COVID-19 Quarantine Dramatically Affected Male Sexual Behavior: Is There a Possibility to Go Back to Normality?

We performed a monocentric longitudinal study on sexually active male patients, from May 2021 to October 2021, with SARS-CoV-2 infection confirmed with a nasopharyngeal reverse transcriptase polymerase chain reaction (RT-PCR). The questionnaires were delivered by email. The study period was divided into the periods before getting tested (T1), during quarantine (T2), 1 month after a negative test (T3), and 3 months after a negative test (T4). All participants were invited to complete these questionnaires: 10- and 6-item questionnaires, a sexual distress schedule (SDS), and the international index of erectile function questionnaire of 15 items (IIEF-15). The primary endpoint was to evaluate the impact of quarantine on male sexual function (SF) during and after the SARS-CoV-2 infection. A total of 22 male patients met the inclusion criteria. The differences for both SDS and IIEF-15 scores, between T1−T2 (27 (IQR 24.0−32.2) vs. 37.5 (IQR 34.2−45.5), 45 (IQR 38.0−50.2) vs. 28.5 (IQR 19.5−38.0)), T2−T3 (37.5 (IQR 34.2−45.5) vs. 28 (IQR 24.0−31.0), and 28.5 (IQR 19.5−38.0) vs. 39.5 (IQR 35.5−44.2)) were statistically significant (p < 0.001), respectively. Moreover, between T1−T4, no statistically significant difference (p > 0.05) was recorded in both SDS (27 (IQR 24.0−32.2) vs. 26.5 (IQR 24−30.2)) and IIEF-15 (45 (IQR 38.0−50.2) vs. 28.5 (IQR 19.5−38.0)). In 20 patients (90.9%), SARS-CoV-2 had a huge impact on relationship and sexual life, but no patient attended a clinic for sexual difficulties. In conclusion quarantine has negatively influenced SF in infected patients; however, 3 months after the rRT-PCR negative test, a promising return to the preinfection SF values is observed.

Ureteral reimplantation after deflux failure for vesicoureteral reflux in renal transplant.

PURPOSE: To evaluate the outcomes of ureteral reimplantation (UR) after failure of endoscopic treatment for symptomatic vesicoureteral reflux (VUR) in renal transplant recipients. METHODS: We conducted a monocentric retrospective study that included all renal transplant recipients with failure of Deflux™ as first-line treatment of VUR from January 2007 to December 2020. Failure of Deflux™ was defined by: VUR on retrograde cystography and at least one acute pyelonephritis of the renal graft. The preferred surgical treatment was native ureteropyelostomy (NPUS) in the recent years. If the native ureter could not be used, ureteroneocystostomy (UNC) was performed. The primary outcome was the clinical efficacy of UR defined as the absence of acute graft pyelonephritis during follow-up. RESULTS: Out of 1565 kidney transplantations, 119 (7.6%) had symptomatic VUR treated with bulking agent. 35 (29.4%) had Deflux™ failure and were addressed to UR: 21/35 (60%) NPUS and 14/35 (40%) UNC. The median estimated blood loss, operative time, and length of stay were 120 mL, 90 min, and 7 days, respectively. After a median follow-up of 7.1 (IQR 4.1-9.8) years, UR was clinically successful in a total of 32 patients (91.4%): 20 (95.2%) and 12 (85.7%) patients in the NPUS and UNC groups, respectively (p = 0.55). Three (8.5%) high-grade complications have been reported. No nephrectomy of native kidney was required in the NPUS group. CONCLUSIONS: After failure of Deflux™ for VUR of renal graft, surgical treatment with native ureteropyelostomy or ureteroneocystostomy is associated to a high success rate and few high-grade complications.

Case Report: The Complete Remission of a Mixed Germ Cell Tumor With Somatic Type Malignancy of Sarcoma Type With a GCT-Oriented Therapy: Clinical Findings and Genomic Profiling.

Somatic malignant transformation in a germ cell tumor (GCT) is the development of non-germ malignancies; much of available literature refers to teratoma with malignant transformation (TMT). There are various transformation histologies such as sarcoma, adenocarcinoma, primitive neuroectodermal tumors, and more rarely carcinoid tumors, hemangioendothelioma, lymphoma, or nephroblastoma. The treatments of these entities include surgery and/or chemotherapy. A standard approach in choosing chemotherapy in TMT cases has not yet been established. Many authors suggest using chemotherapeutic agents based on the transformed histology, while others recommend GCT-oriented therapy combined with surgery as the primary treatment, reserving histology-driven chemotherapies for metastatic relapse. We report the clinical findings and the genomic profile of a mixed GCT case with somatic-type malignancy of sarcoma type. We achieved a complete radiological response with GCT-oriented chemotherapy performed as salvage therapy after sarcoma-histology therapy. In addition, molecular profiles with RNA-sequencing and exome sequencing analyses of the primary tumor and the tumor with somatic-type malignancy of sarcoma type were explored.

Cardiovascular Risks of Androgen Deprivation Therapy for Prostate Cancer.

Androgen deprivation therapy (ADT) is the gold standard treatment in patients with locally advanced or metastatic prostate cancer (PC). Emerging evidence has documented a tight association between ADT and body composition, along with metabolic profile impairment. These alterations might underpin the observed ADT-related increase in cardiovascular (CV) and thromboembolic (venous thromboembolism, VTE) mortality and morbidity. However, the specific mechanisms underlying these associations have not yet been completely elucidated. In the present review we summarize and discussed the available evidence linking ADT to increased cardio-metabolic risk, using both preclinical and clinical data. When possible, meta-analytic studies were preferred. Preclinical evidence, using a rabbit model of gonadotrophin-releasing hormone analogue-induced hypogonadism, indicates that the induced condition is associated with a dramatic increase in visceral adiposity and with an impairment of acetylcholine induced vascular relaxation, along with an increased propensity towards fatty liver. This suggests a direct role of ADT in inducing a worsened metabolic profile. In contrast, available clinical data are not sufficient to clarify a direct pathogeniclink between reduced testosterone (T) and altered metabolism. In fact, although T deprivation is associated with an altered metabolism, it is possible that the association between ADT and CV or VTE risk could simply be the result of a selection bias, related to the poor health status of patients with advanced PC. Despite the aforementioned considerations, all patients who are candidatesfor ADT should be screened for CV risk factors at baseline and monitored during the therapy. Life-style modifications and physical exercise are strongly encouraged.

Subclinical male hypogonadism.

INTRODUCTION: The concept of subclinical or compensated male hypogonadism (SHG), characterized by increased gonadotropins and normal testosterone levels is emerging. However, its real clinical significance is still conflicting. The aim of the present study was to summarize and discuss the available evidence related to the possible definition of SHG and the possible advantages of testosterone replacement therapy (TRT). EVIDENCE ACQUISITION: A comprehensive systematic Medline, Embase and Cochrane search was performed. Publications from January 1, 1969 up to February 29, 2020 were included. The search was restricted to English-language articles and studies of human participants. EVIDENCE SYNTHESIS: Two main clinical forms of SHG can be described. The first identifies young patients who have a positive medical history for testis damage occurring before puberty onset. The second form can occur as a consequence of an age-dependent decline of T. Whereas the former can be the consequence of several congenital or acquired diseases, also possible causes of primary hypogonadism, the real significance of the latter is still debatable. Available evidence indicates that age-related SHG is quite a common phenomenon, occurring in 9.4% of aging men from the general population. Cross-sectional and longitudinal data have documented that it is associated with poor health and can be a sign of forthcoming increased cardiovascular mortality and morbidity. CONCLUSIONS: Although available evidence suggests that in aging populations SHG can be considered a particular condition associated with an increased CV risk, it is still unknown if treatment with T can improve any outcomes in these subjects. Hence, further interventional studies are advisable to better understand the characteristics of SHG and the possible advantages of an early TRT.

A surgical multi-layer technique for pelvic reconstruction after total exenteration using a combination of pedicled omental flap, human acellular dermal matrix and autologous adipose derived cells.

•A multi-layer technique for reconstruction after pelvic exenteration is proposed.•Human acellular dermal matrix used in reconstruction after total pelvic exenteration.•A reconstructive technique based on human dermis, omental flap and fat is proposed.

First case of 18F-FACBC PET/CT-guided salvage retroperitoneal lymph node dissection for disease relapse after radical prostatectomy for prostate cancer and negative 11C-choline PET/CT: new imaging techniques may expand pioneering approaches.

We present the first case of salvage retroperitoneal lymph node dissection based on the results of (18)F-FACBC PET/CT performed for a prostate-specific antigen relapse after radical prostatectomy. The patients underwent (11)C-choline PET/CT, which turned out negative, while (18)F-FACBC PET/CT visualized two lymph node metastases confirmed at pathological examination. Preliminary clinical reports showed an improvement in the detection rate of 20-40% for (18)F-FACBC in comparison with (11)C-choline, rendering the (18)F-FACBC the potential radiotracer of the future. Salvage surgery for prostate cancer is a fascinating but controversial approach. New diagnostic tools may improve its potential by increasing the assessment and the selection of the patients.

The number of nodes removed as well as the template of the dissection is independently correlated to cancer-specific survival after radical cystectomy for muscle-invasive bladder cancer.

PURPOSE: To assess the impact of the number of lymph nodes removed and of the template of dissection during radical cystectomy for bladder cancer on patients' survival rates. MATERIALS AND METHODS: We evaluated 282 consecutive patients who underwent radical cystectomy for muscle-invasive or high-grade superficial bladder cancer between 1995 and 2011. Exclusion criteria were incomplete follow-up data and neo-adjuvant or adjuvant treatments. Patients were divided into groups according to the most informative cut-point of number of lymph nodes retrieved and of the template of dissection. The cancer-specific survival rates were estimated by the Kaplan-Meier method. The univariate and multivariable forward-stepwise Cox proportional hazards regression were applied to analyze the survival outcomes. RESULTS: The mean (SD) follow-up was 59.2 ± 44.3 months, and the mean (SD) age of the entire cohort population was 68.3 ± 8.3 years. The cancer-specific survival rates were 58.7 and 47.7 % at 5 and 10 years, respectively. Considering both node-positive and node-negative patients, those with at least 14 LNs removed and those submitted to extended or super-extended PLND experienced significantly higher cancer-specific survival at both univariate and multivariable analysis. CONCLUSIONS: Patients undergoing a more extended pelvic lymph node dissection, both in terms of number of LN removed and in terms of template of dissection, will experience a better cancer-specific survival. Our data support a potential role of lymphadenectomy on cancer outcome.

Perioperative complications and mortality after radical cystectomy when using a standardized reporting methodology.

PURPOSE: To evaluate, by using a standardized reporting methodology, the perioperative complications and mortality in patients who underwent radical cystectomy. MATERIALS AND METHODS: We retrospectively reviewed all data of 404 consecutive patients who underwent radical cystectomy from 1995 to 2009 for nonmetastatic bladder cancer at the same academic center. Perioperative complications and perioperative mortality were defined as any adverse event or death from any cause within 90 days of surgery. All perioperative complications were reported according to the Martin criteria and were graded according to the Clavien system (grade 1-5). Univariate and multivariate analyses for the clinical and pathologic characteristics were used to evaluate predictors of complications. RESULTS: A total of 296 complications occurred in 209 (51.7%) patients. Among them, 139 (34.4% of the entire population) had only a '"minor"' (grade 1-2) complication, whereas 70 (17.3%) had a "major" (grade 3-5) complication. Eighteen (4.5%) patients died within 90 days after surgery. At univariate analysis, age ≥75 years (2P = .018), serum creatinine level ≥1.4 mg/dL (2P = .025), American Society of Anesthesiologists (ASA) score of 3 to 4 (2P < .001) were significant predictors of complications after 30 days from surgery; conversely, the ASA score was the only significant predictor of complications after 90 days. At multivariate analysis, only the ASA score was independently correlated with the development of complications at 30 and 90 days of follow-up (2P < .001). CONCLUSIONS: Radical cystectomy is one of the most complex procedures in urology, with a high rate of complications and mortality. The use of a standardized methodology is the only way to estimate the actual rate and the severity of complications.

Molecular diagnostic tools for the detection of nodal micrometastases in prostate cancer patients undergoing radical prostatectomy with extended pelvic lymph node dissection: a prospective study.

BACKGROUND: Routine pathological examination can miss micro-metastatic tumor foci in the lymph nodes (LN) of patients with prostate cancer (PCa) that undergo radical prostatectomy and pelvic lymph node dissection (PLND). The aim of the present prospective study was to evaluate the impact of micrometastases assessed by serial section (SS), immunohistochemistry (IHC), and Real-time Polymerase Chain Reaction (RT-PCR) in patients undergoing radical prostatectomy with extended PLND. MATERIALS AND METHODS: 32 consecutive patients who underwent radical prostatectomy with extended PLND (obturator, internal/external and distal 2 cm common iliac lymph-nodes (LN)) for intermediate (clinical T1c-T2 and PSA:10-20 ng/mL and clinical Gleason Score = 7) or high (clinical stage T3 or PSA>20 or clinical Gleason Score = 8-10) PCa were enrolled. The nodes were processed by the one uropathologist, both according to the routine pathological examination (analysis of the central section for 4 mm nodes or every 2 mm for LN>4 mm), which served as comparative method, both according to SS, IHC with antibodies against PSA and broad-spectrum Cytokeratins (BSCK), and quantitative RT-PCR targeting PSA, PSMA (PS Membrane Antigen), and Glucuronidase-S-Beta (GUSB) mRNA, that are over-expressed in prostatic cancer cells. RESULTS: A total of 628 LN were analyzed, with a mean number of LN removed of 19.6 (SD = 7.2). Applying the routine pathological examination, 10 (31.2%) patients and 23 (3.9%) LN resulted positive for nodal involvement, with mean positive LN of 2.2 (SD = 1.4). After applying the SS and the molecular method of analysis (IHC and RT-PCR), micrometastases were found in 7 LN (SS showed micrometastases in 3 of them, IHC in 6 of them and RT-PCR in 7 of them); a total of 3 (9.3%) node-negative patients showed micrometastases at routine pathological examination (in 2 patients with RT-PCR and in 1 with IHC). CONCLUSIONS: The significance of micrometastases in PCa and the potential therapeutic role of PLND is not yet clarified, but the molecular analysis of the LN can detect a significant percentage of patients who harbor micro-metastatic PCa missed at routine pathological examination, and can enhance the accuracy of lymphadenectomy as a staging method.

The extent of pelvic lymph node dissection correlates with the biochemical recurrence rate in patients with intermediate- and high-risk prostate cancer.

OBJECTIVE: • To assess the impact of pelvic lymph node dissection (PLND) and of the number of lymph nodes (LNs) retrieved during radical prostatectomy (RP) on biochemical relapse (BCR) in pNX/0/1 patients with prostate cancer according to the clinical risk of lymph node invasion (LNI). PATIENTS AND METHODS: • We evaluated 872 pT2-4 NX/0/1 consecutive patients submitted to RP between October 1995 and June 2009, with the following inclusion criteria: (i) a follow-up period ≥12 months; (ii) the avoidance of neoadjuvant hormonal therapy or adjuvant hormonal and/or adjuvant radiotherapy; (iii) the availability of complete follow-up data; (iv) no pathological T0 disease; (v) complete data regarding the clinical stage and Gleason score (Gs), the preoperative prostate-specific antigen (PSA) level and the pathological stage. • The patients were stratified as having low risk (cT1a-T2a and cGs ≤6 and PSA level < 10 ng/mL), intermediate risk (cT2b-T2c or cGs = 7 or PSA level = 10-19.9) or high risk of LNI (cT3 or cGs = 8-10 or PSA level ≥ 20). • The 872 patients were divided into two LN groups according to the number of LNs retrieved: group 1 had no LN or one to nine LNs removed; group 2 had 10 or more LNs. • The variables analysed were LN group, age, PSA level, clinical and pathological stage and Gs, surgical margin status, LN status and number of LN metastases; the primary endpoint was the BCR-free survival. RESULTS: • The mean follow-up was 55.8 months. • Of all the patients, 305 (35%) were pNx and 567 (65.0%) were pN0/1. • Of the 567 patients submitted to PLND, the mean number of LNs obtained was 10.9, and 49 (8.6%) were pN1. • In the 402 patients at low risk of LNI, LN group was not a significant predictor of BCR at univariate analysis, while in the 470 patients at intermediate and high risk of LNI, patients with ≥ 10 LNs removed had a significantly lower BCR-free survival at univariate and multivariate analysis. CONCLUSION: • In our study population, a more extensive PLND positively affects the BCR-free survival regardless of the nodal status in intermediate- and high-risk prostate cancer.

Conservative laparoscopic management of urinary tract endometriosis (UTE): surgical outcome and long-term follow-up.

OBJECTIVE: To evaluate surgical outcome and long-term follow-up of conservative laparoscopic management of urinary tract endometriosis (UTE). DESIGN: Prospective study. SETTING: Tertiary-care university hospital. PATIENT(S): Women with laparoscopic diagnosis and histologic confirmation of urinary bladder or ureteral endometriosis who agreed to undergo long-term follow-up after laparoscopic management. INTERVENTION(S): (1) Laparoscopic partial cystectomy for bladder endometriosis. (2) Uretric endometriosis laparoscopically managed by: uretrolysis only; segmental ureterectomy and terminoterminal anastomosis; or segmental ureterectomy and uretrocystoneostomy. MAIN OUTCOME MEASURE(S): Variables assessed were: preoperative findings, operative details (type and site of UTE, type of intervention, perioperative complications), and long-term follow-up (persistence/recurrence of preoperative urinary symptoms, if present, and anatomic relapse of the disease). RESULT(S): Mean operating time was 152.8+/-41.7 minutes. Mean drop in hemoglobin was 1.9+/-1.6 g/dL. Average hospital stay was 6 days. After surgery, 11 women had fever>38 degrees C and four presented transient urinary retention. During a follow-up period of 36 months, endometriosis recurred in eight patients with no evidence of bladder or ureteral reinvolvement, and there was a significant reduction in the mean score of dysuria and suprapubic pain maintained during the whole follow-up period. CONCLUSION(S): Results of long-term follow-up demonstrate significant reduction in preoperative symptoms with no anatomic relapse.

Three-dimensional computed tomography of the orthotopic ileal neobladder reconstruction: normal and abnormal findings.

INTRODUCTION: Our study aimed to assess the usefulness of 3D-CT in patients who have undergone radical cystectomy and orthotopic ileal neobladder. MATERIALS AND METHODS: We performed a CT study with 3D reconstructions in 32 patients 6 months after radical cystectomy and different orthotopic ileal neobladder (8 Studer, group A; 10 Hautmann-Ghoneim, group B; 14 Hautmann with 'double chimney' modification, group C). We evaluated position, shape and volume of neobladder; length of ureters and of afferent limb (in group A), length and diameter of ureteral intramural tunnel (in group B) and length of 'chimney' (in group C); vesico-urethral angle; vesico-ureteral reflux; possible complications. RESULTS: In group A, we observed a renal stone with hydronephrosis, a lateral neobladder and a bilateral vesico-ureteral reflux. In 2 females of group B, neobladder was on the right side and associated in 1 case with a conical shape, hydroureteronephrosis, filling defects and urinary incontinence. In group C, 1 patient had a bilateral vesico-ureteral reflux and 1 had a left hydronephrosis. A pouchocele was detected in 1 patient with vesico-urethral angle less than 120 degrees. CONCLUSIONS: 3D-CT is helpful for better displaying the morphology of a new reno-vesical anatomy, and some features seem to be indicative of a predisposition to develop possible complications. It may be useful for surgeons to plan a reintervention to obviate or prevent complications.

Role of nephron sparing surgery in the treatment of centrally located renal tumors.

OBJECTIVES: In recent years many long-term data have suggested that nephron sparing surgery can be considered as an effective method of treatment also in patients with small, solitary, unilateral renal cell carcinoma and a normal contralateral kidney. Generally, partial nephrectomy is performed for peripheral tumors and usually is limited to imperative indication for central tumors to avoid hemodialysis. We retrospectively evaluate the value of tumor location on technical and oncological results, particularly in patients with elective indication. PATIENTS AND METHODS: Between 1993 and 2002, 112 patients underwent nephron sparing surgery at our institution. The tumor was centrally and peripherally located in 22 and in 90 cases, respectively. The tumor was discovered in 13 (56%) central and in 57 (63%) peripheral tumors incidentally. The indication was imperative in 12 and elective in 10 patients for central group, while it was imperative in 34 and elective in 56 patients for peripheral group. RESULTS: The mean renal ischemia time was longer in central group compared to peripheral group (20.81 versus 18.8 minutes p<0.05) and the collecting system was violated more frequently in central group (53% versus 28% p<0.05). Postoperative complications were higher for central tumors compared to peripheral tumors (18% versus 4% p<0.05) but the ultimate mean serum creatinine level was similar for central and peripheral tumors (1.36 versus 1.22 mg/dl). The mean tumor size was 39.69 mm in central group and 32.77 mm in peripheral group (p<0.05). The mean diameter of central tumors in imperative indication was 42 mm while in elective indication was 32 mm (p<0.05). Pathological tumor stage was T1 to T3 in 18 (82%), 1 (4%) and 3 (14%) cases in central group and in 81 (88%), 6 (7%) and 5 (5%) cases in peripheral group. Grades was 1 to 3 in 4 (18%), 15 (68%) and 3 (14%) cases in central group and in 21 (23%), 61 (66%) and 10 (11%) cases in peripheral group. There was no difference in 5-year cancer specific survival (91% versus 98%) or postoperative local tumor recurrences (9% versus 6%) in central tumors compared to peripheral tumors and there was no local recurrence in elective partial nephrectomy performed in central tumors. CONCLUSIONS: Nephron sparing surgery is technically more demanding in patients with central tumors. However there were no significant differences in cancer specific survival and local recurrence between centrally versus peripherally located tumors. Elective partial nephrectomy can be performed also in patients with central tumors as long as really less than 4 cm.