Video-Assisted informed consent in endoscopic urology: a randomized trial on ureterorenoscopy.

PURPOSE: The aim of this study is to evaluate the possible beneficial effect of using the video - consent in the preoperative URS consent giving process. MATERIAL AND METHODS: Prospective randomized trial took place at two Italian tertiary-care centers from March 2022 to September 2022. Patients were randomly assigned to two groups: Group A (standard verbal/written informed consent) and Group B (informed consent supported by video). We investigated the impact of both types of the informed consent on the level of patients' anxiety assessed with the STAI questionnaire pre- and postoperatively. Additionally, we evaluated the effect of informed consents on the postoperative pain, measured with the VAS scale, and the number of assistances calls during hospitalization as secondary outcomes. To assess the satisfaction level related to the whole process, we asked patients to rate their experience on a scale of 1-10, with 1 indicating "not satisfied" and 10 indicating "completely satisfied." RESULTS: Overall, 166 patients were randomized 1:1 in each group. According to the multivariable regression model, the video-assisted informed consent significantly increased the difference between postoperative and preoperative STAI, reducing the level of anxiety. The video-assisted informed consent significantly predicted the number of assistance calls during the hospitalization. CONCLUSIONS: Video-consent for ureteroscopies are a valid tool to improve patients' satisfaction and awareness of the procedure. Video-consent is able to reduce patients' anxiety related to the procedure and assistance calls during the postoperative period, resulting in a useful tool to administer a better-informed consent for endourological procedures.

Risk Related to Increasing Indications for Retrograde Intrarenal Surgery.

Cite this article as: Mantica G, Ambrosini F, Malinaric R, Calarco A, Terrone C. Risk related to increasing indications for retrograde intrarenal surgery (RIRS). Urol Res Pract. 2024;50(1):66-67.

New minimally invasive solutions for Benign Prostatic Obstruction (BPO) management: A position paper from the UrOP (Urologi Ospedalità Gestione Privata).

To the Editor, In recent years, alternative solutions have been proposed to obtain effective results comparable to TURP, which is currently considered the gold standard, and laser vapo-enucleation techniques (1, 2), but with the possibility of maintaining sexual functions. In recent years there has been a growing trend towards ejaculation preservation. Although the results of TURP (3), and most laser enucleation techniques are undoubted in the Benign Prostatic Hyperplasia (BPH) and Lower Urinary Tract Symptoms (LUTS) management, they often lack in the preservation of ejaculation. All the alternative recently proposed interventions (Rezum, AquaBeam, Urolift, TPLA, i-TIND, LEST) are procedures considered by some authors to be promising in both managing BPO and preserving sexual functions. However, all these methods are limited by a lack of long-term follow-up that would evaluate the efficacy over time, possible complications related to the method and the correct patient selection for a specific method. The aim of this letter is to summarize the available evidence and provide clinicians with practical recommendations on the use of the brand new minimally invasive techniques for the management of BPO. [...].

The Lifetime History of the First Italian Public Extra-Corporeal Shock Wave Lithotripsy (ESWL) Lithotripter as a Mirror of the Evolution of Endourology over the Last Decade.

Extracorporeal shockwave lithotripsy (ESWL) is the only non-invasive treatment for kidney stones. It does not require an operating room, anesthesia, or hospital stay. Its role evolved over the years and nowadays ESWL is slowly disappearing from many stone centers and urologic departments. We present the history and the role of ESWL treatment since its birth in 1959 and its development through the following years. We also present details of its application and impact on the first Italian stone center in 1985. ESWL has had different roles over the centuries: in the early years it was a great alternative to open surgery and percutaneous nephrolithotripsy (PCNL), then it had its decline with the introduction of the miniscopes. Currently, although ESWL is not considered a treatment of excellence, newer models are emerging. With the application of new technologies and artificial intelligence, this technique can become a good option alongside endourologic treatments.

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.

From women to women-hematuria during therapy for metastatic breast cancer, what to suspect and when to be alarmed; Bladder metastasis from breast cancer-our experience and a systematic literature review.

Breast cancer is one of the most important causes of premature mortality in women worldwide. Around 12% of breast cancer patients will develop metastatic disease, a stage associated with poor prognosis, and only 26% of patients are likely to survive for at least 5 years after being diagnosed. Although the most common sites where breast cancer tends to spread are bones, lungs, brain, and liver, it is important that physicians consider other less frequent organs and viscera, like the bladder, as a target destination. In this article we report our experience with this rare form of metastases and a systematic literature review. We analyzed case reports, case series, and review articles present in PubMED/MEDLINE up to March 2022. We excluded the nonrelevant articles, editorials, letters to the editor, and articles written in other languages. We identified a total of 302 articles, with 200 articles being removed before screening; therefore, the total number of abstracts reviewed was 102. Fifty-five articles were excluded before full text review because they did not meet the inclusion criteria, and one article was not retrievable. Therefore, we included a total of 45 articles in this review. The intention of this review is to highlight the importance of the early detection of bladder metastases and to facilitate the diagnostic process for the responsible physician. The most common signs and symptoms and breast cancer subtype associated with bladder metastases, as well as overall survival after their detection, were all assessed. Bladder metastases from metastatic breast cancer are prevalent in the invasive, lobular breast cancer subtype; most patients present with hematuria (39.5%) and the relative 5-year survival rate is 2%. The main limitations of this review are the low number of cases reported in the literature, clinical and pathological differences between the individual cases, and absence of the control group. This study was not funded.

How long should we follow patients managed for muscle-invasive bladder cancer? Lesson learned from a recent clinical practice.

To the Editor, The exact time to stop bladder cancer patient's follow-up is not well known and there is not a clear recommendation on if and when stop to follow a patient managed for muscle invasive bladder cancer (MIBC). Major urological guidelines do not provide a precise indication on the timing of follow-up, and there is currently no real consensus on optimal time schedule [...].

Organ harvesting as a mandatory training step of all PGY1 and PGY2 surgical residents.

To the Editor, Good surgical training is essential for the formation of excellent surgeons, consequently providing the best possible care for our patients in the future. Considering the increase in surgeon shortage over the last two decades (estimated between 14,300 and 23,400 by the year 2032 only in the US), it is important for filling the national health system's needs as well [...].

The Role of Novel Bladder Cancer Diagnostic and Surveillance Biomarkers-What Should a Urologist Really Know?

The aim of this review is to analyze and describe the current landscape of bladder cancer diagnostic and surveillance biomarkers. We researched the literature from 2016 to November 2021 to find the most promising new molecules and divided them into seven different subgroups based on their function and location in the cell. Although cystoscopy and cytology are still the gold standard for diagnosis and surveillance when it comes to bladder cancer (BCa), their cost is quite a burden for national health systems worldwide. Currently, the research is focused on finding a biomarker that has high negative predictive value (NPV) and can exclude with a certainty the presence of the tumor, considering missing it could be disastrous for the patient. Every subgroup has its own advantages and disadvantages; for example, protein biomarkers cost less than genomic ones, but on the other hand, they seem to be less precise. We tried to simplify this complicated topic as much as possible in order to make it comprehensible to doctors and urologists that are not as familiar with it, as well as encourage them to actively participate in ongoing research.

Extraperitoneal cystectomy with ureterocutaneostomy derivation in fragile patients - should it be performed more often?

INTRODUCTION AND OBJECTIVES: Radical cystectomy (RC) continues to be standard of care for muscle-invasive bladder cancer and recurrent or refractory nonmuscle invasive bladder cancer. Unfortunately, it has high rates of perioperative morbidity and mortality. One of the most important predictors of postoperative outcomes is frailty, while the majority of complications are diversion related. The aim of our study was to evaluate safety of extraperitoneal cystectomy with ureterocutaneostomy in patients considered as frail. MATERIALS AND METHODS: We retrospectively collected data of frail patients who underwent extraperitoneal cystectomy with ureterocutaneostomy from October 2018 to August 2020 in a single center. We evaluated frailty by assessing patients' age, body mass index (BMI), nutritional status by Malnutrition Universal Screening Tool, overall health by RAI (Risk Analysis Index) and ASA (American Society of Anaesthesiologists) score, and laboratory analyses. We observed intraoperative outcomes and rates of perioperative (within 30 days) and early postoperative (within 90 days) complications (Clavien-Dindo classification). We defined extraperitoneal cystectomy with ureterocutaneostomy as safe if patients did not develop Clavien Dindo IIIb, or worse, complication. RESULTS: A total of 34 patients, 3 female and 31 male, were analyzed. The median age was 77, BMI 26, RAI 28, ASA 3 and the majority had preexisting renal insufficiency. Blood analyses revealed presence of severe preoperative hypoalbuminemia and anemia in half of our cohort. Intraoperative median blood loss was 250 cc, whilst operative time 245 min. During perioperative period 60% of our cohort developed Clavien Dindo II complication and during early postoperative period 32% of patients required readmission. One death occurred during early postoperative period (2.9%). After 12 months of follow-up, we observed stability of the renal function for most patients. CONCLUSIONS: We believe that extraperitoneal cystectomy with ureterocutaneostomy could be considered as a treatment option for elderly and/or frail patients.

Efficacy of High-Resolution Preoperative 3D Reconstructions for Lesion Localization in Oncological Colorectal Surgery-First Pilot Study.

When planning an operation, surgeons usually rely on traditional 2D imaging. Moreover, colon neoplastic lesions are not always easy to locate macroscopically, even during surgery. A 3D virtual model may allow surgeons to localize lesions with more precision and to better visualize the anatomy. In this study, we primary analyzed and discussed the clinical impact of using such 3D models in colorectal surgery. This is a monocentric prospective observational pilot study that includes 14 consecutive patients who presented colorectal lesions with indication for surgical therapy. A staging computed tomography (CT)/magnetic resonance imaging (MRI) scan and a colonoscopy were performed on each patient. The information gained from them was provided to obtain a 3D rendering. The 2D images were shown to the surgeon performing the operation, while the 3D reconstructions were shown to a second surgeon. Both of them had to locate the lesion and describe which procedure they would have performed; we then compared their answers with one another and with the intraoperative and histopathological findings. The lesion localizations based on the 3D models were accurate in 100% of cases, in contrast to conventional 2D CT scans, which could not detect the lesion in two patients (in these cases, lesion localization was based on colonoscopy). The 3D model reconstruction allowed an excellent concordance correlation between the estimated and the actual location of the lesion, allowing the surgeon to correctly plan the procedure with excellent results. Larger clinical studies are certainly required.

Reporting ChAracteristics of cadaver training and sUrgical studies: The CACTUS guidelines.

INTRODUCTION: Recent systematic reviews highlighted increasing use of cadaveric models in the surgical training, but reports on the characteristics of the models and their impact on training are lacking, as well as standardized recommendations on how to ensure the quality of surgical studies. The aim of our survey was to provide an easy guideline that would improve the quality of the studies involving cadavers for surgical training and research. METHODS: After accurate literature review regarding surgical training on cadaveric models, a draft of the CACTUS guidelines involving 10 different items was drawn. Afterwards, the items were improved by questionnaire uploaded and spread to the experts in the field via Google form. The guideline was then reviewed following participants feedback, ergo, items that scored between 7 and 9 on nine-score Likert scale by 70% of respondents, and between 1 and 3 by fewer than 15% of respondents, were included in the proposed guideline, while items that scored between 1 and 3 by 70% of respondents, and between 7 and 9 by 15% or more of respondents were not. The process proceeded with Delphi rounds until the agreement for all items was unanimous. RESULTS: In total, 42 participants agreed to participate and 30 (71.4%) of them completed the Delphi survey. Unanimous agreement was almost always immediate concerning approval and ethical use of cadaver and providing brief outcome statement in terms of satisfaction in the use of the cadaver model through a short questionnaire. Other items were subjected to the minor adjustments. CONCLUSION: 'CACTUS' is a consensus-based guideline in the area of surgical training, simulation and anatomical studies and we believe that it will provide a useful guide to those writing manuscripts involving human cadavers.

Intravesical Therapy for Non-Muscle-Invasive Bladder Cancer: What Is the Real Impact of Squamous Cell Carcinoma Variant on Oncological Outcomes?

Background and Objectives: To evaluate the oncological impact of squamous cell carcinoma (SCC) variant in patients submitted to intravesical therapy for non-muscle-invasive bladder cancer (NMIBC). Materials and Methods: Between January 2015 and January 2020, patients with conventional urothelial NMIBC (TCC) or urothelial NMIBC with SCC variant (TCC + SCC) and submitted to adjuvant intravesical therapies were collected. Kaplan-Meier analyses targeted disease recurrence and progression. Uni- and multivariable Cox regression analyses were used to test the role of SCC on disease recurrence and/or progression. Results: A total of 32 patients out of 353 had SCC at diagnosis. Recurrence was observed in 42% of TCC and 44% of TCC + SCC patients (p = 0.88), while progression was observed in 12% of both TCC and TCC + SCC patients (p = 0.78). At multivariable Cox regression analyses, the presence of SCC variant was not associated with higher rates of neither recurrence (p = 0.663) nor progression (p = 0.582). Conclusions: We presented data from the largest series on patients with TCC and concomitant SCC histological variant managed with intravesical therapy (BCG or MMC). No significant differences were found in term of recurrence and progression between TCC and TCC + SCC. Despite the limited sample size, this study paves the way for a possible implementation of the use of intravesical BCG and MMC in NMIBC with histological variants.

Bladder cancer histological variants: which parameters could predict the concordance between transurethral resection of bladder tumor and radical cystectomy specimens?

INTRODUCTION: The concordance rate of bladder cancer (BCa) histological variants (HV) between transurethral resection of bladder tumor (TURBT) and radical cystectomy (RC) is sub-optimal and is unclear which factors may influence it. The aim of this study was to identify factors that may be correlated to a higher TURBT-RC concordance rate. MATERIAL AND METHODS: Consecutive patients who had undergone RC between 2000 and 2019 at a single Institution with pathological evidence of HV were included. Patients with diagnosis of HV both at RC and at the previous TURBT were enlisted in the TURBT-RC Concordance Group (CG), whereas patients with only evidence of HV at RC in the TURBT-RC Non-Concordance Group (NCG). Surgical factors evaluated were the source of energy (mono- vs bipolar), surgeon's experience (10 mm represented an independent predictor of concordance [OR 2.95; CI (1.01-8.61); p = 0.048]. Tumor recurrence, focality and dimension, source of energy, surgeon's experience, performance of re-TURBT and total number of specimens at TURBT did not significantly predict the concordance. CONCLUSIONS: Longer specimens at TURBT yield a higher chance to detect HV before RC. In this light, improving the quality of bladder resection means improving the management of BCa.

The Tomato Model.

OBJECTIVES: Percutaneous renal access (PCA) is one of the most difficult intervention in endourology. Hands-on training is a useful tool for a good understanding of the puncturing technique, reducing the learning curve, and lowering risks of complications during first procedures. The ideal surgical simulator should efficiently improve trainees' skills, be easily accessible, low-cost, and realistic. We aim to present novel fluoroscopy-guided PCA simulator named TOMATO model. MATERIALS AND METHODS: The model can be easily built in few minutes using low-cost items: yoga mat, cotton wool, forceps, needle-driver, scalpel, 0 silk suture, chiba needle, small pebble (1 cm ca) and a few kidney-shaped tomatoes. The yoga mat is fold in half, sutured with silk, placed on the operating table, and thanks to the friction created between the mat and sheet underneath there is no need for other fixating methods. Once placed inside the yoga mat, the tomato is held still in the position by the cotton wool, which is placed around the vegetable. The tomato imitates the real renal structure. Therefore is ideal for this use, and there is no need for liquid-contrast enhancement. The goal is achieved when the operator manages to move the pebble with chiba needle during pulsed fluoroscopy. The model was tested 3 times by 3 endourologists and by 10 residents in training with no experience as first operators. A 7-items questionnaire (1-10 rating scale) was administered to the participants in order to evaluate the utility of the model. Trainees' kidney access time (KAT) and radiation time (RT) were assessed at the first use and after 1 hour of training (circa 15 attempts to reach the target per resident). RESULTS: The model allowed residents' significant reduction of the KAT and RT. KAT passed from 114 (144.25-89) to 72.5 (97.25-49.5) seconds (P = .04) while RAT passed from 82 (89.75-56) to 51.5 (60.25-35.75) seconds (P < .001). The residents particularly appreciated the high-fidelity reproduction of the anatomy that the model offers, and its' usefulness for learning the puncturing technique, giving it 8.5 and 10 points, while the same items were rated 7.7, and 9.3 by the experts, respectively. Trainees felt that their skills could be improved by using this model. The main issue was finding the materials mimicking the real-life tissues and their different characteristics. CONCLUSIONS: TOMATO model might be a helpful and creative way to start learning the steps of kidney puncturing using low-cost materials and we believe its' strength is being easily reproducible in all urology units.

Urology apps: overview of current types and use.

INTRODUCTION: In recent years numerous applications have been developed with different purposes, aimed both at simplifying the lives of doctors and patients also within the urological field. MATERIAL AND METHODS: In January 2020 we conducted a search in the Apple App Store and Google Play Store. RESULTS: A total of 521 apps were reviewed, an increase of 8 times as compared to the last complete available review of eight years ago. Most of the urological apps are geared towards the patient and provide information and services to improve the understanding and treatment of different diseases. Some of these apps also get the patient directly in touch with healthcare staff allowing for an improvement in doctor-patient communication. CONCLUSIONS: Although the usefulness of many of these tools is undoubted, the problem of scientific validation, content control and privacy are not yet solved.

Incidental finding of paratesticular aggressive angiomyxoma in a 72-year-old monorchid male.

Aggressive angiomyxoma is an uncommon mesenchymal neoplasm. It arises from soft tissue of pelvis and perineum in fertile females, occurring very rarely in males. Its name emphasizes the common local recurrence and infiltrative tendency, but usually it does not metastasize. Currently, the first line of therapy is surgical excision, achieving R0 surgical margins, and radiological follow-up. This case report describes an uncommon, incidental finding of paratesticular aggressive angiomyxoma in an asymptomatic, cryptorchid 72-year-old male patient.

Transurethral endoscopic approach for large bladder diverticula: Evaluation of a large series.

OBJECTIVE: To present the results of the largest series of patients with bladder diverticula > 4 cm managed with an endoscopic approach and give tips about the execution of the procedure. MATERIALS AND METHODS: Data of male patients undergone the endoscopic approach for an acquired bladder diverticula > 4 cm from December 2004 to August 2018 were prospectively collected and retrospectively analyzed. The description of the monopolar and bipolar techniques are provided. The success of the procedure was defined as the reduction of the diverticula for more of the 80% of its initial diameter documented at the 3- months follow-up imaging. Continuous variables with nonparametric distribution were compared using the Mann-Whitney test, while frequencies of categorical variables were compared between groups by Fisher's exact test with significance level set at 0.05. RESULTS: Thirty-nine patients with a mean (+/- SD) age at surgery of 69.4 ± 8.8 years were enrolled, for an equal number of diverticula managed. The mean diverticular size was 75.1 ± 24.5 millimeters. The mean operative time was 65 ± 21.9 minutes including the prostate surgery. Twelve patients (30.8%) were managed with bipolar energy, the others with monopolar. The success of the procedure was achieved in 30 patients (76.9% - 7 bipolar and 23 monopolar - p = 0.66). CONCLUSIONS: The endoscopic approach might be considered as a useful option for patients with a large bladder diverticulum who are at risk for major or laparoscopic procedure.