). No difference in postoperative creatinine variation emerged in association with the surgical technique (P = 0.411). CONCLUSION: Patients treated with TT or RR for UTUC showed comparable OS, CSS, RFS and postoperative renal function. Our data suggest that bladder cuff removal is not imperative in the treatment of distal ureteric UTUC, and TT can be a safe solution in selected cases.

Once-daily 5 mg tadalafil oral treatment for patients with chronic prostatitis/chronic pelvic pain syndrome.

BACKGROUND: Chronic prostatitis/chronic pelvic pain syndrome (IIIB CP/CPPS) is a condition of unclear aetiology. Many approaches have been used without satisfactory results. The aim of this study is to evaluate the efficacy of once-daily 5 mg tadalafil in pain control and improving quality of life in patients affected by CP/CPPS. METHODS: Twenty patients affected by chronic prostatitis according EAU (European Association of Urology) guidelines were evaluated for once-daily 5 mg tadalafil; 14 patients were eligible for the study. The validated Italian version of the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) and the International Prostatic Symptom Score (IPSS) questionnaires were submitted to all the patients. Every patient underwent uroflowmetry and ultrasound prostatic volume at the beginning and at the end of the study. RESULTS: All 14 patients eligible for the study reported an improvement of symptoms during therapy: statistically significant differences were reported in terms of NIH-CPSI (p < 0.000002) and IPSS (p < 0.0001) during follow-up evaluations. No statistically significant improvement of uroflowmetry parameters was reported during the treatment. CONCLUSIONS: In our study the daily use of 5 mg tadalafil improves symptoms and quality of life in patients affected by CP/CPPS after 4 weeks of therapy. A larger population of patients is needed to confirm the efficacy of this therapy in CP/CPPS.

Laparoscopic Radical Prostatectomy in Patients with High-Risk Prostate Cancer: Feasibility and Safety. Results of a Multicentric Study.

INTRODUCTION: In Western countries about 25% of prostate cancer (PCa) are high-risk tumors at presentation and its treatment is still a matter of debate among urologists. When a surgical approach is preferred the use of a mininvasive tecnique is still difficult due to the lack of data supporting it in literature. The aim of this study is to evaluate feasibility and safety of laparoscopic radical prostatectomy (LRP) for high-risk PCa. MATERIALS AND METHODS: The study included 1114 patients with high-risk PCa submitted to LRP between 1998 and 2014. High-risk patients were defined according to D'Amico classification. We collected functional and oncological long-term outcomes and evaluated with univariate and multivariate analyses the role of predictive factors for survival and biochemical recurrence (BR). RESULTS: Mean age at treatment was 62 ± 8 years; mean follow-up was 74 ± 50 months. We obtained an overall survival (OS) of 96.6% at a mean follow-up of 74 months (1076 patients) and a disease-free survival of 66.2% (737 patients). Age (p = 0.0006), pT (p < 0.0001), pN (p = 0.0018), and surgical margins (p = 0.0076) resulted as independent predictors for BR in multivariate analysis. pN (p = 0.0025) and Gs (p = 0.0003) are independent predictors for OS and cancer-specific survival in a univariate analysis; just the Gs results significant in the multivariate model. CONCLUSIONS: According to our encouraging data about oncological and functional outcomes we believe that radical prostatectomy represents an effective treatment for patients with high-risk PCa and that laparoscopy is a safe approach offering a mini-invasive alternative to open surgery.

A robotic needle driver to facilitate vescico-urethral anastomosis during laparoscopic radical prostatectomy.

PURPOSE: The completion of the vescico-urethral anastomosis (VUA) represents the most critical step of laparoscopic radical prostatectomy (LRP), and it can often discourage the use of minimally invasive surgery in less experienced laparoscopic surgeons. The aim of this paper is to evaluate the usefulness of a new robotic needle driver named Dextérité in performing the VUA after LRP. MATERIALS AND METHODS: This prospective randomized clinical study enrolled 40 consecutive patients eligible for LRP, which were randomized into four groups: group A, patients undergoing LRP done by an expert surgeon; group B, patients undergoing robotic-assisted radical prostatectomy (RARP) performed by the same expert surgeon; group C, patients undergoing LRP performed by a young surgeon at the beginning of the learning curve; group D, patients undergoing LRP performed by another young surgeon at the beginning of the learning curve with the aid of Dextérité needle driver for completion of the VUA. The two young urologists performed the same steps of LRP so that they are at the same step of the learning curve. All the anastomosis were performed with the same technique in order to be comparable. We use interrupted sutures with Vicryl 2/0 and a 5/8 needle; we performed the Rocco stitch technique before all the anastomosis (6) and we applied bladder neck sparing technique. All patients underwent an ultrasound control of the anastomosis on the seventh postoperative day, as we usually do (9, 10). We consider continent who utilised no pad. RESULTS: Operative VUA completion time was 24.9 vs. 25 vs. 86.7 vs. 61 minutes, respectively. When comparing VUA completion time in group 3 and 4, the use of the Dextérité needle driver resulted in a reduction in VUA time. Urinary leakage was seen in zero out of 10 patients in groups 1 and 2 and in three out of 10 and one in 10 patients, respectively, in groups 3 and 4. All urinary leakages were managed conservatively. One-year continence rates were 95%, 97%, 93% and 95%, respectively. Only one patient in group C developed a bladder neck contracture 6 months after the procedure, but he underwent adiuvant radiotherapy after surgery. CONCLUSIONS: Our data suggest that the use of Dextérité needle holder significantly reduces operative time of VUA completion and reduces the incidence of urinary leakage in laparoscopic surgeons at the beginning of the learning curve.

Pentafecta rates of three-dimensional laparoscopic radical prostatectomy: our experience after 150 cases.

INTRODUCTION: Three-dimensional (3D) laparoscopy with a flexible camera was developed to overcome the main limitation of traditional laparoscopic surgery, which is two-dimensional (2D) vision.The aim of our article is to present the largest casistic of 3D laparoscopic radical prostatectomy (LRP) available in literature and evaluate our results in terms of pentafecta and compare it with the literature. METHODS: We retrospectively evaluated consecutive patients who underwent LRP with 3D technology between March 2014 and December 2015. Total operative time (TOT), anasthomosis time (AT), blood loss and complications were registered. All patients presented at least 3 months of follow-up. Surgical outcome was evaluated in terms of Pentafecta. RESULTS: One hundred fifty consecutive patients underwent 3D LRP. Mean follow-up was 16.9 months. Mean age was 67.7 ± 8.3 years (range 50-76). Mean preoperative PSA value was 8.3 ± 5.8 ng/ml and mean bioptic Gleason Score (GS) was 6.6. We had a mean TOT of 158 ± 23 minutes and a mean AT of 25 ± 12.6. Mean blood loss was 240 ± 40 ml. Eighteen (12%) postoperative complications occurred. Pathologic results: pT2 in 91 patients (58%) and pT3 in 59 (39.3%). Pentafecta was reached by 31.3% of patients at 3 months and 51.6% at 12 months. CONCLUSIONS: Our oncological and functional results are comparable to those present in literature for laparoscopic and robotic surgery. We believe that our findings can encourage the use of 3D laparoscopy especially considering the increasing attention to healthcare costs.

Evaluation of the decision-making process in the conservative approach to small testicular masses.

INTRODUCTION: We evaluate the clinical outcome of patients treated with conservative approach for small testicular masses (STMs). We analyzed the steps who brought to the selection of the therapeutic approach: starting from clinical presentation, through imaging and lab studies. METHODS: We considered 18 patients who underwent an organ-sparing approach for STMs from 2005 until 2014. The selection criteria were dimension of the mass and absence of clinical, laboratory and/or radiological malignancy suspicion. Preoperative scrotal ultrasound (US) was carried out in all the patients by the same radiologist. The postoperative fertility profile was evaluated in patients younger than 40 years. RESULTS: We performed 13 enucleations, one partial orchiectomy (PO) and four active surveillances. During surgery, a frozen section examination (FSE) was always requested and no discrepancies were noted between its results and the definitive histology. Only one seminomatous tumor was identified, while the remaining masses were four necrosis, four epidermoid cysts, three Leydig tumors, one Sertoli tumor and one chronic orchitis. After a mean follow-up of 41.6 ± 24.7 months, all the patients resulted free of disease and hypogonadism and five of them reached the fatherhood after surgery. CONCLUSIONS: The clinical and instrumental evaluation consented an accurate selection of patients eligible for the organ-preserving approach. We believe that testis-sparing surgery leads good functional and aesthetic results in patients with benign lesions; it is a safe option for STMs with a reliable pathologist performing FSE and is an important goal in young patients with fatherhood desire.

Critical Analysis of Early Recurrence after Laparoscopic Radical Cystectomy in a Large Cohort by the ESUT.

PURPOSE: We analyze patients with early progression after laparoscopic radical cystectomy in a large cohort by the ESUT (European Association of Urology Section of Uro-Technology). More specifically we focus on patients with favorable pathology (pT2 N0 R0 or less) who experienced an unexpected recurrence and analyze possible causes for such early recurrence, discussing the surgical technique including pneumoperitoneum. MATERIALS AND METHODS: Since 2000 the ESUT has been constructing a large, multicenter, prospective database of patients undergoing laparoscopic radical cystectomy. All procedures were performed via a standard laparoscopic approach without robotic assistance. We specifically analyzed patients with favorable pathological characteristics, in particular pT2 N0 R0 or less, and evaluated those with progression despite these favorable characteristics. Univariate and multivariate logistic regression was performed to evaluate risk factors for early recurrence. RESULTS: A total of 627 patients were available for final analysis with a median followup of 46 months (mean 57). Of these patients 311 had favorable pathological characteristics of pT2 N0 R0 or less. During followup 27 (8.7%) patients experienced disease progression during the first 24 months. Surgical negligence was found in only 1 case. Most of these patients with early recurrence had progression to high tumor volume disseminated metastatic disease. On multivariate logistic regression tumor stage was the only factor significantly associated with early recurrence (p=0.027). CONCLUSIONS: We report early unexpected recurrences after laparoscopic radical cystectomy in nearly 5% of our entire cohort, all in patients with favorable pathological characteristics (pT2 N0 R0 or less). Pneumoperitoneum may have had a role in the development of these relapses. Specifically designed studies are necessary to investigate the possible role of pneumoperitoneum in urothelial cancer recurrence.