Patient and Context Factors in the Adoption of Active Surveillance for Low-Risk Prostate Cancer.

Importance: Although active surveillance for patients with low-risk prostate cancer (LRPC) has been recommended for years, its adoption at the population level is often limited. Objective: To make active surveillance available for patients with LRPC using a research framework and to compare patient characteristics and clinical outcomes between those who receive active surveillance vs radical treatments at diagnosis. Design, Setting, and Participants: This population-based, prospective cohort study was designed by a large multidisciplinary group of specialists and patients' representatives. The study was conducted within all 18 urology centers and 7 radiation oncology centers in the Piemonte and Valle d'Aosta Regional Oncology Network in Northwest Italy (approximate population, 4.5 million). Participants included patients with a new diagnosis of LRPC from June 2015 to December 2021. Data were analyzed from January to May 2023. Exposure: At diagnosis, all patients were informed of the available treatment options by the urologist and received an information leaflet describing the benefits and risks of active surveillance compared with active treatments, either radical prostatectomy (RP) or radiation treatment (RT). Patients choosing active surveillance were actively monitored with regular prostate-specific antigen testing, clinical examinations, and a rebiopsy at 12 months. Main Outcomes and Measures: Outcomes of interest were proportion of patients choosing active surveillance or radical treatments, overall survival, and, for patients in active surveillance, treatment-free survival. Comparisons were analyzed with multivariable logistic or Cox models, considering centers as clusters. Results: A total of 852 male patients (median [IQR] age, 70 [64-74] years) were included, and 706 patients (82.9%) chose active surveillance, with an increasing trend over time; 109 patients (12.8%) chose RP, and 37 patients (4.3%) chose RT. Median (IQR) follow-up was 57 (41-76) months. Worse prostate cancer prognostic factors were negatively associated with choosing active surveillance (eg, stage T2a vs T1c: odds ratio [OR], 0.51; 95% CI, 0.28-0.93), while patients who were older (eg, age ≥75 vs <65 years: OR, 4.27; 95% CI, 1.98-9.22), had higher comorbidity (Charlson Comorbidity Index ≥2 vs 0: OR, 1.98; 95% CI, 1.02-3.85), underwent an independent revision of the first prostate biopsy (OR, 2.35; 95% CI, 1.26-4.38) or underwent a multidisciplinary assessment (OR, 2.65; 95% CI, 1.38-5.11) were more likely to choose active surveillance vs active treatment. After adjustment, center at which a patient was treated continued to be an important factor in the choice of treatment (intraclass correlation coefficient, 18.6%). No differences were detected in overall survival between active treatment and active surveillance. Treatment-free survival in the active surveillance cohort was 59.0% (95% CI, 54.8%-62.9%) at 24 months, 54.5% (95% CI, 50.2%-58.6%) at 36 months, and 47.0% (95% CI, 42.2%-51.7%) at 48 months. Conclusions and Relevance: In this population-based cohort study of patients with LRPC, a research framework at system level as well as favorable prognostic factors, a multidisciplinary approach, and an independent review of the first prostate biopsy at patient-level were positively associated with high uptake of active surveillance, a practice largely underused before this study.

Single-use digital flexible cystoscope for double J removal versus reusable instruments: a prospective, comparative study of functionality, risk of infection, and costs.

BACKGROUND: The removal of ureteral stent can be performed with disposable or reusable flexible cystoscopes, but limited comparative data are available on functionality, risk of infections, and costs. METHODS: We performed a multicentric, prospective, observational study on patients undergoing in-office ureteral stent removal with Isiris-α® or a reusable Storz™ flexible cystoscope. Study endpoints were the functionality and effectiveness of the devices, the rate of postoperative bacteriuria and UTIs, and the costs of the procedure. RESULTS: A total of 135 patients were included, 80 (59.2%) treated with reusable cystoscopes and 55 (40.8%) with Isiris-α®. No significant baseline differences between groups were detected. Isiris-α® outperformed the reusable device in terms of quality of vision (p 0.001), manoeuvrability (p 0.001), grasper functionality (p < 0.001), and quality of the procedure (p 0.01). Mean procedure time was shorter with Isiris-α® (p < 0.001) due to a shorter instrument preparation time (p < 0.001). No differences were found in terms of perceived patient pain (p 0.34), nor postoperative bacteriuria or symptomatic UTIs. According to our cost analysis, the in-office procedure performed with Isiris-α® was more expensive (+ 137.8€) but was independent from instrument turnover or disinfection. Among limitations of study we acknowledge the lack of randomization, the use of antibiotic prophylaxis in several patients, and the high rate of missing preoperative urine cultures. CONCLUSIONS: Isiris-α® outperforms reusable cystoscopes for in-office ureteral stent removal in terms of total operative time and quality of the procedure, at the cost of being more expensive. No significant differences in postoperative bacteriuria or symptomatic UTIs were found.

Feasibility and Outcomes of Temporary Bulbar Urethral Stent Placement After Internal Urethrotomy in the Largest Multicenter Series.

BACKGROUND: Recent years have seen the development of a new generation of temporary urethral stents as an adjuvant option after direct vision internal urethrotomy (DVIU). Despite some early promising results, large series addressing their safety and outcomes are still lacking. OBJECTIVE: To report complications and outcomes from the largest series of patients receiving a temporary bulbar urethral stent to date. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective analysis of bulbar urethral stenting procedures after DVIU in seven centers. Patients either refused urethroplasty or were not fit for surgery. The stents were removed after at least 6 mo in place unless complications requiring earlier removal occurred. SURGICAL PROCEDURE: DVIU with a cold knife or laser is performed, followed by stent placement. At the end of the treatment period, the stent is removed under cystoscopy with gripping forceps. MEASUREMENTS: All patients underwent postoperative follow-up (FU) for assessment of complications while the stent was in place. After removal, the FU schedule consisted of office evaluation at 6 mo and 12 mo, and then annually. Failure was defined as any treatment for urethral stricture after stent removal. RESULTS AND LIMITATIONS: A total of 49% of the patients experienced complications. The most frequent were discomfort (23.8%), stress incontinence (17.5%), and stent dislocation (9.8%). Some 85% of the adverse events observed were Clavien-Dindo grade <3. The overall success rate at median FU of 38.2 mo was 76.9%. The success rate was significantly lower if the stent was removed before 6 mo (53.3% vs 79.7%; p = 0.026). CONCLUSIONS: Temporary urethral stents may be a safe choice with satisfactory results in patients not undergoing urethroplasty. A stent indwelling time shorter than 6 mo provides worse outcomes that are comparable to those with DVIU alone. PATIENT SUMMARY: We assessed complications and outcomes after placement of a temporary narrow tube in the urethra after surgery to widen a narrowing of the urethra. The treatment is safe and easily reproducible with satisfactory results. Further studies are needed to confirm our findings.

Preliminary Results of ERAS Protocol in a Single Surgeon Prospective Case Series.

Background and Objectives: The aim was to compare the intra and postoperative outcomes between the Enhanced Recovery After Surgery (ERAS) protocol versus the standard of care protocol (SCP) in patients who underwent radical cystectomy performed by a single surgeon. Materials and Methods: A retrospective comparative study was conducted including patients who underwent radical cystectomy from 2017 to 2020. Length of stay (LOS), incidence of ileus, early postoperative complications, and number of re-hospitalizations within 30 days were considered as primary comparative outcomes of the study. Results: Data were collected for 91 patients who underwent cystectomy, and 70 and 21 patients followed the SCP and ERAS protocol, respectively. The mean age of the patients was 70.6 (SD 9.5) years. Although there was a statistically significant difference in time to flatus (TTF) [3 (2.7−3) vs. 1 (1−2 IQR) days, p < 0.001, in the SC hospital and in the ERAS center respectively], no difference was reported in time to first defecation (TTD) [5 (4−6) vs. 4 (3−5.8), p = 0.086 respectively]. The median LOS in the SCP group was 12 (IQR 11−13) days vs. 9 (IQR 8−13 p = 0.024). In the postoperative period, patients reported 22 complications (37% in SCP and 42.8% in ERAS group, p = 0.48). Conclusions: The study reveals how even partial adherence to the ERAS protocols leads to similar outcomes when compared to SCP. As a single surgeon series, our study confirmed the role of surgeons in reducing complications and improving surgical outcomes.

Flexible Ureterorenoscopy Versus Shockwave Lithotripsy for Kidney Stones ≤2 cm: A Randomized Controlled Trial.

BACKGROUND: No clear recommendations are available on whether retrograde intrarenal surgery (RIRS) via flexible ureterorenoscopy or shockwave lithotripsy (SWL) should be preferred for kidney stones ≤2 cm, except for lower-pole stones. OBJECTIVE: To compare outcomes between RIRS and SWL. DESIGN, SETTING, AND PARTICIPANTS: This was a single-center randomized controlled trial from March 2015 to May 2018. Patients with a single 6-20-mm kidney stone were enrolled (NCT02645058). INTERVENTION: Patients were randomized to RIRS or SWL. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was the single-procedure stone-free rate (SFR) at 1 mo. Two levels of success were set: fragments ≤4 mm (SFR-4) and no residual fragments (SFR-0). Secondary endpoints were the SFR at 6 mo and 1 yr and rates of complications and further treatments. RESULTS AND LIMITATIONS: A total of 138 patients underwent treatment (70 RIRS vs 68 SWL). In comparison to SWL, RIRS SFR results were higher at 1 mo (SFR-4 70.0% vs 45.6%; p = 0.004; SFR-0 50.0% vs 26.5%; p = 0.004) and 6 mo (SFR-4 79.7% vs 63.6%; p = 0.038; SFR-0 59.4% vs 40.9%; p = 0.032). There was no difference in SFR measures between the groups at 1 yr (SFR-4 p = 0.322; SFR-0 p = 0.392). Overall complications were comparable (p = 0.207), but the complication rate for stones >10 mm was higher for the SWL group (p = 0.021). The need for further treatment was comparable (p = 0.368). In terms of patient satisfaction, 86.8% and 77.1% of patients would choose SWL and RIRS again, respectively (p = 0.24). CONCLUSIONS: RIRS achieved better SFRs in comparison to SWL at 1 and 6 mo, but not at 1 yr. The RIRS complication rate was lower for stones >10 mm. SWL remains a viable alternative, especially for 6-10-mm stones, providing comparable results to RIRS in the long term. PATIENT SUMMARY: We compared outcomes for the treatment of kidney stones ≤2 cm with two techniques: flexible ureteroscopy, in which a flexible telescope is passed through the urethra and bladder to reach the ureter between the bladder and kidney; and shockwave lithotripsy, in which shockwaves are applied to the skin over the location of the kidney stone. Ureteroscopy achieved better stone-free results at 1 and 6 months, but not at 1 year.

Penile injection of aedile silicone: A dangerous shortcut.

INTRODUCTION: The size of penis can cause concern in patients, even if the organ is clinically normal. Additionally, the cost of phosphodiesterase 5 inhibitors (iPDE5) and long waiting lists to access penile prosthesis placement can lead patients to resort to non-medical and potentially dangerous alternatives. One of these dangerous alternatives is the injection of building silicone at the level of the subcutis of the penis or the corpora cavernosa causing the formation of a granuloma that increases the girth and consistency of the penis. CASE REPORT: The article describes the case of a 43-year-old patient who self-injected aedile silicone at the level of his penis in an attempt to achieve greater penile size and greater rigidity. The patient reported that he could not economically afford the iPDE5.The persistence of severe pain in the penis forced the patient to go to a urological examination. The patient subsequently underwent the penile granuloma exeresis procedure and skin reconstruction with scrotal flap. CONCLUSION: The pursuit of sexual well-being can lead some patients to rely on unconventional and potentially harmful techniques. The role of the andrologist and of the scientific society should be to dissuade the patient from using these dangerous methods and to provide valid alternatives accessible to the patient. The economic difficulty in purchasing drugs that facilitate erection or the long waiting lists for the placement of penile prostheses can favor dangerous methods such as penile injection of silicon. There is therefore a clear need to facilitate access to drugs and surgical techniques that favor the patient's sexual well-being.

Stone free rate and clinical complications in patients submitted to retrograde intrarenal surgery (RIRS): Our experience in 571 consecutive cases.

INTRODUCTION: The purpose of this study is to report the stone free rate (SFR) and clinical complications in patients submitted to retrograde intrarenal surgery (RIRS). MATERIALS AND METHODS: A total of 571 procedures of upper urinary stones treated using flexible ureteroscopy and holmium laser lithotripsy from January 2014 to February 2020 have been analyzed. Overall SFR was evaluated after 3 months following the procedure by means of a non-contrast computed tomography. Success was considered as stone-free status or ≤ 0.4 cm fragments. RESULTS: The overall SFR was 92.3% in group 1 (stone size: < 1 cm), 88.3% in group 2 (stone size: > 1 ≤ 2 cm), 56.7% in group 3 (stone size: 2-3 cm) and 69.6% in group 4 (multiple stones). Post-operative complications, according to the Clavien- Dindo (CD) classification system, were recorded in 32 (5.6%) procedures. The major complications recorded were: one case of subcapsular hematoma (SRH) associated with pulmonary embolism two days after the procedure (CD Grade IIIa) treated conservatively and one case of hemorrhagic shock 2 hour with multiple renal bleedings requiring urgent nephrectomy (CD Grade IVA). CONCLUSIONS: The RIRS is an effective and safe procedure with a high SFR significantly correlated with the stone size; at the same time, RIRS could be characterized by severe clinical complications that require rapid diagnosis and prompt treatment.

UVENTA urethral stents: Are we taking a step forward? The first clinical series. / Stent uretral UVENTA: ¿Un paso para adelante? La primera serie clínica.

OBJECTIVES: To describe first clinical results in term of safety, complications and short term efficacy of temporary placement of UVENTA urethral stent in the treatment of urethral and bladder neck strictures. METHODS: UVENTA urethral stent (Taewoong Medical) is a temporary self expandable covered metallic stent. Anti-migration system and different radial force distribution are the two main innovations. This is a retrospective evaluation of UVENTA stent temporary placements for urethral diseases in two urological Centers. RESULTS: 15 patients underwent UVENTA stent placement between 2016 and 2018. Stent placement was easy and quick in all cases. Considering indwelling period: one patient reported urethral pain related to the stent in the first month, three patients had urinary infection treated with antibiotics; temporary stress incontinence was noted in 21% of bulbar-membranous stents; stent migrations was noted in 3 out of 4 bladder neck cases whereas no bulbar-membranous stents migrated. At removal no significant incrustation, stone or tissue ingrowth were noted, as well as new proximal or distal strictures. Stent removal was uncomplicated in all cases. Median follow up is 9.5 months (6-24). Considering strictures overall success rate is 73% (11/15): 82% for bulbar urethra (9/11) and 50% for bladder neck (2/4). CONCLUSIONS: UVENTA urethral stent showed a satisfying safety profile with few and low grade complications. Absence of migration and damage on healthy mucosa are main achievements. Further cases are needed to confirm these results and to really explore its efficacy.

OBJETIVOS: Describir los primeros resultados clínicos en términos de seguridad, complicaciones y eficacia a corto plazo de la colocación temporal de stent uretral UVENTA en el tratamiento de estenosis de uretra y de cuello vesical.MÉTODOS: El stent uretral UVENTA (Taewoong Medical) es un stent metálico temporal autoexpandible. Las dos principales innovaciones son el sistema antimigración y la distribución de la fuerza radial. Esta es una evaluación retrospectiva de la colocación de UVENTA en enfermedades uretrales en dos centros urológicos. RESULTADOS: 15 pacientes recibieron UVENTA entre 2016 y 2018. La colocación del stent fue fácil y rápida en todos los casos. Teniendo en cuenta el periodo de catéter: un paciente describió dolor uretral relacionado con el stent en el primer mes, 3 pacientes tuvieron infección urinaria tratada con antibióticos; incontinencia urinaria de estrés en el 21% de pacientes con stent en uretra bulbomembranosa; la migración de stents se demostró en 3 de 4 casos con estenosis de cuello vesical, mientras, ningún caso de uretra bulbomembranosa migro. Al quitar el stent, no se observó incrustación significativa, litiasis o tejido en crecimiento, así como nuevas estenosis distales o proximales. La retirada del stent no fue complicada en la mayoría de casos. La mediana de seguimiento fue de 9,5 meses (6-24). Considerando la tasa de éxito en global fue de 73% (11/15): 82% para uretra bulbar (9/11) y 50% para cuello vesical (2/4). CONCLUSIONES: El stent uretral UVENTA demostró un perfil de seguridad satisfactorio con mínimas complicaciones. La ausencia de migración o daño de la mucosa sana son las principales virtudes. Son necesarios más casos para confirmar estos resultados y explorar su eficacia.

Uventa urethral stents: are we taking a step forward? The first clinical series / Stents uretrales de Uventa: ¿estamos dando un paso adelante? La primera serie clínica

Objetives: To describe first clinical results in term of safety, complications and short term efficacy of temporary placement of UVENTA urethral stent in the treatment of urethral and bladder neck strictures. Methods: UVENTA urethral stent (Taewoong Medical) is a temporary self expandable covered metallic stent. Anti-migration system and different radial force distribution are the two main innovations. This is a retrospective evaluation of UVENTA stent temporary placements for urethral diseases in two urological Centers. Results: 15 patients underwent UVENTA stent placement between 2016 and 2018. Stent placement was easy and quick in all cases. Considering indwelling period: one patient reported urethral pain related to the stent in the first month, three patients had urinary infection treated with antibiotics; temporary stress incontinence was noted in 21% of bulbar-membranous stents; stent migrations was noted in 3 out of 4 bladder neck cases whereas no bulbar-membranous stents migrated. At removal no significant incrustation, stone or tissue ingrowth were noted, as well as new proximal or distal strictures. Stent removal was uncomplicated in all cases. Median follow up is 9.5 months (6-24). Considering strictures overall success rate is 73% (11/15): 82% for bulbar urethra (9/11) and 50% for bladder neck (2/4). Conclusions: UVENTA urethral stent showed a satisfying safety profile with few and low grade complications. Absence of migration and damage on healthy mucosa are main achievements. Further cases are neededto confirm these results and to really explore its efficacy.(AU)

Objetivos: Describir los primeros resultados clínicos en términos de seguridad, complicacionesy eficacia a corto plazo de la colocación temporal de stent uretral UVENTA en el tratamiento de estenosis de uretra y de cuello vesical. Métodos: El stent uretral UVENTA (Taewoong Medical) es un stent metálico temporal autoexpandible. Lasdos principales innovaciones son el sistema antimigración y la distribución de la fuerza radial. Esta es unaevaluación retrospectiva de la colocación de UVENTA en enfermedades uretrales en dos centros urológicos. Resultados: 15 pacientes recibieron UVENTA entre 2016 y 2018. La colocación del stent fue fácil y rápida en todos los casos. Teniendo en cuenta el periodo de catéter: un paciente describió dolor uretral relacionado con el stent en el primer mes, 3 pacientes tuvieron infección urinaria tratada con antibióticos; incontinenciaurinaria de estrés en el 21% de pacientes con stent en uretra bulbomembranosa; la migración de stents se demostró en 3 de 4 casos con estenosis de cuello vesical, mientras, ningún caso de uretra bulbomembranosa migro. Al quitar el stent, no se observó incrustación significativa, litiasis o tejido en crecimiento, así como nuevas estenosis distales o proximales. La retirada del stent no fue complicada en la mayoría de casos. La mediana de seguimiento fue de 9,5 meses (6-24). Considerando la tasa de éxito en global fue de 73% (11/15): 82% para uretra bulbar (9/11) y 50% para cuello vesical (2/4). Conclusiones: El stent uretral UVENTA demostró un perfil de seguridad satisfactorio con mínimas complicaciones. La ausencia de migración o daño de la mucosasana son las principales virtudes. Son necesarios más casos para confirmar estos resultados y explorar su eficacia.(AU)

Flexible ureteroscopy using a 120-w holmium laser: The low-energy/high-frequency approach. / Ureteroscopia flexible utilizando laser holmium 120 W: baja energía/alta frecuencia.

OBJECTIVES: With the spread of more powerful lasers and the advent of new technologies, endoscopic interventions for urolithiasis are continuously evolving. The aim of this study is to present our experience and technique regarding Low Energy (LE)/High Frequency (HF) lithotripsy by using a 120-W Holmium laser (Lumenis®). METHODS: We retrospectively analysed our prospectively maintained Retrograde Intra Renal Surgery (RIRS) database. Lithotripsy was performed using LE/HF settings with a Long Pulse Width (LPW) and consisted of the following steps: 1) contact Laser lithotripsy (LE/HF/LPW dusting - 0,5 J/50 Hz or 02 J/70 Hz); 2) extraction ofmain fragments; 3) non-contact Laser lithotripsy (LE/HF/Short Pulse Width Pop Dusting - 0,5 J /80Hz). Pre-operativeand peri-operative outcomes were collected. Post-operative complications were recorded according to Clavien-Dindo Grading System. Finally, all patients under went a CT scan at three months after RIRS to assess the success of procedure, defined as stone-free or presence of ≤4 mm fragments (Clinical Insignificant Residual Fragments - CIRF). RESULTS: Overall, 104 LE/HF/LPW RIRS from December 2017 to January 2019 were performed. Mean operative time was 59 (SD ±23) minutes, median post-operative stay was two days (IQR 2-3). The post-operative complication rate was 4,8%: one patient had nausea and vomiting (Clavien-Dindo I) and four patients developed urosepsis (Clavien-Dindo II). The success rate was 88,5% (71,2% stone-free and 17,3% CIRF). CONCLUSIONS: LE/HF/LPW RIRS seems to be safe and effective in terms of positive success rate, safety and standard operative time. However, randomized clinical trials are needed to compare this technique to standard RIRS.

OBJETIVOS: Con la aparición de láseres de alta potencia y las nuevas tecnologías, las intervenciones endoscópicas para las urolitiasis continúan evolucionando. El objetivo de este estudio es presentar nuestra experiencia y técnica de baja energía (BE), alta  frecuencia (AF) de litotricia utilizando el laser holmium120 W (Lumenis®). MÉTODOS: Retrospectivamente analizamos nuestra base de datos prospectiva de ureteroscopia retrograda intrarenal. La litotricia fue realizada utilizando BE/AFcon pulsos amplios y largos (LPW). La técnica consistió en los siguientes pasos: 1) Contacto litotricia laser (BE/AF/LPW polvo- 0.5J/50 Hz o 02 J/70 Hz); 2) extracción de los fragmentos principales; 3) litotricia laser sin contacto (BE/AF/pulso corto polvo- 0,5 J /80Hz). Los resultados preoperatorios y perioperatorios fueron recogidos. Las complicaciones postoperatorias fueron recogidas por el sistema Clavien-Dindo. Finalmente, todos los pacientes recibieron un TAC a los 3 meses después de la ureteroscopia retrograda para evaluar el éxito del procedimiento, que se definió como la no existencia de litiasis o de fragmentos de menos de 4 mm (fragmentos clínicamente insignificantes). RESULTADOS: 104 BE/AF/LPW ureteroscopias retrógradas se realizaron entre diciembre de 2017 y enero de 2019. El tiempo operatorio medio fue de 50 minutos( SD ± 23), la estancia media postoperatoria fue de 2 días (IQR 2-3). La tasa de complicaciones postoperatorias fue de 4,8%: un paciente tuvo nauseas y vómitos (Clavien I) y 4 pacientes desarrollaron urosepsis (Clavien II). La tasa de éxito fue de 88%, 71,2% libre de litiasis y 17,3% fragmentos clínicamente insignificantes. CONCLUSIONES: BE/AF/LPW ureteroscopia retrógrada es un procedimiento seguro y efectivo en términos de tasa de éxito, seguridad y tiempo quirúrgico. Aunque, estudios randomizados son necesarios para comparar esta técnica con la ureteroscopia retrógrada estándar.

Flexible ureteroscopy using a 120-w holmium laser: the low-energy/high-frequency approach / Ureteroscopia flexible con láser de holmio de 120 w: el abordaje de baja energía/alta frecuencia

Objetives: With the spread of morepowerful lasers and the advent of new technologies,endoscopic interventions for urolithiasis are continuouslyevolving.The aim of this study is to present our experience andtechnique regarding Low Energy (LE)/High Frequency(HF) lithotripsy by using a 120-W Holmium laser (Lumenis®).Methods: We retrospectively analysed our prospectively maintained Retrograde Intra Renal Surgery (RIRS)database. Lithotripsy was performed using LE/HF settings with a Long Pulse Width (LPW) and consisted of the following steps: 1) contact Laser lithotripsy (LE/HF/LPWdusting – 0,5 J/50 Hz or 02 J/70 Hz); 2) extraction ofmain fragments; 3) noncontact Laser lithotripsy (LE/HF/Short Pulse Width Pop Dusting - 0,5 J /80Hz). Pre-operative and peri-operative outcomes were collected.Post-operative complications were recorded accordingto Clavien-Dindo Grading System. Finally, all patientsunderwent a CT scan at three months after RIRS to assessthe success of procedure, defined as stone-free or presence of ≤4 mm fragments (Clinical Insignificant ResidualFragments – CIRF).Results: Overall, 104 LE/HF/LPW RIRS from December 2017 to January 2019 were performed. Mean op-erative time was 59 (SD ±23) minutes, median post-operative stay was two days (IQR 2-3). The post-operativecomplication rate was 4,8%: one patient had nauseaand vomiting (Clavien-Dindo I) and four patients developed urosepsis (Clavien-Dindo II). The success rate was88,5% (71,2% stone-free and 17,3% CIRF).Conclusions: LE/HF/LPW RIRS seems to be safeand effective in terms of positive success rate, safety andstandard operative time. However, randomized clinicaltrials are needed to compare this technique to standardRIRS.(AU)

Objetivos: Con la aparición de láseresde alta potencia y las nuevas tecnologías, las intervenciones endoscópicas para las urolitiasis continúanevolucionando. El objetivo de este estudio es presentarnuestra experiencia y técnica de baja energía (BE), alta frecuencia (AF) de litotricia utilizando el laser holmium120 W (Lumenis®).Métodos: Retrospectivamente analizamos nuestrabase de datos prospectiva de ureteroscopia retrogradaintrarenal. La litotricia fue realizada utilizando BE/AFcon pulsos amplios y largos (LPW). La técnica consistióen los siguientes pasos: 1) Contacto litotricia laser (BE/AF/LPW polvo- 0.5J/50 Hz o 02 J/70 Hz);2) extracción de los fragmentos principales; 3) litotricia laser sincontacto (BE/AF/pulso corto polvo- 0,5 J /80Hz). Losresultados preoperatorios y perioperatorios fueron recogidos. Las complicaciones postoperatorias fueron recogidas por el sistema Clavien-Dindo. Finalmente, todoslos pacientes recibieron un TAC a los 3 meses despuésde la ureteroscopia retrograda para evaluar el éxito delprocedimiento, que se definió como la no existencia delitiasis o de fragmentos de menos de 4 mm (fragmentosclínicamente insignificantes).Resultados: 104 BE/AF/LPW ureteroscopias retrógradas se realizaron entre diciembre de 2017 y enerode 2019. El tiempo operatorio medio fue de 50 minutos (SD ± 23), la estancia media postoperatoria fue de2 días (IQR 2-3). La tasa de complicaciones postoperatorias fue de 4,8%: un paciente tuvo nauseas y vómitos (Clavien I) y 4 pacientes desarrollaron urosepsis(Clavien II). La tasa de éxito fue de 88%, 71,2% libre delitiasis y 17,3% fragmentos clínicamente insignificantes.Conclusiones: BE/AF/LPW ureteroscopia retrógrada es un procedimiento seguro y efectivo en términos detasa de éxito, seguridad y tiempo quirúrgico. Aunque,estudios randomizados son necesarios para compararesta técnica con la ureteroscopia retrógrada estándar.(AU)

Self-Expandable Covered Metallic Stent (UVENTA) to Treat a Ureteral Stricture After Renal Transplant: A Case Report.

We present the use of a self-expandable covered metallic stent (UVENTA; TaeWoong Medical, Gyeonggi-do, South Korea) to treat a ureteral stricture after kidney transplant. In this report, we describe the procedure and short-term outcomes of a patient with a recurrent distal stricture who did not respond to percutaneous balloon dilation. We decided to place this temporary stent as an alternative to complex surgery. The aim of the procedure was to get a chronic dilation of the stricture up to 7 mm to stabilize the fibrotic tissue. The procedure was easily and quickly performed by an antegrade and retrograde combined approach. The postoperative course was uneventful. The stent was left in situ for 7 months. No complications were noted, and the renal function remained stable. The stent was easily removed, and 5 months later there were no signs of recurrence. The UVENTA device was shown to be an easy, safe, and effective minimally invasive treatment for ureteral stricture in renal transplant. Proper permanence time and long-term results need to be explored.

Is it worth to perform salvage radical prostatectomy for radio-recurrent prostate cancer? A literature review.

PURPOSE: Salvage radical prostatectomy (sRP) represents a curative option for prostate cancer (PCa) biochemical recurrence (BCR) after radiation therapy (RT). In this review, we aimed to outline the contemporary results and use of sRP. METHODS: A web search was performed on the Ovid platform using Embase and Medline databases from January 2010 using pre-defined search terms. Web search was implemented by manual search. Oncological and functional outcomes and complications were summarized using standard classification systems, when feasible. RESULTS: sRP is currently underused, being chosen for radio-recurrent PCa treatment in around 1% of the cases. Surgery is complex due to radiation-induced tissue changes making posterior planes and apex dissection particularly challenging. Patient selection is paramount to maximize the oncological benefit. Most series report a BCR-free survival > 60%, mainly at the end of a short- to intermediate-term follow-up. Five-year progression-free survival is nearly 50% and 5-year cancer-specific survival rates are around 90%. Major peri-operative complications, anastomotic leaks and strictures, still more frequent than in a primary RP setting, have been steering towards more acceptable rates in recent years, when compared to historical series. Continence rates are widely variable, often in between 39 and 60%. Potency remains difficult to recover. CONCLUSIONS: sRP represents a curative option with promising short- to medium-term oncological results and acceptable side effects, in high-volume institutions. In appropriately selected patients, the procedure should not be underused due to the fear of poor functional outcomes and/or complications. Prospective studies are needed to assess the long-term outcomes and to further refine patient selection criteria.

How bothersome double-J ureteral stents are after semirigid and flexible ureteroscopy: a prospective single-institution observational study.

PURPOSE: To evaluate in details the actual extent of double-J stent-related symptoms after semirigid (URS) and flexible (RIRS) ureteroscopy using a validated questionnaire. METHODS: We asked to complete the Ureteric Stent Symptoms Questionnaire (USSQ) to all stone patients undergoing URS or RIRS with stent placement from 2010 to 2015. Stent-related symptoms' prevalence, severity, and impact on daily life were analyzed using descriptive statistics and five-order Likert scales. Subgroups analyses were performed. RESULTS: 232 patients completed the USSQ. Stents had a deep impact on urinary symptoms (daily frequency ≥ 1 per hour 59.1%, ≥ 1 nocturnal micturition 90.1%, urgency 86.6%, burning 82.3%) that represented a problem for 88.4% of patients. 83.2% complained of pain, mostly in the kidney (67.9%) or in the bladder area (31.3%), particularly during physical activity (72.9%) and micturition (77.0%). Pain interfered with everyday life in 92.2%. General health, working, and sexual activity were also affected. 62.0% of patients would be dissatisfied (51.6% unhappy or terrible) if further ureteral stenting was proposed in future. Younger patients and females were more affected. Limitations include observational design and lack of baseline evaluation. CONCLUSIONS: Ureteral stents are responsible for significant urinary symptoms and pain after semirigid and flexible ureteroscopy. They also considerably affect general health, working and sexual activity. Urologists should consider it carefully before stenting, inform patients about stent-related symptoms, and minimize stent indwelling time.

Retrograde intra-renal surgery under spinal anesthesia: the first large series.

BACKGROUND: Retrograde intra-renal surgery (RIRS) has become increasingly common and is mainly performed under general anesthesia (GA). There are no specific papers about RIRS performed under spinal anesthesia (SA). Our objective was to evaluate feasibility and results of RIRS performed under SA. METHODS: We analyzed all consecutive RIRS performed for stones in day surgery from March 2008 to September 2012. Single procedures outcomes of RIRS performed under SA were evaluated with US and KUB X-ray at 2 weeks. Further treatments, operative time and complications were also evaluated. Outcomes of RIRS performed under SA and GA were compared. Difference between groups was statistically analyzed. Significance level was set at P<0.05. RESULTS: One hundred thirty-nine RIRS under SA and 47 under GA were considered. Mean stone burden was 14±6 mm. No case of conversion from SA to GA occurred. Stone-free rate (SFR) level 4U of RIRS under SA and under GA were respectively 63.6% and 48.6%, SFR level 0U 24.5% and 25.7%, CIRF 39.1% and 22.9%. Further treatments were performed respectively in 20.8% and in 23.4%. No anesthesia-related and Clavien-Dindo grade ≥3 complications occurred. No statistically significant difference was found in stone-free rates, CIRF and significant residual fragments rates, need for further procedures, operative time and complications between the two groups. CONCLUSIONS: RIRS under SA seems feasible and effective for renal stones in day surgery. Results seem equivalent to RIRS under GA. SA can be considered for RIRS as an alternative to GA.

De Novo Bladder Urothelial Neoplasm in Renal Transplant Recipients: A Retrospective, Multicentered Study.

BACKGROUND AND OBJECTIVES: Renal transplant recipients (RTRs) have a 2- to 7-fold risk of developing a neoplasm compared to general population. Bladder urothelial neoplasms in this cohort has an incidence of 0.4-2%. Many reports describe a more aggressive behavior. The objective of this study is to describe oncologic characteristics of bladder urothelial neoplasms in RTRs and to evaluate its recurrence, progression, and survival rates. METHODS: A retrospective multicentered study was performed evaluating all de novo bladder urothelial neoplasms cases in RTRs from 1988 to 2014. Descriptive statistical analysis and evaluation of recurrence, progression, and survival rates were performed. RESULTS: A total of 28 de novo bladder transitional cell carcinomas (TCCs) were identified (incidence rate 0.64%). Cancer-specific survival rates were 100, 75, and 70% after 1, 5, and 10 years, respectively. Age at diagnosis superior to 60 years was found to be a statistically significant variable for recurrence risk. Progression rate was 14%. Presence of CIS was significantly associated with progression. All cancer-specific deaths were in the high-risk group and all were progressions from non-muscle invasive to muscle invasive bladder cancer. CONCLUSIONS: Bladder urothelial neoplasms following renal transplant is associated with a trend toward worst prognosis. Early aggressive treatments, such as early radical cystectomy, might be advisable to reduce cancer-specific deaths.

Prostate cancer treatment in renal transplant recipients: a systematic review.

The aim of this review was to summarize the current evidence and to highlight the main issues future research needs to address regarding prostate cancer (PCa) treatment in renal transpant recipients (RTRs). We conducted a search of AMED, Medline and Embase up to 17 November 2016 to investigate oncological and functional outcomes of PCa treatment in RTR. Type and use/protocols of immunosuppression and peri-operative antibiotic drugs were also assessed. The search was implemented manually. Exclusion criteria were absence of full text or absence of information that allowed us to differentiate oncological and/or functional outcomes of each therapeutic approach used. We included 241 patients from 27 retrospective studies published between 1991 and 2016; seven of the studies were case-control and 20 were case series. We also considered nine case reports published between 1999 and 2016. Follow-up ranged from 1 to 120 months. PCa was organ-confined, with Gleason score ≤6 in 75.2% and 60.4% of patients. Surgery was the most frequent treatment used (n = 186), for which cancer-specific (CSS) and overall survival (OS) rates were both 96.8%. Functional outcomes, including continence and erectile function, and complications were less frequently reported and were generally similar to those reported for radical prostatectomy (RP) in non-RTRs. Other treatment methods in the patients included in the review were radiotherapy (RT) ± androgen deprivation therapy (ADT; n = 34; OS 88.2%; CSS 88.2%), ADT alone (n = 14; OS 42.9%; CSS 64.3%), brachytherapy (BT; n = 11; OS and CSS 100%), watchful waiting (n = 4) and active surveillance (n = 1). Overall no treatment-related graft loss occurred. Immunosuppression and antibiotic schemes were poorly reported and inconsistent. Outcomes of PCa treatment in RTRs are encouraging and do not appear to be inferior to those of non-RTR. RP was the most commonly assessed approach, whilst RT, BT and ADT were less frequent. Immunosuppression and antibiotic use were poorly reported and highly variable. High-quality studies are needed because the current level of evidence is low, and our results should therefore be interpreted with caution.

Role of perioperative dynamic sentinel node biopsy for cN0 penile cancer management: experience from an Italian tertiary referral center.

PURPOSE: Inguinal lymphadenectomy (iLAD) reduces mortality in patients with cN0 penile cancer but yields high complication rates. Thus, its prophylactic role has been questioned and dynamic sentinel node biopsy (DSNB) was introduced to select men who should undergo the procedure. Our aim was to investigate the accuracy of a contemporary DSNB cohort. METHODS: We performed a retrospective analysis of ≥T1 or ≥G2 cN0 penile cancer undergoing perioperative DSNB from June 2009 to June 2015 at a tertiary referral center. We excluded men with <18 months follow-up or with local recurrence after primary curative treatment. Complications were graded according to the Clavien-Dindo classification. RESULTS: Thirty-five men underwent DSNB; 85.71% had ≤T2 penile cancer with ≤G2a histology. Per groin detection rate was 80% (scintigraphy being positive bilaterally in 60% and unilaterally in 20.0%). In no cases did DSNB prolong the postoperative course compared to primary surgery. Nine men (n = 15/109 nodes removed) had positive results, 8 of whom underwent iLAD. Among negative DSNB patients, 2 developed nodal penile cancer recurrence; none of them had node biopsy due to inconclusive scintigraphy. At a median follow-up of 42 months (interquartile range 30-78 months), if considering only men with scintigraphy detected inguinal nodes, per-patient sensitivity and specificity were 50% and 80% whereas positive predictive value and negative predictive value were 25% and 92.3%, respectively. CONCLUSIONS: Perioperative DSNB is a safe procedure, yielding promising results when performed at a tertiary referral center. Future prospective large studies are needed to investigate how to optimize detection rate and reduce false-negative rates.

Subcapsular Hematoma Causing Anuria After Renal Graft Trauma.

A 67-year-old man presented to the emergency department 22 hours after a trauma to his kidney graft. He was asymptomatic during the first 10 hours, then he became anuric. His serum creatinine level was 2.73 mg/dL (baseline, 0.7 mg/dL), and his hemoglobin concentration was 13.1 g/dL. Computer tomography showed a 4-cm subcapsular hematoma without active bleeding. He underwent urgent decompression of the hematoma, and we did not find any active bleeding or parenchymal laceration. Urinary output had already recovered by the end of surgery without early or late complications. In conclusion, subcapsular hematoma, complicating a traumatic event on a kidney graft, can lead to a progressive parenchymal compression resulting in anuria. So, although in the absence of anemia, such events require urgent surgical decompression. Symptoms cannot be immediate, so all the graft trauma should be investigated with early ultrasound. Little is known in the case of major renal trauma but mildly symptomatic. Probably surgical exploration is better than observation to prevent possible early and late complications such as organ rejection or a Page kidney.

Robot-assisted laparoscopic pyeloplasty in a pediatric patient with horseshoe kidney: surgical technique and review of the literature.

OBJECTIVE: The aim of this study was to describe the technical aspects of a robotic pyeloplasty in pediatric patients with uretero-pelvic junction obstruction (UPJO) in horseshoe kidney (HSK) through the report of our recent case, and to outline the state of the art of minimally invasive pyeloplasty (MIP) with a systematic review of the literature. METHODS: We describe all the steps of our surgery performed on an 11-year-old patient with left UPJO in HSK in detail. All the anatomic landmarks are clearly showed, with particular attention to trocar placement in a pediatric patient. A systematic review of the literature on the outcomes of MIP in HSK patients has been performed, including 16 articles. RESULTS: Our surgery was successful following a standardized approach. However, we recorded a rare complication, the herniation of a small portion of omentum through the 8 - mm defect used for the caudal robotic port. The evidence synthesis shows excellent postoperative outcomes for both laparoscopic and robot-assisted laparoscopic pyeloplasties in HSK patients. Probably, MIP should be preferred to the traditional open approach in these patients, when feasible. CONCLUSIONS: Transperitoneal robotic pyeloplasty is an excellent minimally invasive choice for the treatment of UPJO in HSK pediatric patients. The pediatric setting should prompt attention to every detail to avoid unfortunate complications.